Sketchy Pharm PDF No Pictures

Sympathetic

Sympathomime1cs



• General • One lane road- vasoconstric1on • Two lane road- vasodila1on • Alpha-1 and 2, Beta-1 and 2 ○ QISS respec1vely • Alpha-1 (one alpha candle) • IP3-DAG- increased intracellular Ca lead to vasoconstric1on increasing BP and resistance (map with arrow) ○ venoconstric1on leading to increased venous return, good for shock • mydriasis (binoculars) • urethral sphincter and prosta1c muscle constric1on (drawstrings on shorts) ○ urinary reten1on • Phenylephrine (guys wearing flannel) ○ treats nasal conges1on because of nasal vasoconstric1on ○ mydriasis ○ vaso/venoconstric1on- increased SVR, diastolic pressure, systolic pressure ○ used in shock to increase blood flow and return ○ reflex bradycardia • Norepinephrine (alpha>beta 1) ○ some beta-1 ac1vity (bugle) ○ vasoconstric1on, increased SVR ○ reflex bradycardia ○ used in shock • Alpha-2 (two alpha candles) • sympatholy1cs- decrease vascular tone leading to vaso/venodila1on • decreased cAMP (broken tent) • inhibi1on of neurotransmiSer release (broken extension cord) • decreased insulin release (rolled up mat) • decreased lipolysis (pig with doused fire) • decreased aqueous humor produc1on (water coming out of hat) • Brimonidine (brim of the hat) ○ used in open angle glaucoma • Beta-1 (bugle) • increased cAMP leads to increased intracellular Ca, increasing contrac1lity • Beta-1 found on cardiac myocytes, SA and AV node ○ increased heart rate, contrac1lity and output • increases renin release • Dobutamine (beta-1>beta-2) ○ increased HR ○ increased contrac1lity, increased output (heart flashlight) ○ increased systolic pressure ○ some beta-2 ac1vity (girl with tuba) § vasodila1on § decreased diastolic pressure (makes a bicep shape with systolic pressure on pressure tracing) ○ good for acute HF and cardiogenic shock ○ good for cardiac stress test

Isoproterenol (beta-1=beta-2)

○ increased HR and contrac1lity (le^ girl in tent) ○ vasodila1on, decreased diastolic and decreased SVR (right girl in tent) • Beta-2 (tuba) • relaxa1on of smooth muscles, vasodila1on, decreased diastolic BP, decreased SVR • bronchodila1on (taking a deep breath) • increased lipolysis (pig on fire) • increased gluconeogenesis (marshmallows from liver bag) • increased insulin release (welcome mat) • hypokalemia due to increased insulin (bananas on floor) • increased aqueous humor produc1on (girl filling balloon) • Isoproterenol (beta-1=beta-2) ○ increased HR and contrac1lity (le^ girl in tent) ○ vasodila1on, decreased diastolic and decreased SVR (right girl in tent) Terbutaline + Ritodrine • ○ relaxes smooth muscles of uterus blocking birth • Albuterol, Formoterol, Salmeterol ○ bronchodila1on ○ used for asthma and COPD • Epinephrine (beta>alpha) • dose dependent ○ low doses give beta effects ○ high doses give alpha effects • bronchodila1on (beta-2 effect) • vasodila1on (beta-2 effect) • decreased diastolic pressure (beta-2 effect) • elevated HR and increased contrac1lity (beta-1 effect) • increased BP, increased SVR, vasoconstric1on (alpha-1) • used for anaphylac1c shock

Indirect Sympathomime1cs



• General • enhance the ac1on of catecholamines (epi, norepi, and dopamine) (cabish) • dock represents nerver terminal • tyrosine is converted to L-dopa at the nerve terminal ○ blocked by Metyrosine • boat represents vesicle containing the neurotransmiSers in presynap1c neuron ○ dopamine is converted to norepi in presynap1c vessicle • most drugs will block reuptake or neurotransmiSers in the synap1c cle^ • NET and DAT transport norepi and dopamine back into presynap1c neuron (kid with net) by VMAT • VMAT transports catecholamines into presynap1c vessicle ○ blocked by reserpine • Cocaine (cocoa) • inhibits NET and DAT increasing concentra1on of norepi and dopamine in synapse • HTN, agita1on, pupillary dila1on, angina, and tachycardia (kid with cocoa cup) • seen with nasal mucosal atrophy or septal perfora1on due to vasoconstric1on (bloody nose) • coronary constric1on leading to vasospasm and ischemia (crown on mug) • beta-blockers cause severe hypertension due to unopposed alpha s1mula1on (girl with plugged bugle) ○ cocaine s1mulates both alpha and beta, blocking beta will give unopposed alpha s1mula1on • Atomexi1ne • treats ADHD • NET inhibitor • Amphetamines (like methylphenidate) • displace catecholamines into the synapse • mood eleva1on • treats ADHD and narcolepsy • decreased appe1te • Modafinil • treats narcolepsy • "gets you out of sleep mode" • D1 and D2 receptors • D1 (first swing) ○ relaxa1on of smooth muscles in renal vasculature § increases bloodflow to kidney ○ beta at low doses, alpha at high doses § cardiac ac1va1on, pressor effects respec1vely • D2 (second swing) ○ receptors are found in CNS

Parasympathetic

Cholinomime1cs



• General • Cholinomime1cs mimic the effects of AcH ○ AcH receptor agonists ○ not specific so may s1mulate M1-3 • 2 types of receptors ○ Nico1nic (smoker on the le^), they are found on autonomic ganglia, NMJ motor end plate, and adrenal gland § act as ion channels ○ Muscarinic (motorcycles in the middle), found on autonomic effector 1ssue of heart and glands § coupled to G-proteins that act as inducers § M1- Gq, IP3-DAG cascade (3 dogs, leads to increased intracellular Ca), found in CNS and enteric nervous system (brain helmet) § M2- Gi, inhibi1on of cAMP produc1on (tent), found on heart (jacket, receptors are in atria + SA/AV node) § M3- Gq, IP3-DAG cascade (3 dogs, leads to increased intracellular Ca), found on glands and smooth muscles (sponge and paint job) □ ac1va1on causes release of NO from endothelial cells causing vasodila1on through cGMP • Bethanechol (construc1on worker in the back) • Increase secre1on and motor ac1vity of gut (cement spout that looks like colon) ○ used in post-op ileus, non-obstuc1ve GI disorders, or congenital megacolon (do not obstruct sign) § will not help with obstruc1ve diseases ○ treats urinary reten1on from post-op or spinal injury (hose) • Pilocarpine (pile of carp) • increases salivary secre1on (open fish mouthes with saliva) ○ treats Sjogrens, drive mouth or side effects of other drugs • reduces intraoccular pressure by contrac1on of ciliary body releasing aqueous humor causing accommoda1on of lens (round glass at the top of the net) ○ treats glaucoma • causes pupillary constric1on causing miosis (closed hood) ○ good for acute glaucoma • Carbechol (person in the window) • causes pupillary constric1on causing miosis (closed hood) ○ good for acute glaucoma • both a muscarinic and nico1nic agonist (fumes from smoker) • Methacholine (marathon challenger) • ins1gates asthma for pulmonary tes1ng ○ contract bronchiol smooth muscle which exacerbates asthma and COPD (runner in the back) • Varenicline (smoking cessa1on sign) • used for smoking cessa1on

AChesterase Inhibitors



• General (knocked over dumpster) • indirect cholinomime1cs (ACh mime sign in the background) • blocks the degrada1on of ACh in the synapse, increasing the concentra1on of ACh • -s1gmine is the usual suffix • similar effects to cholinomime1cs in eye, GI, respiratory tract, and urinary tract • enhance effects of ACh at NMJ motor end plate (brick wall that looks like skel muscle with electrical plug plate) • used in the treatment of Myasthenia Gravis ("gravis" graffi1 on wall) ○ only treat symptoms of MG, immunosuppressants affect an1body levels • Pyridos1gmine (lady with community "pride" jacket cleaning the graffi1) • used in long term treatment of MG • Neos1gmine (neon sign) • not as commonly used • treats urinary reten1on (bladder hose) • Edrophonium (phone booth) • "quarters only"- pyridos1gmine, neos1gmine and edrophonium are quaternary amines and do not have CNS effects • used in MG diagnosis (tensilon test- tense phone wire) ○ short dura1on of ac1on. If edrophonium improves symptoms it means either MG or not enough AChesterase inhibitors for pa1ent. If it does not improve symptoms then it means too much ACh s1mula1on (graffi1 covering second phone booth) Physos1gmine (phys ed center) • • reverses Atropine overdose (Alice graffi1) by increasing ACh concentra1on at synapse to overcome compe11ve inhibi1on (phys ed teacher punishes graffi1 kid) • can enter the CNS ○ toxic effects- DUMBBELS. Diarrhea, Urina1on, Miosis, Bronchospasm, Bradycardia, Excita1on of skel muscles, Lacrima1on, Saliva1on with flaccid paralysis (guy working out in gym) • AChesterase inhibitor overdose • seen in organophosphate poisoning (THIOL spray) • causes DUMBBELS • seen with gardening scenarios • Pralidoxime reverses peripheral organophosphate toxicity (toxic waste dumpster) • Atropine reverses central and peripheral muscarinic toxicity • aging of organophosphate-cholinsterase complex leads to irreversible binding • Alzheimers drugs • All penetrate the CNS • Galantamine ("Gala" sign) • Rivas1gmine ("reverse the s1gma" sign) • Donepezil ("done" brain puzzle) • NMJ blockade • Nondepolarizing neuromuscular blocking agents (crayons stuck in end plate) ○ inhibit nico1nic ACh receptors and NMJ endplate ○ reversed by AChesterase inhibitors like Neos1gmine (owner kicking out kid) • Depolarizing neuromuscular blocking agent ○ Succinylcholine ("sucks" graffi1) § overs1mulates ACh receptors at NMJ

An1muscarinics



• General • Muscarinic antagonists reversibly inhibit muscarinic receptors (mouse reversing into parking) • block the effects of cholinomime1c agents ○ blocks DUMBBELS and acetyl-cola • penetrate CNS and block M1 receptors • Atropine (Alice) • found in belladonna plant jimson weed • non-selec1ve antagonist of M1-3 receptors • blocks M2 receptors on SA/AV nodes (queens heart septor) ○ reverses depressed SA/AV node ac1on in MI or shock (rabbit with heart shaped watch) causing tachycardia • treats heart block (heart shield) by increasing AV conduc1on • Scopalamine (walrus with sailor suit) • used for mo1on/sea sickness • Mydriasis (big telescope) and cycloplegia losing the ability to accommodate near distances • usually transdermal administra1on (eye patch) • Ipratropium + Tiotropium • M3 antagonists • used in COPD pa1ents to bronchodilate and decrease secre1ons (caterpillar with hookah) • inhaled drugs • Tiotropium is longer las1ng • Oxybutynin + Tolterodine • M3 antagonists • relaxes smooth muscles of ureters and bladder wall ○ relieves spasm a^er bladder surgery ○ treat incon1nence • Benztropine + Trihexyphenidyl • Central M1 antagonist • used to treat Parkinsons tremor and rigidity by lowering ACh s1mula1on • treat extrapyramidal side effects of an1psycho1cs • An1muscarinic Toxicity • Hot as a hare, dry as a bone, blind as a bat, acute angle glaucoma, stuffed as a sausage, mad as a haSer

Alpha Drugs



• General • A-2 agonists affect the CNS to reduce BP ○ side effects are due to CNS depression • A-2 can be used as sympatholy1cs for HTN Alpha Agonists • Clonidine • Alpha-2 agonist (two lit alpha candles) • treats HTN • useful for HTN urgency • can be used in ADHD • used for managing ToureSe's 1cs ○ preferred over other agents because theres no extra-pyramidal side effects • Alpha-methyldopa • A-2 agonist • analogue of L-Dopa • lowers BP • HTN in pregnancy treatment • causes lupus-like syndrome (lupus wolf) • Tizanidine (chair with to x-1ne leSer) • A-2 agonist • muscle relaxant Alpha Antagonists • Phentolamine • reversible A-1 and A-2 antagonist (ex1nguished single and double candle holders) • causes vasodila1on (dilated sleeves) • used intraopera1vely for Pheo surgery • can be used to treat cocaine toxicity (hot cocoa cup being spilled) • can be used to treat HTN crisis from MAO inhibitors (wine, cheese and mousetrap) ○ blocks the alpha mediated vasoconstric1on • side effects ○ orthosta1c hypotension (hypotension table) ○ reflex tachy (heart shaped hammer • Phenoxybenzamine (phoenix taSoo) • irreversible A-1 and A-2 antagonist • use preopera1vely for Pheo surgery to normalize BP • may take days to make new, unopposed alpha receptors a^er cessa1on • can be used to treat cocaine toxicity (hot cocoa cup being spilled) • can be used to treat HTN crisis from MAO inhibitors (wine, cheese and mousetrap) ○ blocks the alpha mediated vasoconstric1on • side effects ○ orthosta1c hypotension (hypotension table) ○ reflex tachy (reflex hammer)



Alpha-1 Selective Antagonists

• Prazosin, Terazosin, Doxazosin, Tamsulosin (-osin) • A-1 selec1ve antagonism (ex1nguished alpha-1 candle) • treats symptoms of BPH by relaxing smooth muscle in prostate/urethra (guy on banister) ○ do not change volume of prostate, that is testosterone mediated • vasodila1on (dilated sleeves) • Prazosin used for PTSD treatment (guy praying with PTSD tags) • side effects ○ first dose hypotension with orthosta1c hypotension • Mirtazapine (mirth and misery sign, "mirsadsapine") • atypical an1depressant w/ A-2 antagonism (happy face for enhanced serotonin release and depression treatment, sad face for treatment of depression)

Beta Blockers



• General (N through Z in alphabet) • beta-1 is bugle • beta-2 is tuba • muted bugles and tubas for beta blockers • -lol suffix • decrease cardiac contrac1lity (pianist w/ hand stuck) due to beta-1 antag ○ remember beta-1 agonist fire hydrant sketch • suppress SA/AV node ac1vity due to beta-1 antag ○ bradycardia ○ can cause or exacerbate heart block due to AV node suppression (shield on wall) • management of chronic stable angina due to decreased cardiac contrac1lity which leads to decreased myocardial oxygen demand (angina anvil with oxygen tank coming off) • Labetalol (organ with alpha and beta "labels") • vasodila1on (dilated sleeves) • alpha-1 antagonism (ex1nguished alpha-1 candle) • treats HTN in pregnancy (pregnant woman) • useful in hypertensive emergency (emergency stop switch) • given IV (ivy on organ) ○ IV beta blockers treat hypertensive emergency § useful in acute management of aor1c dissec1on (cracked organ pipe) • depresses renin secre1on causing depressed RAAS system (closed umbrella being thrown away) • remember beta-1 agonist girl with umbrella sketch • useful in management of hypertrophic obstruc1ve cardiomyopathy (big obstructed heart bag) • useful in migraine prophylaxis (bell with face on it) • useful in symptoma1c treatment of thyroid storm (bow 1e with lightning) • 3 P's of treatment- propranolol, propylthiouracil, and prednisalone treat essen1al tremor • • class 2 an1arrhythmics • side effects • exacerba1on of asthma/COPD (tuba player in front) • decreased aqueous humor produc1on (tuba with eyeball) ○ treats glaucoma • can cause impotence in men • beta blocker toxicity is treated with glucagon (glucagon packets with conductor) ○ s1ms heart by glucagon receptors on heart • Pindolol • par1al agonist ac1vity • not for pts with HF or MI history • Esmolol, Metroprolol, Labetolol • given IV (ivy on organ) ○ IV beta blockers treat hypertensive emergency § useful in acute management of aor1c dissec1on (cracked organ pipe) Beta-1 Selec1ve Antagonists (A-BEAM on muted bugler) (A through M in alphabet) • A-BEAM: Atenolol, Betaxolol, Esmolol, Acebutolol, Metoprolol • reduces infarct size and early mortality in MI pts when given within 24 hours (broken s1ngs harp) • reduces mortality when given long term to MI pts (angel costume) • can exacerbate symptoms so given at low dose first • helps manage chronic heart failure • Carvedilol useful in CHF management (carved candle holder) ○ alpha-1 antagonism as well (ex1nguished A-1 candle)

• reduces early mortality in CHF pts (angel costume) • reduces cardiac remodeling by protec1ng the heart from excess catecholamine circula1on (remodeling sign) • can be used to lower HTN in pts post MI or CHF (organ in background) • caused by ○ decreased cardiac contrac1lity ○ depresses renin secre1on causing depressed RAAS system (closed umbrella being thrown away) § remember beta-1 agonist girl with umbrella sketch • Acebutolol (blue plas1c bugle in front) • par1al agonist ac1vity • not for pts with HF or MI history

Cardio + Renal

Heart Failure Drugs



• Inotropy • changes in cardiac contrac1lity in ventricles • posi1ve inotropy- increases contrac1lity • nega1ve inotropy- decreases contrac1lity • Chronotropy • chronos means 1me • changes in heart rate • posi1ve chronotropy- increases heart rate • nega1ve chronotropy- decreases heart rate • Digoxin • a cardiac glycoside • comes from foxglove plant (DJ foxglove) • inhibits Na/K ATPase (knocked over NA/K ATPase vending machine) ○ potassium cannot enter cell, sodium cannot exit cell (guy trapped inside with peanuts) § promotes Ca influx/Na efflux from Na/Ca exchanger (kids bringing ice cream in, peanut kid exi1ng) □ improves cardiac contrac1lity due to increased sarcoplasmic Ca stores (jock flexing) ○ increased K+ § can lead to hyperkalemia, helps indicate Digoxin toxicity and mortality • symptoma1c treatment of CHF (kid with HF balloon) • narrow therapeu1c index, only used when other drugs do not work • direct s1mula1on of vagus nerve treats certain atrial arrhythmias (Las Vegas sign, an1arrhythmic record player) • adverse effects ○ toxicity § hyperkalemia § premature ventricular contrac1ons § arrhythmias (kids dancing on the dance floor) § scooped, concave ST segment on ECG (scooped ice cream container) § bradycardia due to parasympathe1c ac1vity on SA node (kid with pocket watch where SA node is) § heart block due to parasympathe1c ac1vity on AV node (girl with shield blocking kid where AV node is) § contraindicated in drugs that can cause heartblock (ex. beta blockers) § GI symptoms- abd pain, vomi1ng, and nausea § Confusion and disorienta1on § yellow appearing vision § predisposing factors □ hypokalemia (kid stuffed in vending machine), can be from diure1cs □ renal insuffiency increases half life of Digoxin (damaged kidney juke box with long flag) many an1arrhythmics inhibit renal clearance of Digoxin, causing toxicity § Digoxin immune Fab reverses digoxin toxicity • Milrinone ("one in a million" poster with donkey) • inotropic agent

ACE Inhibitors



• General • increases mortality in post MI pts • Renin ○ released from JGA § due to direct s1m of beta-1 receptor, reduced renal arterial pressure, reduced Na delivery (low volume or low pressure states) ○ cleaves angiotensinogen (loose red 1e) to angiotensin 1 (tense red 1e) • ACE ○ in vascular endothelium of lungs (lung spots on dealer) ○ converts angiotensin 1 (tense red 1e) to angiotensin 2 (tense suspenders) § causes vasoconstric1on • Angiotensin 2 ○ increases GFR by efferent arteriolar constric1on (GFR coffee machine) ○ acts at PCT to increase Na resorp1on (guy watching tv) ○ increases aldosterone secre1on from zona glomerulosa of adrenal cortex (suspender guy at mineral bar) § increases Na reten1on but wastes K+ (lots of peanut snacks, bananas on the floor) • • • • • • • • • • • • •

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ACE Inhibitors -pril suffix blocks conversion of angiotensin 1 to 2 (guy with floppy suspenders) promote diuresis decreases GFR by efferent arteriole dila1on decreases Na resorp1on at PCT decreases aldosterone release causes expected bump in crea1nine (crea1nine credit card) increase levels of angiotensin 1 and renin first line agents in treatment of HF by decreased preload (floppy balloon) reduces mortality in HF and MI pts (angel above couple) • inhibits angiotensin 2 mediated cardiac remodeling (remodeling sign) first line agents in primary HTN (high pressure candy pipes) slow the progression of diabe1c nephropathy (kidney shaped lollipops) • will be detected with proteinuria/albuminuria adverse effects • hypotension and syncope in pts with high renin levels like HF pts • hyperkalemia due to decreased aldosterone levels (raised glass with banana) • dry cough due to increased bradykinin (girl with braids) • contraindicated in hereditary angioedema (woman with "C" lip ring) ○ due to C1 esterase deficiency teratogenic • • NSAIDS block prostaglandins which usually dilate afferent arteriole causing constric1on and decreased blood flow (kidney fire ex1nguisher case) causing acute kidney injury ○ increased crea1nine • contraindicated in bilateral renal artery stenosis (kidney shaped purse) ○ increased crea1nine ARBs -sartan suffix similar effects to ACEI with less side effects no cough hyperkalemia

Diure1cs (PCT)



• General • PCT is highly permeable • majority of concentra1on of Na, K decrease in PCT • bicarb reabsorp1on happens here • Na/K ATPase on basolateral membrane (vending machine) • Na/H+ exchanger on apical membrane (peanut guy) moves Na out of lumen, H+ into lumen • bicarb is reabsorbed in PCT lumen (biCARb), combines with H+ to form carbonic acid (H2CO3) ○ keeps pH levels in balance ○ Carbonic anhydrase converts carbonic acid into H2O and CO2 § enters the intracellular space § water is reabsorbed in the PCT § H2O and CO2 are combined again by carbonic anhydrase to carbonic acid § carbonic acid disassociates back into H+ and bicarb

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Acetazolamide (car with leaky baSery) inhibits carbonic anhydrase, thus preven1ng reabsorp1on of bicarb carbonic anhydrase inhibitors like Acetazolamide cause bicarb to remain in lumen causing urine alkaliza1on • also leads to metabolic acidosis since bicarb is not in lumen to balance pH • can be used to prevent stone forma1on CA inhibitors also block reabsorp1on of Na causing na1uresis decreases aqueous humor produc1on, manages glaucoma (cup with eyeball that is leaking) bicarb reduc1on leads to decreased CSF produc1on, lowering intracranial pressure (big head balloons) useful in treatment/preven1on of mountain sickness (guy on wobbly ref stand) side effects (mario kart kids) • hypokalemia (banana on ground) from potassium was1ng • type 2 renal tubular acidosis (tubes on the red kart) • forma1on of calcium stones due to insolubility at basic pH • sulfa drug Mannitol (tall man) acts on PCT and descending LOH pulls water into the lumen to be excreted (stream of water) draws water out of CSF to treat increased intracranial pressure draws water out of eye to decrease intraoccular pressure (cup pouring out water)

• • • • • • side effects • can cause pulmonary edema (lung spots on kid) • can exacerbate HF (floppy balloon drenched in water) • without appropriate water replenishment there will be hypernatremia

Diure1cs (LOH)



• General • work on ascending LOH • Na/K+ ATPase on basolateral membrane • Na/K/Cl (NKCC) cotransporter reabsorbs these ions at luminal membrane (no food allowed sign) • blocks NKCC on luminal membrane • reduces reabsorp1on of ions • blocks Calcium and Magnesium reabsorp1on causing excre1on ○ prolonged use can cause hypomagnesemia (falling magnet) • hypokalemia due to K+ was1ng • the thick ascending limb is impermeable to water ○ only solutes are reabsorbed here § this leads to a concentra1on gradient that promotes water reabsorp1on in places like the collec1ng duct • promote expression of COX-2, synthesizing prostaglandins that enhance salt excre1on and dilate afferent arteriole (kid with bat) ○ blocked by NSAIDs by decrease Prostaglandin synthesis • 1st line in treatment of acute decompensated HF with fluid overload (guy with HF balloon and lung spots) • treats ascites in liver failure (yellow tube around lady) • treats HTN (red pipes) • side effects ○ ototoxic (giant gong) ○ sulfa drugs ○ inters11al nephri1s (kidney 1cket holder) ○ hyperuricemia (girl with yarn ball) ○ dehydra1on leads to contrac1on metabolic alkalosis (guy with boSle of cleaner) Furosemide (furious kid) • block NKCC on luminal membrane • reduces reabsorp1on of ions • blocks Calcium and Magnesium reabsorp1on causing excre1on ○ prolonged use can cause hypomagnesemia (falling magnet) Ethacrynic acid (ethics sign) • blocks NKCC on luminal membrane • reduces reabsorp1on of ions • blocks Calcium and Magnesium reabsorp1on causing excre1on ○ prolonged use can cause hypomagnesemia (falling magnet)

Diure1cs (Thiazides)



• Normal Physio in DCT • Na/K ATPase on basolateral membrane pumps sodium out • yellow slide is lumen, outside is intracellular compartment • selec1vely permeable to water • NaCl cotransporter on apical membrane ○ brings NaCl back into cell • Ca is reabsorbed in the DCT which is regulated by PTH

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Hydrochlorothiazide and Chlorthalidone (diving board) blocks NaCl cotransporter dumping NaCl into lumen, water follows (bumping NaCl into water) enhance Ca reabsorp1on (kid dropping ice cream from slide) first line in primary HTN by decreasing intravascular volume and decreasing cardiac output • good for mild or moderate HTN with normal cardiac func1on ○ as opposed to loop diure1cs which work on HF and liver failure HTN chlorthalidone has longer half-life can be used with loop diure1cs in treatment of HF (floppy balloon) treatment for nephrogenic diabetes insipidus prevents forma1on of Ca stones (removal of stones in slide) can help osteoporosis pts (broken piece of chalk) side effects • enhanced calcium reabsorp1on can cause hypercalcemia (elevated girl with ice cream) • causes hyperlipidemia and hyperglycemia (kid with buSer and candy) • causes hyperuricemia (girl with yellow yarn) • causes increased lithium levels due to decreased renal clearance (guy with lithium balloons) ○ can treat nephrogenic DI • hypokalemia (banana on the floor) due to potassium was1ng • hyponatremia (spilled peanuts) • sulfa drug • contrac1on metabolic alkalosis (guy cleaning puddle) due to hypovolemia induced renin produc1on at the kidney--> aldosterone produc1on s1mulates H+ excre1on in collec1ng duct--> alkalosis

Diure1cs (Collec1ng Duct)



• General • K+ sparing diure1cs work here • site of ac1on of aldosterone • principal cell is the major site of Na, K+ and H20 transport (principal court) • Na/K ATPase on basolateral membrane • Epithelial Na Channels (ENaC) reabsorb Na across the luminal membrane of collec1ng duct (peanut cart guy) • K+ channels allow excre1on of K+ into lumen (banana stand guy) ○ Na+ creates nega1ve poten1al in lumen causing K+ excre1on • alpha intercalated cells excrete H+ into lumen through H+ ATPase on apical membrane (food truck) • aldosterone upregulates (mineral key): ○ K+ excre1on ○ Na+ absorp1on ○ Na/K ATPase ○ H+ ATPase, H+ excre1on • • • • •

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Potassium Sparing Diure1cs Amiloride (almond box) inhibits Na+ absorp1on through ENaC promo1ng na1uresis • treats Lithium induced nephrogenic DI Triamterene (tangerine) inhibits Na+ absorp1on through ENaC promo1ng na1uresis Eplerenone (apple) antagonizes aldosterone receptors Spirinolacone (spiral notebook) antagonizes aldosterone receptors Spironolactone and Eplerenone are useful in treatment of primary and secondary hyperaldosteronism (mineral mountain) • useful in treatment of HF ○ reduces mortality in HF pts ○ inhibi1on of remodeling from high levels of aldosteronism post-MI • treats symptoms of androgen excess in PCOS (ex. hirsu1sm) side effects • hyperkalemia (lady with raised bananas) ○ balance with another K+ was1ng diure1c • metabolic acidosis due to decreased H+ excre1on from H+ ATPase (truck driving off) • type 4 renal tubular acidosis (guy with 4 vials) • spironolactone ○ non specific ○ blocks testosterone synthesis at 17alpha-hydroxylase (fryer) § gynocomas1a (guy holding plates on his chest) § impotence and decreased libido (kid with floppy churro)

An1 HTN (CCBs)



• General • voltage gated calcium channels (L shaped handles) • dihydropyradines block L-type Ca channels in smooth muscle (dairy sign) ○ cause vasodila1on (dilated nozzle) • non-dihydropyradines block L-type Ca channels in cardiac mucle (non-dairy sign) ○ verapamil has greatest effect on cardiac suppression (small nozzle) ○ dil1azem depresses cardiac muscle and small vasodila1on (middle dispenser with medium nozzle)

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Dihydropyradines -dipine suffix treat HTN IV CCB given for hypertensive emergency Nifedipine • used to treat HTN in pregnancy (pregnant lady with knife) treats stabile angina (angina anvil) • dilate coronary arteries (big red crown) • reduce a^erload treats Prinzmetal angina • due to coronary artery spasm at rest treats Raynaud's syndrome (guy with fingerless gloves) prevents vasospasm in subarachnoid hemorrhage (ice cream with berries) side effects • flushing • dizziness • headache • peripheral edema (puffed up pants) • reflex tachy ○ especially nifedipine in pts with unstable angina or MI (huge knife) Non-dihydropyradines • Dil&azem and Verapail • decrease cardiac contrac&lity and output (kid cannot pull handle) • decrease SA/AV node ac&vity (music notes) • bradycardia • treat HTN • treats stabile angina (angina anvil) • decrease myocardial oxygen demand • treats Prinzmetal angina (angina medal) • due to coronary artery spasm at rest • migraine prophylaxis (head bell) • have an&arrhythmic proper&es • treat atrial fib and fluGer • side effects • cons&pa&on • peripheral edema • gingival hyperplasia (bubble gum) • contraindicated in heart block pts • can worsen HF (HF balloon)

HTN + Emergency



• General (1tanic ship) Primary HTN Treatment (primary deck) • called essen1al HTN • 2 an1hypertensives should be used for BP 20/10 over the goal (2 life preservers sign) • use CCB, ARBs, ACEI or Beta Blockers • ND CCBs and Beta blockers can be used if pt has rate control problem as well • Hydrochlorothiazide is first line for primary HTN (kid with white thighs) • or chlorthalidone because of long half life and reduc1on of cardio events • black people respond best to dihydro CCBs and thiazides for HTN treatment (black guy with ice cream/speedo) • ACEI are first line in HTN pts with HF, MI and diabetes (casino table with HF balloon, candy and guitar)

• • • • •

• •

•

•

Hypertensive Emergency Treatment (boiler room with shut off switch) when systole is >180 or diastole is >120 (protractor and ruler) pt will present with end organ damage, blurry vision, or neurologic problems pressure must be lowered gradually to avoid ischemic damage Beta blockers like esmolol and metoprolol can be used in IV form for HTE (muted beta bugles) • short term control • labetolol can be used as well but also antagonizes alpha to vasodilate all drugs but esmolol and metoprolol cause vasodila1on (big red smoke stack) • leads to decreased TPR • can lead to hypotension causing reflex tachy and increased renin release (tachy hammer and umbrella) • reduces a^erload (pushing box off scale) dihydro ccbs can be used IV (lady in boat with ice cream with dilated sleeves) • clevidipine (clover on card) • nicardipine (nice card) hydralazine (hydroboat) • direct arteriolar vasodilator with no venous effect (direct hose to hydrant) • safe for pregnancy (pregnant woman gesng on boat) • can cause hypotension (fain1ng woman) • can cause reflex tachy that worsens angina (angina anvil) ○ prevent with beta blocker (beta bugler gesng on boat) § blocks reflex tachy and reflexive renin release (falling doctor with closed umbrella) • give nitrate with it to treat HF giving decreased mortality (guardian angel) • can cause drug-induced lupus Nitrates (s1ck of dynamite) • nitroprusside (nitropressure boat) ○ vasodila1on via nitric oxide ○ increases cGMP to relax smooth muscle (grump in the water) ○ different from other nitrates because it dilates veins and arteries, not just veins (lady with dilated sleeves) ○ metabolizes to cyanide (poisonous blue smoke) fenoldopam (old lady on side of boat) • dopamine 1 agonist (single rope) • increases cAMP (tent) ○ causes vasodila1on (dilated sleeves) ○ coronary vasodila1on (red crown) • dilates renal arteries increasing perfusion (kidney floa1e) • causes Na excre1on and na1uresis

Class 1 An1arrhythmics



• General (heartbreak hotel) • class 1 (soloist) • block sodium channels (peanut buSer jar) ○ decrease the slope of phase 0 slowing AP • microphone wire shows normal ac1on poten1al • have greater effect on rapidly depolarizing 1ssue like tachycardia ○ the faster the heart beat the more the drug works (called state dependence) • widen QRS on ECG (crack in neon sign) • do not affect nodal ac1vity • effect strength- 1C > 1A > 1B •

•

• • • • • • • • • •

• •

Class 1A Quinidine (prom queen) • side effects ○ toxicity can cause cinchonism- 1nnitus, headache, dizziness (1n cans) ○ thrombocytopenia (broken plates) ○ drug induced lupus-like syndrome Procainamide (prom king) • side effects ○ toxicity can cause cinchonism- 1nnitus, headache, dizziness (1n cans) ○ thrombocytopenia (broken plates) ○ drug induced lupus-like syndrome Disopyramide (disappear on newspaper) • side effects ○ can exacerbate HF have medium effect on Na channels (queen holding peanut buSer gently) also block K channels to increase AP 1me and refractory period (pushed banana curtain) used in supraventricular and ventricular arrhythmias (fully lit sign) used in WPW syndrome (WPW sign) can cause QT interval prolonga1on leading to Torsades (twisted streamer) Class 1B Lidocaine (you lied sign) • best for post-MI ventricular tachy Mexile1ne (mexican flag) Phenytoin (friendly towing guy) have small effect on Na channels (low peanut buSer) • liSle effect on phase 0 and shorten phase 3 • shorten AP dura1on used in ventricular arrhythmias (broken sign) due to ischemia side effects • neurologic effects- tremor, convulsions, cns depression (brain hat)

• • • • • •

Class 1C Propafenone (purple phone) Flecainide (flake cereal) • large Na channel ac1vity (raised peanut buSer) • strongest state dependence biggest effect on phase 0, does not touch phase 3, AP dura1on, or refractory period used in SVT and ventricular arrhythmias (lit up sign) • treat Afib and fluSer (tv screen) ○ restores normal rhythm side effects • contraindicated in pts with history or structural or ischemic heart disease (healthy heart cereal)

Class 2 An1arrhythmics

• •

• •



Beta blockers (muted bugle) do not affect ion channels, work on nodal ac1vity treat arrhythmias by blocking sympathe1c input to SA/AV nodes (notes on music stand) • decrease cAMP levels (torn band camp sign) ○ leads to closure of membrane Ca channels (crushed ice cream cartons) • nodal ac,vity is dependent on Ca channels • prolong depol stage phase 4 in SA pacemaker node (piano keys) • decrease atrioventricular conduc1on (disconnected heart sign) • treat SVT arrhythmias ○ IV beta blockers can be used for SVT (ivy on sign) treats Afib and fluSer (tv screen) • controls ventricular rate (metronome) side effects • heart block (heart shield hat) ○ looks like prolonged PR interval on ECG (PR guy)

Class 3 An1arrhythmics

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• • • • •



Amiodarone, Ibu1lide, Dofe1lide and Sotalol (AIDS) blocks K channel to prolong phase 2 (Ca) and 3 (K) Amiodarone (amigos) shares proper1es of classes 1, 2, 3, and 4 (Spanish numbers on wall) • side effects ○ neurologic effects- tremor, periph neuropathy, sleep disturbance (brain on hats) ○ gray corneal microdeposits (gray sunglasses) ○ hypo or hyperthyroidism (small and large bow1es) ○ pulmonary fibrosis causing restric1ve lung disease (lung s1tching on suit) ○ heart block (heart shield hat) ○ HF (HF balloons) ○ hypersensi1vity hepa11s (liver shape spot on cow) ○ gray-blue skin discolora1on (gray suits) ○ photoderma11s (photographer) ○ CYP450 inhibitor -1lide suffix ("1ll I die") • dofe1lide and ibu1lide Sotalol (soda boSles) • has proper1es of class 3 and class 2 (beta blockers) treat SVT and ventricular arrhythmias (heart shaped lights) treat Afib and fluSer (tv screen) • restore and maintain sinus rhythm (remote) side effects • widened QT with Torsades (twisted streamer)

Class 4 An1arrhythmics

• • • • • • •



ND CCBs- Dil1azam and Verapamil (quartet) rate control at SA/AV node (music notes) block L-type Ca channels • has effect on SA/AV node AP (piano keys) decrease conduc1on from atria to ventricles (disconnected heart sign) treat SVT arrhythmias (lit atria) treat Afib and fluSer (tv screen) • first goal is to control rate with CCBs (metronome) prolong PR interval (PR guy) side effects • heart block (heart shield hat)

Class 5 An1arrhythmics



• General • these drugs don't fit into the other classes

• • •

•

Digoxin, Adenosine, Magnesium (DJ Foxglove, Digoxin directly s1mulates vagus nerve to inhibit AV node ac1on (Vegas metronome) • treats Afib and fluSer (tv screen) through rate control Magnesium (magnet guy) • treats torsades (torn streamers) Hyper/hypokalemia can induce arrhythmia (yellow dancers) • hyperkalemia has peaked T waves (ECG streamer) • hypokalemia has U wave at the end of T wave (ECG streamer) Adenosine (center stage music note) • a purine nucleo1de • ac1vates inhibitory A1 receptors on myocardium and SA/AV nodes (A1 sign) ○ increases outward K current (banana flying high) ○ suppresses inward Ca current (ice cream on the floor) ○ decreases AV conduc1on with prolong refractory period (music notes on stage) ○ decreases atrioventricular conduc1on (disconnected heart sign) ○ treats SVT arrhythmias • short half life • coronary dila1on (red crown) • side effects ○ heartblock (heart shield hat) ○ flushing ○ SOB ○ chest pain ○ sense of impending doom ○ hypotension • effects are inhibited by caffeine and theophylline (xanthine drink guy)

Blood + Inflamm

An1coag (Heparin)



• General • Normal ○ fibrinogen is cleaved to fibrin by thrombin to form a clot (beaver making a dam) ○ thrombin is called factor II (beaver with II shaped teeth) ○ prothrombin is converted to thrombin and ac1vated by factor Xa (fox) • • • • • • • •

• • • • • • • • • •

Unfrac1onated Heparin (hunter) indirectly inhibits thrombin and factor Xa by bind to an1thrombin complex 3 (cage with 3 bars) • it irreversibly inac1vates thrombin and factor Xa PTT levels are monitored to assess heparin level (woodpecker being watched) prevents clot forma1on, does not lyse clots used in acute treatment for DVT and PE (bird in pulmonary tree) • DVT is common in illiac, femoral and popliteal veins (illeofemoral river sign) used in acute MI (broken string guitar) administered IV in acute sesngs useful in prophylaxis during pregnancy, LMWH is preferred side effects • bleeding • heparin induced thrombocytopenia (hunter shoo1ng clay plates) ○ an1bodies against heparin bound to platelet factor 4 ○ results in paradoxical thrombosis • hyperkalemia due to hypoaldosteronism (depleted mineral mine) • osteoporosis (weak tree branch) reversed with protamine sulfate (protected area sign) LMWH -parin suffix same MOA as heparin (an1thrombin 3 cage) except it only inhibits factor Xa, not thrombin same uses as Heparin protamine is not as effec1ve in reversal longer half life (long white flag) does not require rou1ne monitoring, based on pt weight eliminated renally • renal insufficiency can prolong half life (kidney shaped rock) useful in prophylaxis during pregnancy, LMWH is preferred (pregnant mom) less likely to induce HIT (girl missing clay plates)







Fondaparinux (Fido dog) • not affected by protamine sulfate

• similar MOA to LMWH except it binds to an1thrombin 3 with higher specificity (2 an1thrombin 3 cages) • same uses as Heparin and LMWH • lowest risk of HIT (dog cannot pick up gun) Direct Thrombin Inhibitor (no intrudin sign) • -rudin suffix (no intrudin sign) • Bivalrudin • -gatr suffix (gators in water) • argatroban and dabigatran • used in HIT a^er cessa1on of Heparin • • • •

Direct Factor Xa Inhibitors (banned fox sign) -xaban suffix • rivaroxaban and apixaban directly inhibit factor x (guy grabbing fox) no need for monitoring oral administra1on • useful in long term an1coag in the sesng of Afib and fluSer (tv screen)

An1coag (Warfarin)



• General • blocks Vitamin K epoxide reductase ○ usually converts Vit K to its ac1ve form (medic) ○ factors 2, 7, 9, 10, C and S cannot work properly (diSCo started in 1972) • Vit K promotes gamma carboxyla1on of factors 2, 7, 9, 10, C and S (gamma shaped gauze) ○ factor 2 (thrombeaver guy) ○ factor 7 (seven deadly sins guy) ○ factor 9 (cat with nine lives guy) ○ factor 10 (fox guy) ○ protein C (corporal in background) ○ protein S (sergeant in background) • Vit K epoxide (inac1ve form) gets converted into Vit K (ac1ve form) by Vit K epoxide reductase (VKOR) in liver (medic grabbing supplies from VKOR boat) Warfarin • blocks Vitamin K epoxide reductase (warhead destroys VKOR ship) ○ usually converts Vit K to its ac1ve form (medic) ○ factors 2, 7, 9, 10, C and S cannot work properly (diSCo started in 1972) ○ causes no new closng factors to be produced • is not immediate, delayed because remaining closng factors must be cleared from circula1on (delayed warhead detona1on) ○ factor 7 is first to be reduced (factor 7 soldier being patched up first) ○ cause of increased PT • oral administra1on (jelly bean guy) • long half life (long white flag) • narrow therapeu1c range ○ PT must be monitored (ParaTrooper) ○ INR is also used to measure (INtercom Radio) ○ normal is 1, goal in therapy is 2-3 • used for long term coag in Afib (ship tv screen) • treatment/prophylaxis of DVT (ileofemoral river sign) ○ Acute DVT needs heparin first ○ used for around 6 months a^er DVT side effects • ○ teratogenic (turantula) ○ hypercoagulable state (troops charging past corporal) ○ protein C is reduced early which has an1thrombin effects causing increased coagula1on ○ leads to skin necrosis (black soot on corporal) § increased risk in pts with protein C deficiency ○ coadministra1on with heparin early prevents hypercoag state (heparin bridge) • an1coag can be reversed ○ Vit K but it is a delayed effect (vit k boat in the distance) ○ fresh frozen plasma for immediate effect (FFP fighter pilot) by replenishing factors • metabolized by CYP450 (chrome tank) ○ drugs that inhibit or s1mulate CYP450 change the effects of warfarin

An1platelet Agents



• General • damage to endothelium exposes collagen and vWf to s1mulate platelet forma1on (damaged vW sign) ○ platelet adheres to vWf by GpIb (GPIb on bat) ○ ac1vated platelet ready to degranulate (home plate) § degranula1on releases ADP, 5-HT, and TXA2 § ADP binds to P2-Y12 receptor on platelet causing aggrega1on (aggregate players sign) § 5-HT (serotonin) causes platelet aggrega1on and vasoconstric1on (smiley helmet) § TXA2 causes aggrega1on and ac1va1on (A2 baSers box) □ causes vasoconstric1on (twisted red hat) □ synthesized by COX (coach COX) □ COX synthesizes prostaglandins and TXA2 COX-1 (head coach) always ac1ve COX-2 is not always ac1ve (asst coach) induced by inflamm □ synthesized from arachdonic acid (AA minor league kid) Aspirin (ASA) (referee) • irreversibly acetylates COX-1 and 2 preven1ng TXA2 synthesis (ref yelling at coach with whistle) • TXA2 does not get synthesized un1l new platelets are formed • reduces cardiovascular events in pts with peripheral artery disease (greasy pipe) • reduces angina in these pts • use in MI (broken string guitar) • prevents ischemic stroke (black paint on hat) • pseudo-allergy • due to leukotriene synthesis • use ADP receptor inhibitor instead • dual therapy (ASA and ADPRI) prevent coronary stent thrombosis (corked bat) • • • • • • •

ADP Receptor Inhibitor -grel suffic • 1clopidine, clopidogrel, prasugrel (dog grill guy) irreversibly block ADP receptors reduces cardiovascular events in pts with peripheral artery disease (greasy pipe) • reduces angina in these pts use in MI (broken string guitar) dual therapy (ASA and ADPRI) prevent coronary stent thrombosis (corked bat) prevents ischemic stroke (black paint on hat) 1clopidine (Ty Cobb shirt guy) • causes neutropenia







• • • •

Glycoprotein IIb/IIIa inhibitors (french fry guys) usually GP IIb/IIIa binds fibrinogen to cause platelet aggrega1on abciximab (ABC sports guys) • monoclonal IgG an1body binds GPIIb/IIIa receptor (guy blocking people catching fibrinogen fries) ep1fiba1de and 1rofiban ("1ed" sign) • short half life side effects • thrombocytopenia (broken plates) ○ increased bleeding 1me (ketchup on clock) § assesses platelet func1on

Phosphodiesterase Inhibitors (dont phoster disinterest guy) • dipyridamole (2 pyramid tent) and cilostazol (lost the ball in the sun kid) • increases cAMP (camp sign) • impairs platelet func1on and aggrega1on • cilostazol • arterial vasodila1on • treats claudica1on (mud clods) • coronary artery dila1on (crown design hat) • can cause coronary steal

Thromboly1cs



• General • usually factor II cleaves fibrinogen to fibrin to create a mesh crea1ng a platelet plug (s1cks) • goal is to break down fibrin mesh • prolong PTT (long PT soldier) • prolong PT (paratrooper) • d-dimer is a fibrin degrada1on product formed from clot lysis (d-shaped twigs) ○ measured to show if there is excessive lysis like in DIC • useful in ischemic stroke (painter with black hat) ○ useful in 3-4.5 hours a^er onset (pain1ng session sign) • IV fibrinoly1cs can be used in treatment of DVT or PE (bird nest in lung branch) • used in acute management of MI (broken string guitar) • side effects ○ increased risk of bleeding (painter with red paint hat) ○ contraindicated in pts with recent head trauma (plasma beam) and intracranial surgery (bloody scalpel) ○ contraindicated in sever HTN (high pressure tube) and cerebral hemorrhage (white area on CT) • reverse with amino caproic acid (teacher with cap) or tranexamic acid to reverse tPA (exams) • FFP or cryoprecipitate to reverse coag factor deficiencies (fighter pilot and cryopack) Tissue Plasminogen Ac1vators (toy playset) • -teplase suffix • alteplase, reteplase, tenecteplase • released from damaged endothelium to break down fibrin • cleaves plasminogen (general toy) to plasmin (laser buSon ac1va1on) which breaks down fibrin and thrombin Streptokinase (streptokinectors) • synthesized from streptococci (cocci chains) • cleaves plasminogen (general toy) to plasmin (laser buSon ac1va1on) which breaks down fibrin and thrombin • can cause allergic reac1on and anaphylaxis (choking kid)

Sta1ns



• General • the liver is the importer and exporter of lipoprotein transporters (liver shaped building) • normal lipid metabolism pathway ○ FFA and cholesterol (gold bars) are absorbed in small intes1ne (microvilli flags) ○ cholesterol is converted into cholesteryl ester (chest) and packaged into chylomicron (hot air balloon) § triglycerides take up most space in chylomicrons (trident guys) § chylomicrons all have Apolipoproteins (E flag) to help crea1on and metabolism of chylomicrons ○ chylomicrons deliver triglycerides to peripheral 1ssue that are broken down by lipoprotein lipase (light house) § once broken down they can be used for energy by heart and skel muscle (shells) or stored in adipose 1ssue (sea foam) ○ the chylomicron remnants then go to liver and get taken up by LDL receptor on liver and ApoE on chylomicron interac1on (Load-L flag) ○ cholesterol will then either be converted to bile acids or repackaged and sent into circula1on ○ cholesterol can also be synthesized in the liver by HMG CoA reductase (HMG crude ore reducer) § first intermediate is mevalonic acid (evaluator) ○ cholesterol is then packaged into "chests" and put on VLDL transport § ApoB-100 is found on bad cholesterol, LDL and VLDL (B anchor) ○ VLDL delivers triglycerides to peripheral 1ssue to be broken down by LPL ○ once VLDL loses triglycerides it becomes LDL with a cholesteryl ester rich core ○ LDL delivers cholesterol to peripheral 1ssues ○ LDL is then taken up into liver by ApoB100 on LDL receptor ○ HDL are mostly protein. HDL scavenges cholesterol from peripheral 1ssues (scuba collector) and converted to cholesteryl ester by LCAT ○ LCAT delivers cholesterol to liver through cholesterol transferase on LDL (chest transfer) and directly to the liver via scavenger 1 receptor (scavenger 1 name) Sta1ns halt HMG CoA reductase (knocking over can) increase LDL receptor expression leading to increased LDL clearing (pirate at LDL receptor) most effec1ve LDL lowering agent (sinking LDL ship) decreases triglycerides (falling triglyc guy) slight increase in HDL prevents future cardiac events (angel) only lipid lowering drug to reduce risk of atherosclero1c heart disease (red crown) useful in acute MI (broken s1ng guitar) reduced risk of cardiac events and mortality in: • diabetes (candy guy) • pts with peripheral artery disease (red pipe) • TIA or stroke pts (black stroke hat) • side effects • teratogenic • myopathy (chicken leg) with elevated CK • eleva1ons in LFT • metabolized by CYP-450 (CYP tank) • • • • • • • • •

Cholestyramine + Eze1mibe



• General • not first line agents • work by binding bile acids and dietary cholesterol in small intes1ne ○ causes increased LDL receptor expression, pulling more LDL from circula1on • Steps ○ the liver metabolizes cholesterol into bile acids (man giving gold bar) ○ bile acids are secreted from liver to gallbladder ○ the gallbladder makes water soluble bile acids (bile salts) ○ excre1on into duodenum ○ fat emulsion ○ 95% of bile acids are recycled back to liver (sweeping bars) • •

• • •

• • • •

Bile Acid Binding Resins (golden lobster) Cholestyramine, coles1pol, and colesevelam interrupt enterohepa1c recycling of bile acids (fallen bile acid sweeper)) • depletes liver cholesterol stores (empty chest) • causes liver to synthesize more bile acids • increases HMG CoA produc1on of cholesterol (ac1vated ore reducer) increases LDL receptor expression and uptake of LDL (3 guys pulling LDL ship) can be used with sta1ns side effects • increased serum triglycerides and VLDL (air ship with trident guys) • gall stones (seagull with stones) • GI upset with cons1pa1on and bloa1ng (blocked brown pipe) • fat malabsorp1on with decreased Vit KADE (DEcK-A sign) • decrease sta1n absorp1on (figh1ng pirate) Exe1mibe (golden eel) inhibits GI absorp1on of cholesterol (eel blocking gold bars) • leads to decreased cholesterol available to liver (empty chest) • leads to increased HMG CoA ac1vity to synthesize more cholesterol increases LDL receptor expression and uptake of LDL can be used to lower LDL further with sta1ns side effects • diarrhea (brown water) • elevated LFTs (guy with white flag)





PCSK9 Inhibitor (octopus man)

• • • • • •

evolocamab PCSK9 usually degrades LDL receptors inhibits the degrada1on of LDL receptors (removing "9" crabs) significantly lower LDL levels very new IgG an1bodies

Fibrates + Niacin



• General • LPL hydrolyzes triglycerides for use in peripheral 1ssue (lighthouse) • hypertriglyceridemia can lead to pancrea11s and atherosclerosis • Fish oil ○ high in omega 3 faSy acids (omega shaped tails) ○ lowers triglycerides by decreasing VLDL and ApoB produc1on (anchor and tridents) • • • • • •

• • • • • • •

Fibrates (jellyfish) Gemfibrozil and fenofibrate ac1vate PPAR-alpha receptor at liver and peripheral 1ssue to lower VLDL (newspaper) • upregulates LPL leading to increased hydrolysis of VLDL and triglycerides at peripheral 1ssues (jelly fish aSack ship with escaping trident guys) decreases secre1on of VLDLs from liver decreases LDL (sinking LDL ship) increases HDL (li^ed HDL ship) side effects • myopathies with sta1n pts (chicken leg) • cholesterol gall stones Niacin (loch ness) Vit B3 decreases VLDL/triglycerides increases HDL, most effec1ve agent (li^ed HDL ship) reduces triglycerides and secre1on of VLDL (VLDL ship in background) decreases LDL by lowering VLDL (sinking ship) feeling of warmth upon administra1on (furnace) side effects • flushing (red monster) by prostaglandins (pro slugger bat) ○ counteracted by NSAIDs (fire ex1nguishers) • high glucose (candy guy) • hyperuricemia (yellow yarn) • elevated LFTs (white flag)

NSAIDs



• General • arachidonic acid is converted to prostaglandins by COX ○ first step mediated by phospholipase A2 (play ball sign) • COX-1 is ac1vely expressed in a lot of cells ○ synthesizes thromboxane A2 (baSers box) causing vasoconstric1on (twisted hat) ○ synthesizes prostaglandins (slugger bat) that protect the GI • COX-2 is only ac1vated during inflamma1on (guy on fire) ○ expressed in endothelium and smooth muscle (dugout wall) ○ synthesizes PGI2 that vasodilates and prevents platelet aggrega1on (dilated baseball shooter) § increase pain sensi1vity (other guy on fire) § increase vascular permeability (sprinkler) § induce fever (fire head guy) • COX-1 + 2 ○ synthesize prostaglandins that dilate the afferent arteriole to increase renal perfusion (purple team tunnel) • usually NSAIDs will reversibly inhibit both COX-1 and 2 promo1ng analgesia and an1pyrexia (fire ex1nguisher kid) NSAIDs • inhibit COX-1 and 2 • diclofenac and ketorolac ("go blac sox) • indomethacin ("dont mess with the indigo sox) • used to close PDA • meloxicam and piroxicam (sox cam sign) • naproxen ("approximately") • side effects for COX-1 inhibi1on • gastric inflamma1on, erosion and ulcera1on (catcher on fire) • GI bleed (ketchup squirt) • prolonged bleeding 1me (blood on clock) • side effects on kidneys • increased blood pressure due to decreased COX ac1vity in kidney, decreasing sodium excre1on (exploding ex1nguisher) • acute inters11al nephri1s (knocked over ball containers) • afferent arteriole vasoconstric1on, decreased GFR causing renal papillary necrosis (sloughing off cleats) • decrease of renally cleared drugs ○ lithium toxicity (elevated lithium balloons) • aplas1c anemia, mostly indomethacin (bone balloon) • hyperkalemia (k-shaped boards) • hypoaldosteronism (mineral mine) Aspirin (ASA umpire) • irreversibly inhibits COX-1 and 2 • effects last un1l life1me of the platelet • acetylates COX-1 and 2 (whistle) • used in management of Kawasaki's disease (ATV) • side effects • Reye's syndrome- encephalopathy and hepatomegaly when given with a viral illness (confused kid) • metabolic acidosis (mudpiles) • 1nnitus • toxicity ○ ac1vated charcoal used to treat toxicity (charcoal face lines)

○ alkaliniza1on of serum and urine increases the renal excre1on of aspirin (hose) • contraindicated ○ pts at risk for acute kidney injury (cracked kidney glass) ○ prematurely closes ductus arteriosis in 3rd trimester (pregnant woman) COX-2 Specific Inhibitors (pusng out COX-2 coach fire) • celecoxib (celebra1ng catcher) • does not inhibit platelet aggrega1on, minimizing bleed risk • reduces GI ulcera1on and bleeding risk (normal GI padding) • side effects ○ blocks synthesis of prostacyclins increasing risk of ischemic cardiovascular disease (ice cubes) § normal TXA2 and decreased PGI2 leads to increased thrombus risk ○ sulfa drugs (sulfur eggs) • acetaminophen (icy-spray on coach) • has an1pyre1c and analgesic proper1es but not an1-inflammatory • side effects ○ toxic levels deplete glutathione in the liver (scared liver goat) ○ treat with ac1vated charcoal and n-acetlycysteine (charcoal face lines and sunflower seeds)

Gout Drugs



• General • uric acid is a product of nucleo1de metabolism • purine metabolism ○ hypoxanthine is converted to xanthine by xanthine oxidase (small kid with XO note) ○ xanthine is converted to uric acid by xanthine oxidase (big kid with XO note) ○ uric acid is then excreted by kidneys • 2 causes of gout ○ overproduc1on of uric acid ○ underexcre1on of uric acid (most pts) • acute gouty aSacks usually involve one joint, ac1vate release of prostaglandins and lysosomal enzymes, and ac1vate neutrophil chemotaxis to increase inflamma1on (priest with foot on fire) • calcium pyrophophate crystal deposi1on is pseudogout (lie tablet) ○ looks different on birefringence of synovial fluid § posi1ve, blue on birefringence and rhombus shaped • uric acid crystals can form in tumor lysis syndrome a^er cytotoxic chemotherapy (shaSered crab glass) ○ most common with treatment of lymphoma and ALL (white knights on glass) • Lesch-nyhan (needle in flesh kid) ○ causes hyperuricemia due to absence of HGPRT Drugs • Acute gout • NSAIDs are treatment for acute gout (ex1nguisher) • glucocor1coids can treat severe gout (moon facies) • colchicine treats acute gout (singing choir) ○ inhibits microtubule polymeriza1on and stops neutrophil chemotaxis (first responders blocked by choir) ○ can cause diarrhea (mud footsteps) • Chronic gout • allopurinol (pure nun) ○ inhibits xanthine oxidase reducing uric acid in body • febuxostat (stopped XO note in pocket) ○ inhibits xanthine oxidase • probenecid (sid the proba1on officer) ○ decrease reabsorp1on of uric acid in PCT (preven1ng the kid grabbing the yarn) ○ increases risk of renal stone forma1on, keep pt hydrated (mul1ple yarn balls) ○ prevents certain drugs from being excreted like penicillin (purple pencil) ○ sulfa drug • ASA ○ at high doses it acts like probenecid (preven1ng kid) ○ at low dose inhibits uric acid excre1on (kids playing catch) • peglo1case ○ converts uric acid into water soluble allantoin ("just in case" holy water table) ○ can cause hemolysis in G6PD deficiency (watermelon) ○ administered IV • side effects ○ inhibit breakdown of purine analogs like 6-MP and Azathioprine increasing the risk for toxicity (long purine beads) ○ skin reac1ons- TEN and Stevens-Johnson syndrome (red mask) ○ DRESS syndrome § eosinophilia with systemic symptoms

Smooth Muscle

Nitrates



• General • used for an1anginal therapy (angina anvil rock) • angina is due to ischemic occlusion of coronary vessels • prinzmetal angina is due to coronary vasospasm (anvil medal) •

• • •

• • • •

Nitrates nitrates are metabolized and release nitric oxide which increases cGMP in vascular smooth muscle (nitric oxide drill controlled by grump) ○ causes myosin light chain dephosphoryla1on preven1ng the interac1on with ac1n (cut p-lock off chain) ○ venous dila1on and increased capacitance (dilated blue pants) ○ decreased preload (preload tank) ○ decrease myocardial oxygen requirement (discarded O2 mask) used in chronic stable angina (angina anvil) given sublingual (folded shoe tongue) for acute symptoms given orally for long term treatment (dynamite in the cave) ○ isosorbide dinitrate (double nitro s1ck) ○ isosorbide mononitrate (single nitro s1ck) ○ requires larger doses used in acute coronary syndrome (broken string guitar) used in hypertensive emergency (shut off switch) acute treatment of pulmonary edema side effects ○ avoid in right sided MI (no right turn sign) ○ orthosta1c hypotension (fain1ng lady) ○ use with beta blocker to stop side effect (beta bugle guy) ○ reflex tachy (reflex heart hammer) ○ use with beta blocker to stop side effect (beta bugle guy) ○ throbbing headache and flushing (guy holding his head) ○ methemoglobinemia (rusty wheels) ○ a tolerance can be built up (tolerance sign) ○ nitrate free interval to stop tolerance ○ monday disease- workplace nitrate exposure, tolerance built through the week, no exposure on the weekend, headache and dizziness recur on monday (monday clock) ○ contraindicated in ○ sildenafil- a PDE5 inhibitor for erec1le dys., avoid nitrate for 24 hours before use ○ hypertrophic obstruc1ve cardiomyopathy (heart smoke stack) ○ some vasodila1on (red sleeves)

Triptans (Migraines)



• General • a migraine consists of headache, aura, nausea, and visual scotomas (face bell) ○ the pain is due to ac1va1on of trigeminal nerve afferents in the meninges (3 gems in hat) § trigeminal afferents release vasoac1ve pep1des like CGRP, substance P, neurokinin A which vasodilate meningeal vessels and lead to protein extravasa1on (dilated sleeves) causing inflam. • • •

• • •

•

Triptans (sumowrestler) used in acute treatment for migraine MOA is not understood agonists of 5-HT 1b/1d receptors (smiley face headband, finger leSers) • also ac1vates 5-HT 1b/1d on trigeminal preven1ng release of vasoac1ve pep1des (sumo pushing ref) • also ac1vates 5-HT in brain stem inhibi1ng pain pathways • cause vasoconstric1on of cerebral and meningeal vessels (red headband) used for acute treatment of cluster head with inhaled oxygen (lantern cluster) NSAIDs are acute treatment for migraine (ex1nguisher pusng out fire) migraine prophylaxis drugs • CCBs (ice cream machine) • beta blockers(muted beta bugle) • valproic acid (fes1val pro banner) • topiramate (kid with toupee) • tricyclic an1depressants (toupee kid on tricycle) side effects • coronary vasospasm (coronary crown) • contraindicated in pts with coronary artery disease and angina pts ○ known triggers of prinzmetal angina

Prostaglandins



• General • COX-1 and 2 produce prostaglandins (COX coaches) Prostaglandin E (extreme sports sec1on) • Alprostadil (dill skateboard) • PGE1 • vasodilator (red dilated hoodie) • keeps PDA open (open air duct system) ○ important in certain congenital heart defects ○ NSAIDs, indomethacin, close the PDA (guy with ex1nguisher) • used in erec1le dysfunc1on (erect pickle and slugger bat) • Misoprostol (kid swinging bat) • PGE1 • promotes mucus secre1on to protect gastric mucosa (GI body pads) • prevents NSAID-induced pep1c ulcer (hisng the ex1nguisher) by COX-1 inhibi1on • promotes uterine contrac1on to facilitate labor or terminate pregnancy (open uterus bag) • side effects ○ diarrhea (brown puddle by bathroom) • Dinoprostone (dino helmet kid) • PGE2 • promotes uterine contrac1on to facilitate labor or terminate pregnancy (open uterus bag) Prostaglandin F (foot wear sec1on) • Carboprost (box head kid) • PGF-2α • promotes uterine contrac1on to control post partum hemorrhage or terminate pregnancy (open uterus bag) • Latanoprost and Travoprost (LA tan and world traveler signs) • used to treat glaucoma by increasing aqueous humor oublow (leaking eyeball container) ○ can produce brown pigmenta1on (brown sunglasses) • • • •

• • • • •

Prostacyclin Agonists (procycler launcher) PGI2 analogues • iloprost, epoprostenol (iLow and ePro sesngs) vasodilator and platelet inhibitor (dilated barrel) used in treatment of pulmonary hypertension (tense tennis rackets) side effects (fainted woman) • flushing • headache • hypotension PDE-5 Inhibitors (fill sign) -fil suffix vasodila1on used in treatment of pulmonary hypertension (tense tennis rackets) inhibi1on of phosphodiesterase-mediated breakdown of cGMP (dont phoster sign and grump) • leads to smooth muscle relaxa1on used in erec1le dysfunc1on (erect baseball bat on sign)









• • • •

Endothelin Inhibitors (end of the line check) Bosentan (boss man stan) used in treatment of pulmonary hypertension (tense tennis rackets) vasodila1on (dilated red sleeves) side effects • associated with fatal hepatotoxicity (liver sweat spot) • hypotension (fainted woman)

An1histamines



• General • Histamine func1ons ○ gastric acid secre1on ○ neurotransmiSer ○ mediator or allergic inflam • histamine receptors are found in vascular endothelial cells, bronchial airways, and in brain • histamine is sequestered inside granules of mast cells (beehive) • H1 receptor is coupled to Gq protein (dandelion) ○ normal allergic responses are from H1 § increased nasal and bronchial mucus sec1on (dripping tree nose) § pain, pruri1s, ur1caria, and increased vascular permeability (dripping red sap) § bronchial constric1on (constricted lung branch) ○ func1ons as a neurotransmiSer to regulate sleep and arousal (brain tree) • H2 receptor is coupled to Gs protein (honeypot with 2 "S" handles) ○ mediate gastric secre1on from principal cells (leaking honey) • • • • • • • •

•

•

H1 Blockers (bee swaSer) treat allergies treat mo1on sickness (seasick fairy sailor) can cross BBB for CNS effects • cause drowsiness (guy asleep under brain tree) antagonize peripheral/central muscarinic receptors • pupillary dila1on, dry mouth, urinary reten1on, cons1pa1on, glaucoma exacerba1on, delirium (tea party) • suppresses extra pyramidal side effects of psych drugs (yellow cone) s1mulate appe1te and weight gain (fat fainted fairy) antagonize serotonin receptors in CNS (smiley face cake) antagonize alpha-1 receptors (ex1nguished alpha-1 candle) 1st gen H1 blockers • diphenhydramine and dimenhydrinate (dragonfly fairy) • chlorpheniramine (colorful fairy) • hydroxyzine, meclizine, promethazine (fairy cuiSINE sign) side effects • dizziness (fat fainted fairy) • hypotension (fat fainted fairy) • cogni1ve impairment in elderly (crazy old man) 2nd gen H1 blockers • fexofenadine, ce1rizine, lora1dine (fox, satyr, and rat) • do no cross BBB ○ less seda1ng • less an1muscarinic, an1serotonergic, and an1-alpha 1 proper1es

Asthma Drugs



• General • pts must slowly increase dosage or # of medica1ons un1l control is achieved • allergic asthma is mediated by IgE in response to foreign substances ○ IgE then binds to mast cells so that when rexposed to allergen, mast cells will degranulate • • • •

Short Ac1ng Beta-2 Agonists (beta 2 tuba players) treats bronchoconstric1on in asthma -rol suffix drugs (roll call sheet) terbutaline (do not disturb sign) albuterol given as metered dose inhaler for acute symptom relief

Cor1costeroids (moon face balloon) • given if severe asthma • added as daily maintenance for persistent symptoms • inhibit inflamma1on and cellular infiltra1on (moon blocking the inflammatory sun balloon) • can cause oropharyngeal candidiasis (canadian flag and snow cone tongue) • gargle and spit a^er inhala1on to prevent Leukotriene Inhibitor (truck) • arachidonic acid is the precursor to leukotrienes (AA lacrosse league) • lipoxygenase converts AA into leukotrienes (coach LOX) • inhibi1on of COX pathways through NSAIDs shi^s to LOX pathway, exacerba1ng asthma (ASA umpire w/ coach COX) • main inflammatory subtypes are LTB4, LTC4, LTD4, LTE4 • LTB4 is a chemoaSractant for inflammatory cells like neutrophils (neutro first responders) • LTC4, D4, E4 increase vascular permeability, mucus prod, and bronchoconstric1on (constricted lacrosse s1ck) • LTD4 is most potent and it acts on CysLT1 receptor (lacrosse net) • Montelukast and other -lukast drugs block CysLT1 receptor (monte the broadcaster) ○ bronchodila1on (dilated scarf) ○ administered orally (popping pill) • Zileuton directly inhibits LOX (godzilla falling on coach LOX) • used for mild persistent asthma • risk of hepatotoxicity (liver spot on godzilla) • • • • • • • • • •

Long Ac1ng Beta-2 Agonists (second beta tuba band) salmeterol and formoterol (salute forma1on) used in severe persistent asthma long half-life (long white flag) increase dosage of cor1costeroid if persistent (higher moon face balloon) Methylxanthine (large caffeine drink) theophylline are used as alterna1ve therapy ("youll be flyin") inhibits phophodiesterase-mediated breakdown of cAMP (camping store) administered orally (guy drinking) narrow therapeu1c index metabolized by CYP-450 (chrome bumper) side effects • CNS effects like nervousness and tremor (shaking guy) • tachycardia

• • • • •

Omalizumab (limosine) monocloncal an1body directed against Fc por1on of IgE blocks IgE-mediated mast cell ac1va1on/degranula1on (guy grabbing gun) used as adjunc1ve therapy for moderate or severe persistent asthma used in pts with allergic sensi1za1on used in pts with resistance to steroids and beta agonists

Chromolyn Sodium (lynn's bee control) • inhibits mast cell degranula1on (seda1ng bee spray)

• • • •

Acute Severe Asthma Exacerba1on (flying band guy) inhaled short ac1ng beta-2 agonist IV or oral systemic glucocor1coids ipratropium bromide (blue caterpillar) epinephrine ("epic!" sign)

GI

An1eme1cs



• General • the nucleus tractus solitarius located in the medulla receives inputs from the GI tract, ves1bular system, and area postrema (NTS track) • the stomach directly communicates with the NTS via vagus nerve s1mula1on (Vegas sign at stomach area) • GI irrita1on from infec1on, chemo, or disten1on leads to mucosal serotonin release (smiley face ball) ○ serotonin ac1vates 5HT-3 receptors on vagus nerve (1-2-3 sign) • the ves1bular system communicates to NTS directly via CN 8 (semicircular canal sign) ○ the ves1bular system is responsible for ver1go and mo1on sickness • area postrema is the chemoreceptor trigger zone adjacent to the NTS and reacts to chemo agents (extreme posture guy next to track) ○ contains D2 receptors (D-ring ropes) ○ contains neurokinin 1 receptors (plaNK1) which is bound by substance P (pee sign) § antagonized by Aprepitant Odansetron (dancing woman) • blocks 5HT-3 receptor on vagus nerve in GI tract (blocking the hammer toss) • treats chemo-induced or post-op vomi1ng • side effects • cons1pa1on (smiley face 1ghtening the runners gut) • headache and dizziness (smiley face hisng runners head) • prolong QT interval leading to torsades (twisted torsades ribbon) • serotonin syndrome- rigidity, tremor, hyperthermia, confusion (pile of smiley faces) ○ especially with concomitant SSRI therapy Histamine Blockers (bee swaSer) • the ves1bular system contains H1 receptors (dandelions next to river) • 1st gen H1 blockers treat mo1on/sea sickness • side effects • significant seda1on • an1muscarinic proper1es (remember tea party) due to M1 antagonism (M1 parking spot) • • • •

Metoclopramide (1ckling guy) antagonizes D2 receptors in the area postrema (1ckling D2 guy) treats chemo-induced vomi1ng has upper GI prokine1c effects. Useful in trea1ng delayed gastric emptying from post-op disorders (guy landing on stomach) side effects • contraindicated in small bowel obstruc1on (do not obstruct sign) • diarrhea (brown puddle) • drowsiness (sleeping judge) • depression (crying coach) • extra pyramidal effects like dystonia, akathisia, parkinsonian features (newspaper hat) • tardive dyskinesia in chronic use (tongue s1cking out) • neurolep1c malignant syndrome- fever, rigidity, mental status change (NMS on chicken) • elevated prolac1n levels (squir1ng milk) • QT prolonga1on leading to torsades (torsades streamer)

GERD Drugs



• General • parietal cells in gastric mucosa are responsible for acid secre1on ("pour-it-all" sign) ○ s1mulated by gastrin from G-cells (gas tank on puree pump) • acid is secreted from apical membrane of parietal by H/K ATPase pump (puree pump) ○ exchanges 1 K+ for 1 H+ into lumen (sidewalk) • factors that s1mulate acid secre1on ○ histamine ac1vates H2 receptors (honey pot with bees) and upregulates H/K ATPase § the histamine released is from enterochromaffin-like cells close to the parietal cells ("enter" sign) § gastrin s1mulates ECL cells to release histamine (gas tank on leaf blower) § gastrin is released from G-cells and ac1vated by pep1des (gas truck with gas cans) ○ direct s1m by acetylcholine release from vagus nerve (M3 motorcycle with s1cker) § also s1mulates G-cells to release gastrin via gastrin-releasing pep1de (GRP lever)

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• •

H2 Blockers (2 bee swaSers) -1dine suffix (1e dye guy) • Cime1dine, rani1dine, famo1dine, niza1dine inhibit acid secre1on from parietal cells good for nocturnal acid secre1on, but small effect on meal acid secre1on • mediated by vagus and gastrin treat GERD (gargling woman) treat gastric and duodenal ulcers (ulcerated sidewalk) side effects of cime1dine (1e dye kid with cement) • CYP-450 inhibitor (banged up CYP bumper) • gynecomas1a (pot lids on chest guy) • impotence (limp honey wand) • elevated prolac1n (squir1ng milk) Proton Pump Inhibitors (girl scout block puree pump) -prazole suffix ("prize") first line agents in GERD (gargling lady) first line agents in gastric and duodenal ulcers (ulcerated sidewalk) best treatment for Zollinger-Ellison syndrome (jumbo gas tank with crab) • ZE has gastrinoma which overac1vates ECL cells to release more histamine (more bees) and directly s1mulates parietal cell to release gastrin • blocks both histamine and direct parietal s1m pathways, H2 blockers only block H2 path treats H Pylori infec1on (helicopter hat) with triple therapy side effects • increased risk of C Difficile infec1on (chocolate fountain) • increased risk of respiratory infec1ons/pneumonia (dark lung spots) • decreases absorp1on of Ca, Mg, and Fe since they need an acidic environment (medals on wagon) ○ increases risk of osteoporo1c hip fractures in elderly because of low Ca (broken axel) ○ hypomagnesemia (falling magnets)





• • • •

Somatosta'n + Analogues (stop signs) inhibits the release of histamine from ECL cells inhibits the release of gastrin from G-cells inhibit gastrin from gastrinomas Octreo1de inhibits ECL cells (octagon stop sign)

Laxa1ve/An1diarrheals



• General • do not directly s1mulate GI movement (except s1mulant laxa1ves) • changes the consistency of GI material • VIPoma and carcinoid tumor can cause secretory diarrhea (crab sign) ○ reduce symptoms with octreo1de (stop sign) Osmo1c Laxa1ves (bubbling spa water) • Magnesium compounds (magnets) • magnesium hydroxide, magnesium citrate • s1mulates rapid movement of water into small bowel leading to high volume of stool with bowel evacua1on • Polyethylene glycol (peg drain cover) • used for complete colonic cleansing before GI endoscopy • Lactulose (relactulose) • non-absorbable sugar • severe gas and cramps • used in hepa1c encephalopathy (liver and brain in fish tank) ○ cirrhosis of the liver impairs its ability to convert ammonia/toxins ○ ammonia/toxins cross the BBB leading to altered mental status ○ gut flora degrade it into metabolites (lac1c acid and ace1c acid) that promote NH3 excre1on as NH4+ (NH4 valve) ○ also can use rifaximin to eradicate ammonia producing intes1nal bacteria (fisherman) • can cause diarrhea leading to dehydra1on (spilling mud) Bulk Forming Laxa1ves (bulky seaweed) • absorb water to distend colon and s1mulate peristalsis • leads to bloa1ng and gas Surfactant Agents • Docusate facilitates penetra1on of stool by water and lipids (water in canoe) • given orally or rectally S1mulant Laxa1ves • directly s1mulate enteric nervous system • leads to electrolyte and fluid secre1on MOA is not completely understood • • Senna (sun tan lo1on guy) • chronic use leads to brown pigmenta1on of colon called melanosis coli An1diarrheal Agents (muddy slippers) • used in pts with mild to moderate acute diarrhea • should not be used in pts with bloody diarrhea or fever (stool with inflam candles) • Opioid agonists (utopia μssage) • act on μ-opioid receptors in GI tract • Loperamide (lop-eared rabbit) ○ does not cross the BBB so no analgesia or addic1on poten1al) ○ increases colonic transit 1me causing increased water absorp1on • Diphenoxylate (dolphin statue ○ crosses the BBB, give with Atropine to prevent abuse ○ increases colonic transit 1me causing increased water absorp1on • can cause cons1pa1on (clogged bathroom sign)

Direct Diabetes Drugs



• General • insulin is the storage and anabolic hormone of the body ("inside" mat) • produced in the islets of langerhans beta cells of pancreas (beta tuba guy) • glucose is the most potent s1mulator of insulin release (candy in tuba guys hand) • hypoglycemia • tachycardia, palpita1ons, swea1ng, nausea • C-pep1de is a marker for endogenous insulin release 1) glucose enters circula1on, then beta cells--> increased ATP levels--> K+ channels close (closed sign) 2) K+ channels close, reducing K+ efflux--> beta cell depolariza1on--> voltage-gated Ca2+ channels open--> Ca2+ influx--> insulin secre1on (girl with ice cream flower) ○ while in beta cell secretory granules, proinsulin is cleaved into insulin and C-pep1de remnant (Candy wrapper) 3) insulin is released and diffuses into 1ssues, it binds to insulin receptor on target cells which contains an intracellular tyrosine kinase domain (tyrosine swing) 4) tyrosine ac1va1on leads to GLUT 4 inser1on into membrane (coSage 4 sign), allows for glucose transport into cells and s1mulates: a. liver- increased glycogen produc1on, decreased glycogen breakdown (liver candy jar) b. muscle- increased glycogen storage and protein synthesis (glazed ham) c. adipocytes- increased triglyceride storage (faSy donuts) 5) insulin decreases serum K+ driving it into cells (banana with a bite taken out)

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•

•

Type 1 DM Exogenous Insulin Prepera1ons exogenous insulin skips all steps before diffusion into 1ssues Rapid ac1ng, short dura1on "they do not LAG" • Lispro, Aspart, and Glulisine (girls and lads sign) • early onset and peak (tall, peaked tower) • used postprandial (nibbling birds) ○ closely mimics endogenous postprandial insulin Intermediate ac1ng (rest now sign) • Regular insulin, NPH insulin • delayed onset and peak (short house peak) • Regular insulin given IV (ivy) for DKA (candy key) ○ DKA- glucose will be locked out of cells ○ monitor K levels, can lead to hypokalemia Long ac1ng insulins (dont go sign) • Detemir and Glargine • long, steady basal level of insulin (flat roof) • used with short ac1ng insulins

Type 2 DM Sulfonylureas (swan with sulfa eggs) • bind the ATP-dependent K+ channels on beta cells • K+ channels close, reducing K+ efflux--> beta cell depolariza1on--> voltage-gated Ca2+ channels open--> Ca2+ influx--> insulin secre1on

• 1st gen • -amide suffix (maid oubit) • long dura1on • rarely used • disulfiram-like reac1on with alcohol inges1on (do not drink sign) 2nd gen (goslings riding swans back) • • -ride suffix • smaller doses, long ac1on (zig-zagging gosling) • risk of hypoglycemia (falling candies) • can cause weight gain (fat hag lady) Megli1nides (gliding goose) • -glinide suffix • bind the ATP-dependent K+ channels on beta cells • K+ channels close, reducing K+ efflux--> beta cell depolariza1on--> voltage-gated Ca2+ channels open--> Ca2+ influx--> insulin secre1on • not sulfa drugs • risk of hypoglycemia (falling candies) • can cause weight gain (fat hag lady) • • • • • • •

GLP-1 analogs (hag with laundry) -1de suffix (1de laundry detergent) increases endogenous GLP ("GLP" from hag) ac1vate GLP-1 receptor ("GLP" by tuba guy) to increase insulin release increased insulin release, decreased glucagon release ("GLP" from hag, empty glucagon packets) delayed gastric emptying, early sa1ety (sealed stomach-like container) do not cause hypoglycemia (candy in trees) side effects • increased risk of pacrea11s (pancreas sponge)

• • • • • •

DPP-4 inhibitors (4 dripping clothes) -glip1n suffix prevent breakdown of GLP-1, increasing endogenous GLP increased insulin release, decreased glucagon release ("GLP" from hag, empty glucagon packets) delayed gastric emptying, early sa1ety (sealed stomach-like container) do not cause hypoglycemia (candy in trees) side effects • increased risk of nasopharyngi1s and upper resp infec1ons (clothes pin on nose)

Indirect Diabetes Drugs



• General • agents used in treatment of DM2 • drugs require func1onal beta cells Mebormin (kneeling kid) • a biguanide • decreases hepa1c glucose produc1on • inhibits gluconeogenesis by blocking mitochon enzymes (biSen mitochondrial candy) • decreases intes1nal glucose absorp1on • increases peripheral glucose uptake/u1liza1on ("inside" mailbox) • increases insulin sensi1vity • ac1vates the enzyme AMP-ac1vated protein kinase (AMPKandy) ○ decreases liver gluconeogenesis (girl stopping candy release) • side effects • lac1c acidosis (spoiled milk) ○ renal insufficiency increases risk (kidney shaped tray) • nausea, diarrhea, vomi1ng, anorexia (nauseous girl) • weight reduc1on (skinny kid) • • • • • • •

• • • • • • •

Thiazolidinediones (gliSer) -glitazone suffix oral agents increase sensi1vity to insulin in peripheral 1ssue binds to PPAR-γ intranuclear receptor (circled PPAR on kids shirt) upregulates adiponec1n (turtle neck) to increase insulin sensi1vity • increases number of adipocytes (elevated donut jar) upregulates GLUT4 in peripheral 1ssue ("4" mailbox) side effects • weight gain by increased triglyceride storage (fat kid) • fluid reten1on and peripheral edema (baggy pants on fat kid) ○ can exacerbate HF (crushed HF balloon) • increase risk of fracture in women Amylin Analogues (Amy and Lynn) pramlin1de decreases glucagon (empty glucagon packets) decreased gastric emptying (stomach shaped water cooler) decreased appe1te used in DM 1 or 2 used for postprandial glucose spike (cupcake) side effect • hypoglycemia (falling candy) • GI side effects







Alpha-glucosidase Inhibitors (box in the corner) • Acarbose and miglitol ("A-carb" and "wigglers") • inhibit alpha-glucosidase enzymes in the brush border to decrease conversion of disaccharides into absorbable monosaccharides (brush border flags) • delays carbohydrate absorp1on (kid struggling with bag) • used in postprandial glucose spike (cupcake) • side effects • GI effects- gas and diarrhea

• • • •

SGLT-2 Inhibitors (flossing guy) -flozin suffix sodium-glucose transporter 2 reabsorbs glucose in PCT (salty glucose snack, pro cart track poster) • inhibi1on leads to glucosuria usually added to exis1ng diabe1c drug regimen side effects • UTI (bladder cup) due to increased glucose in urine • vaginal candida infec1on (snow crotch) • hypotension (fain1ng kid) • contraindicated in renal insufficiency pts (cracked kidney tray)

Endocrine

Bone Drugs



• General • useful in the treatment of osteoporosis by inhibi1ng bone resorp1on (fresh chalk piece) ○ only prevents bone loss • osteoblasts promote new bone growth (osteo builders) • osteoclasts reabsorb bone (destruc1ve kids) • estrogen therapy can prevent postmenopausal osteoporosis, has increased risk of breast cancer (cavewoman) • PTH (PthD guy) ○ regulates calcium and phosphate homeostasis ○ s1mulates osteoblasts to express RANKL (crank-drill) ○ binds to RANK on osteoclast, increasing its ac1vity • • • • • • • • • •

Bisphosphonates (donate box) -dronate suffix first line of osteoporosis similar chemical structure to pyrophosphate (2 "p" coins next to each other) aSach to hydroxyapa1te in bone (large t-rex appe1te) • osteoclasts then bind to bisphosphonates inhibi1ng their adherence to bone (kid with arm stuck in box) decreases development/recruitment of osteoclast precursors (2-p coin mom stopping kids from entering) induce osteoclast apoptosis (popping dino balloon) stabilizes or mildly increases bone mineral density useful in treatment of hypercalcemia (elevated ice cream) • common in malignancy, treat with Bisphosph and calcitonin (calcified rock with crabs) useful in management of Paget disease which is uncontrolled osteoclast resorp1on with disorganized bone forma1on (homo pagets) side effects • esophagi1s (corroded neck) if taken orally • osteonecrosis of jaw (crumbling jaw) • hypocalcemia (fallen ice cream cup)

Selec1ve Estrogen Receptor Modulator • Raloxifene (relax sign) • useful in treatment/preven1on of postmenopausal osteoporosis • has estrogen agonist ac1vity in bone, but antagonist ac1vity in breast and uterus • decreased risk of breast cancer compared to estrogen therapy Denosumab (dino suit man with spikes) • monoclonal an1body against RANKL on osteoclasts (dino guy grabbing crank-drill) • useful in treatment for postmenopausal osteoporosis Calcitonin (curator) decreases bone resorp1on (curator grabbing destruc1ve kid) useful in treatment of osteoporosis promotes calcium excre1on from kidney (ice cream pouring down leg) useful in treatment of severe hypercalcemia with bisphosphonates (giant calcified bone rock with crabs) useful in management of Paget disease which is uncontrolled osteoclast resorp1on with disorganized bone forma1on (homo pagets) • side effect • hypocalcemia (fallen ice cream) • • • • •

Other Endocrine Drugs



• General • GH (somatotropin) (growth beans) ○ secreted from anterior pituitary (beans spilling out of front of sack) ○ associated with the JAK tyrosine kinase pathway (tyrosine 1re swing) ○ promotes insulin-like growth factor 1 (inside mat) responsible for long bone growth (vine li^ing mat) § s1mulated from the liver (liver rock) ○ anabolic effects in skeletal muscle (skeletal muscle leaf) ○ catabolic effects in adipose 1ssue (falling donut jar) ○ GH therapy useful in GH deficiency and idiopathic short stature (short kid) ○ useful in Prader-Willi syndrome to increase growth (father willi) ○ useful in Turner syndrome (tumbling "X" girl) ○ GH secre1ng pituitary adenoma causes § adults- acromegaly § children- gigan1sm Mecasermin (sermon sign) • recombinant form of IGF • treats growth failure due to severe IGF-1 deficiency • can cause hypoglycemia (falling candy) Octreo1de (octagon stop sign) treats acromegaly and gigan1sm by GH secre1on inhibi1on somatosta1n analogue treats VIPoma and carcinoid tumor (VIP crab sign) treats insulinoma (big inside mat) treats glucagonoma (giant glucagon packet) treats gastrinoma (giant gas tank) controls bleeding of esophageal varices (exposed variceal pipes) • treats esophageal varices arise by decreasing hepa1c blood flow and variceal pressure • side effects • nausea, vomi1ng, abd cramps, and steathorrhea (nauseous woman on yellow stool) • • • • • • •

D2 Receptor Agonists (2 dopamine ropes) • Cabergoline and Bromocrip1ne (burglar with broom) • inhibits prolac1n, treats prolac1noma • inhibits secre1on of GH from pituitary • • • •

GH Receptor Antagonist Pegvisomant (ants on 1re swing) treats acromegaly inhibits interac1on with receptor can lead to pituitary adenoma size increase

Glucocor1coids



• General • cor1sol, an endogenous glucocor1coid, is released from adrenal cortex (adrenal hat) Glucocor1coids (moon face) • -sone suffix • glucocor1coid receptors in cytoplasm, then enters nucleus (ac1vated scepter in inner circle) • inhibit phospholipase A2 which is first step in AA inflam pathway (cataPuLt A2) • prevents produc1on of inflammatory prostaglandins by COX (pro slugger bat) • prevents produc1on of inflammatory leukotrienes by LOX (lacrosse s1ck) • inhibit NF-KB from synthesizing proinflammatory cytokines (N-Flame Krossbow) • prevents ac1va1on of T and B cells • prevents produc1on of neutrophil adhesion molecules leading to decreased margina1on/migra1on (block first responders) • reduce T and B cell counts (falling knights and archers) • reduce eosinophil count (falling slingshot guy) • useful in treatment of inflammatory disorders (elipsed inflammatory sun) • like gout, RA, asthma, and IBD • useful in immunosuppressive therapy for transplant rejec1on preven1on and autoimmune disorders (cracked an1bodies on stone) • cause insulin resistance (locked out inside mat) leading to hyperglycemia (elevated candy jar) • s1mulate gluconeogenesis (liver bag producing candy) • increase glycogen storage (liver shaped candy storage jar) • very important in adrenal insufficiency due to Addison's disease (cracked moon face) • body does not produce enough glucocor1coids • adrenal crisis ○ leads to circulatory shock and death (fainted guy) ○ hypoglycemia when a lot of exogenous cor1costeroids are administered (falling candy) ○ happens when chronic steroid pts abruptly stop taking them § long term glucocor1coids nega1vely feeds back on the pituitary to suppress ACTH release, adrenal cor1cal atrophy (shriveled adrenal hat) • side effects • proteolysis at skeletal muscles (falling ham) • lipolysis at adipose 1ssue (falling donuts) • long term use leads to Cushing's syndrome (cushion under statue) ○ moon facies, central adiposity, muscle weakness, skin thinning, imunosuppression (statue body) • decreased bone mass leading to osteoporosis and fractures (broken chair leg) • psychosis- hypomania, confusion, hallucina1ons (cracked statue head) • hypokalemia due to mineralocor1coid effects (empty banana peel) • immunosuppression (statue cane) ○ can lead to reac1va1on of latent infec1ons like TB (TB cac1)

Pituitary Drugs



• General • ADH and Oxytocin are made in the hypothalamus but stored/secreted from the posterior pituitary (posterior water boy back pack) • Diabetes Insipidus (peeing fountain) ○ Nephrogenic DI (dry kidney sand trap) § ADH is released from pituitary but cannot act on collec1ng duct due to pharmacological receptor blockade or hereditary receptor muta1on (golfer ignoring water boy) § Lithium is a common cause of drug induced nephrogenic DI (lithium balloon guy) § treat nephrogenic DI with thiazides (speedo kid), amiloride (almond cart guy), or NSAIDs (ex1nguisher) □ monitor Lithium levels ○ Central DI (dry brain sand trap) § pituitary does not release adequate amounts of ADH (no water boy to give golfer water) § treat with exogenous ADH administra1on (water boy entering from outside sand trap) § treat with Desmopressin Acetate (DDAVP) a long ac1ng synthe1c analogue of ADH (desert mobile) Syndrome of Inappropriate An1diure1c Hormone (SIADH, inappropriate water hazard) • ○ caused by overproduc1on of ADH (over-hydra1ng water boy) ADH (water boys) • works on the collec1ng duct (collec1ng duct sign) • secreted with decreased plasma tonicity or decreased BP • 2 pathways ○ ac1vates V1 receptors coupled to Gq to increase intracellular Ca2+ (V1 hole with "Q" shape) § V1 is found on vascular smooth muscle causing vasoconstric1on and increased BP (constricted golf club) ○ ac1vates V2 receptors couples to Gs to increase cAMP (V2 hole with "S" grass path) § V2 is found on basolateral membrane of collec1ng duct, causes aquaporins to translocate to apical membrane and reabsorb free water (V2 green is next to collec1ng duct, water boy giving woman water boSle) § V2 also found on vascular endothelium to cause release of vWF and factor 8 (endothelial 1les, Von Willi pool table, 8 ball) • • • • • •

Desmopressin Acetate (DDAVP, desert mobile truck) long ac1ng synthe1c analogue of ADH acts at V2 only (V2 engine), meaning no pressor ac1vity treats von Willibrand disease by increasing release of vWF from vascular endothelium (scratched pool table) • vWD pts will present with increased bruisability and mucosal bleeding (bruised bleeding guy) treats Hemophilia A by increasing factor 8 release (8 ball hisng bleeding guy) • HA presents with hemarthrosis and prolonged bleeding, X-linked treats nocturnal enuresis (wet maSress) can cause hyponatremia (falling salty peanuts)

Exogenous ADH (water boy on truck) • useful in management of esophageal variceal bleeding (bulging blue golf club bag) • constricts mesenteric arterioles leading to reduced portal pressure



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V2 ADH Receptor Antagonists -vaptan suffix (vaporizer water gun) used to treat SIADH promote free water excre1on blocking aquaporin transloca1on (wet pants) • corrects hyponatremia ○ can cause hypernatremia and Central Pon1ne Myelinolysis (elevated peanuts hisng head) due to overly rapid correc1on of hyponatremia can also use Demeclocycline (bicycle) • tetracycline • ADH antagonist

Neuro + Psych

Benzodiazepines



Benzodiazepines (ben's diner) • -pam suffix ("best PAM-cakes" sign) • short ac1ng agents • Oxazepam (fast ox) is short ac1ng • -olam suffix of short ac1ng benzos ("all A.M." sign) • Alprazolam, Triazolam, Oxazepam, Midazolam (ATOM) • poten1al to cause addic1on • metabolized by liver (liver spot) • long ac1ng agents form metabolites to prolong their effects ○ pts with liver dysfunc1on will have more seda1ng effects • bind to allosteric site on GABA-A receptor (Cab-A) • benzos enhance GABA-A transmission in CNS (CNS light) • a chloride channel ("chlor-rider" sign) • a major inhibitory neurotransmiSer in CNS ("take it easy") • alcohol binds to separate allosteric site (alcoholic guy) and enhances inhibitory GABA ac1on • barbiturates bind to a separate allosteric site (barbershop) • increases frequency of Cl- channel opening ("open more frequently" sign) • since alcohol and benzos work on GABA-A, they increase dependence of one another leading to necessity of larger doses for same effects ("all are welcome" tolerance sign) • alcohol withdrawals • leads to CNS excita1on • treated with benzos (hangover special menu) ○ long ac1ng agents (long tapered flag) to smooth withdrawal symptoms ○ use short agents in pts with liver dysfunc1on • 8-12 hours: insomnia, tremulousness, anxiety, diaphoresis (brown shirt guy) • 12-48 hours: seizures (seizure guy) ○ IV benzos are useful in seizure treatment (ivy next to shaking worker) • 48-96: delirium tremens (fever, disorienta1on, severe agita1on) (agitated guy) • useful for: • status epilep1cus (guy unplugging seizure jackhammer) • general anesthesia (sedated customer) ○ can induce conscious seda1on for minor procedures ("lite" drink) • insomnia, not first line (sleeping customer) • sleepwalking and night terrors (crying pajama kid) • spas1city due to MS, stroke, spinal trauma, tetanus (reclining guy) • generalized anxiety, not first line (anxious guy) • panic disorder, not first line (The Scream pain1ng) • same withdrawals as alcohol • causes anterograde amnesia (? mark on hat), useful for uncomfortable procedures like colonoscopy • elderly pts are more sensi1ve to benzo side effects (disoriented old man) • causes central ataxia/loss of balance, causes falls in elderly (wobbly pancake stack) • avoid use with other CNS depressants- barbiturates, alcohol, neurolep1cs, or 1st gen an1histamine (bee) • reverse seda1on effects with Flumazenil, a compe11ve benzo receptor antagonist (fluffy muzzled dog) • can precipitate benzo withdrawal seizures in pts with a tolerance

Non-Benzo Hypno1cs

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Non-Benzodiazepine Hypno1cs 3 Z's • Zolpidem, Zaleplon, Eszopiclone (ZZZ sign) similar MOA to benzos • bind to allosteric site of GABA-A (Cab-A) ○ a chloride channel ("chlor-rider" sign) ○ a major inhibitory neurotransmiSer in CNS ("take it easy") ○ CNS depression (CNS light) • binds to the same allosteric GABA-A site as benzos (guys grabbing same car door) • alcohol binds to separate allosteric site (alcoholic guy) and enhances inhibitory GABA ac1on • barbiturates bind to separate allosteric GABA-A site (barber shop) rapid onset of ac1on ("fall asleep fast" sign) short dura1on of ac1on (quick jump and fall over fence) metabolized by liver (liver spot on sheep) used in insomnia pts that have trouble falling asleep ("fall asleep" sign) • eszopiclone has longest half life and can be used in falling asleep and sleep maintenance less likely to cause tolerance than benzos ("returns not tolerated") less likely to cause withdrawal symptoms and dependence ("break those sleeping habits") side effects • similar to benzos with decreased severity • elderly are most sensi1ve • cogni1ve impairment and delirium • balance problems leading to falls (wobbly stack) • avoid use with other CNS depressants- barbiturates, alcohol, neurolep1cs, or 1st gen an1histamine ("cannot combine coupons", bee swaSer) reverse seda1on effects with Flumazenil, a compe11ve benzo receptor antagonist (fluffy muzzled dog) • can precipitate withdrawal seizures

Melatonin (melt away) • Ramelteon is a melatonin receptor agonist • has few side effects, safe to use in elderly (sleep old man) • used in maintenance of circadian rhythm (ceiling fan lights) • MT1 and 2 melatonin receptors are located in the suprachiasma1c nucleus of hypothalamus (base of fan above "x" shaped blades)

Barbiturates



Barbiturates (barber shop) • bind to GABA-A receptor (Cab-A) • a chloride channel ("chlor-rider" sign) • a major inhibitory neurotransmiSer in CNS ("take it easy", CNS light) • binds to different site than benzos and non-benzo hypno1cs (ben's dinner) • alcohol binds to separate allosteric site (alcoholic guy) and enhances inhibitory GABA ac1on • prolong the dura,on of Cl- channel opening ("long hours" sign) • as opposed to benzos which increase frequency • longer half lives than benzos (white tapered flag) • "hangover" effects are more common • longer seda1ng effects • except IV Thiopental which is short ac1ng, used for induc1on of anesthesia (ivy, "the ol" sign) ○ highly lipid soluble and crosses BBB quick ○ plasma levels of thiopental rapidly redistribute to skel muscle and adipose 1ssue (hair going from head to body, graph on shirt)

• IV Phenobarbital is used to treat seizures (IV, guy unplugging jackhammer) • not first line treatment due to respiratory depression • Primidone (perm is done girl) • used in seizure treatment • 1st line for essen1al tremor with propranolol (shaking guy) • CYP-450 inducer (chrome P450 bumper) • side effects • significant seda1ve effects • hypotension (fainted old woman) • cardiac and respiratory depression (heart and lungs shirt) • CNS depression, like coma (brain hair dryer) • avoid in elderly • long term use leads to tolerance ("all welcome" tolerant sign) • physical dependence with withdrawal symptoms ("addicted to curls" sign)

IV Anesthe1cs

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IV Anesthe1cs (ivy) Propofol (prospero the hypno1st) • used for induc1on ("introducing") and maintenance ("maintain") • lipophilic and accounts for rapid onset of ac1on • poten1ates Cl- current through the GABA-A receptor complex (Cab-A) • profound vaso/venodila1on leading to hypotension (dilated sleeves and pants) Etomidate (in1midator) • used for induc1on ("introducing") • poten1ates Cl- current through the GABA-A receptor complex (Cab-A) • preserves cardiovascular stability (stable pt being li^ed) ○ minimal changes to BP, HR, or cardiac output Ketamine (snaKE TAMINg nomad) • used for induc1on ("introduc1on") • works by inhibi1on of NMDA receptor complex (hitched NoMaDic cAmel) • dissocia1ve anesthesia- eyes remain open with slow nystagmic gaze (entranced man) • unpleasant emergence reac1ons- vivid colorful dreams, hallucina1ons, out of body experiences (vivid smoke) • causes cardiovascular s1mula1on- increased BP, HR, and cardiac output (heart shaped cobra) Benzos (Ben's diner) • Midazolam • used for conscious seda1on in minor procedures like colonoscopy (bowel shaped water pump) Barbiturates (barber shop) • used for induc1on ("introducing") • Thiopental ("Sweeny Pental") • highly lipid soluble, acts very rapidly and finishes quickly ("The ol' quick shave")

Inhaled Anesthe1cs



• General • inhaled anesthe1c proper1es ○ highly soluble anesthe1cs (fast kid in ball pit) § delayed satura1on, slower onset of ac1on (fast kid passes out later) § takes more anesthe1c to saturate blood § longer dura1on of ac1on (long tapered flag) ○ less soluble anesthe1cs (fat immediately saturated kid in ball pit) § saturate the blood very quickly, faster onset of ac1on § take less anesthe1c to saturate blood § faster recovery 1me (friend rescuing fat friend) • Blood:gas par11on coefficient = solubility ("par11on") ○ higher par11on means high solubility ○ lower par11on means lower solubility • arterial tension curve (graph on side of ball pit) ○ higher arterial tension = higher solubility ○ lower arterial tension = lower solubility

• Minimum Alveolar Concentra1on (mac and cheese) ○ the dose of anesthe1c that causes 50% of pts to become unresponsive to painful s1muli (1 unresponsive kid) ○ potency is inversely propor1onal to MAC (inverted mac and cheese bowl) § the lower the MAC, the more potent the drug § N20 has high MAC, low potency, low solubility § vola1le anesthe1cs have low MAC, high potency, high solubility



Inhaled Anesthe,cs • supplemental agents that deepen anesthesia a^er IV induc1on • Nitrous Oxide (kid inhaling balloon gas) • less soluble anesthe1c (fat immediately saturated kid in ball pit) • side effects ○ • Vola1le anesthe1cs • -ane suffix • Enflurane, Isoflurane, Halothane • highly soluble anesthe1c (fast kid in ball pit) • liquid at room temperature (air tank falling in pool) • these anesthe1cs are fluorinated (balloon flower) • myocardial depression (defla1ng heart balloon), decreased cardiac output and hypotension • respiratory depression (defla1ng lung balloons) • increase cerebral blood flow/decrease vascular resistance (red brain wig) • side effects ○ Halothane- hepatotoxicity with necrosis (cracked liver piñata) ○ Enflurane- nephrotoxicity and convulsions (guy gesng hit with bat, shaking piñata) ○ malignant hyperthermia (magnificent birthday sign) § hypersensi1vity to vola1le anesthe1cs or succinylcholine ("sucks" note) § related to defect in ryanodine receptors in sarcoplasmic re1culum (falling "ryan" sign) □ releases excess Ca2+ leading to heat produc1on (flame theme sign) leads to consump1on of ATP-induced muscle damage (biSen chicken) § presents with fever and muscle rigidity soon a^er surgery under anesthesia (flame birthday hat) § life threatening § treat with Dantrolene (trampoline) □ a muscle relaxant □ acts on ryanodine receptors to block Ca2+ release (adult blocking ryan)

Opiates



Opiates (utopia resort) • μ receptor is important one (μssage parlor) • analgesia, seda1on, cons1pa1on, respiratory depression) • opiate receptors open K+ channels (open banana barrel) • close voltage-gated Ca2+ channels (closed ice cream cooler) ○ inhibits at presynap1c channel to prevent neurotransmiSer release (disconnected presynapse wire) § blocks glutamate, acetylcholine, norepi, serotonin, substance P release • μ receptors are located in GI tract (colon table) • • • • •

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Pure μ Agonists Fentanyl ("fantasy" sign) Morphine ("more fun") Tramadol (tram car) • weak μ-opioid agonist • inhibits norepi and serotoniin reuptake (compass with N and S) used as an1diarrheals (muddy footprints) • loperamide and diphenoxylate do not cross BBB (lop-eared rabbit and dolphins • increase stool transit 1me used for pathologic cough suppression (coughing guy) • codeine, an opioid an1tussive (barcode) • dextromethorphan, an opioid an1tussive (orphan on package) ○ antagonizes NMDA receptor (NoMaD cAmel) Methadone (done 1mer) and Buprenorphine (blueprint screen) • long ac1ng opioid with long half life (white tapered flags) ○ withdraws slowly over 1me leading to less symptoms • used to aSenuate withdrawal symptoms neonatal abs1nence syndrome (crying pool baby) • withdrawal symptoms of opiates that crosses the placenta • diarrhea, swea1ng, sneezing, tachypnea, irritability • treat with morphine or methadone side effects • cons1pa1on due to delayed stool transit (plunger) • seda1on and CNS depression (red cerebral towel) • respiratory depression (defla1ng lung vest) • miosis (constricted hoodie) • biliary colic due to biliary smooth muscle contrac1on (biliary tree with seagull) • tolerance due to prolonged use ("all are welcome" tolerant sign) • miosis and cons1pa1on tolerance does not occur ("out of order" sign) • opiate induced hyperalgesia with chronic use (massage lady hur1ng guy) ○ hypersensi1ve to pain • dependence with withdrawal symptoms ("withdraw" sign) ○ rhinorrhea, lacrima1on, yawning, hyperven1la1on, hyperthermia, muscle aches, vomi1ng, diarrhea, anxiety (anxious hot guy surrounded by brown water) μ-opioid antagonists • Naloxone ("no lax zone" guy) ○ used to reverse acute opioid toxicity (helping the sedated red towel lady)

○ acts very quickly ○ can precipitate withdrawals • Naltrexone ("no tricks" guy) ○ blocks all effects of heroin ○ reduces craving for alcohol in alcoholics (beer) ○ reduces nico1ne craving ○ helps with weight loss (guy working out) Par1al μ Agonists (par1al/foot massage) • Buprenorphine, Nalbuphine, Butorphanol (blue fin bad) • can induce withdrawals (waiter falling into withdrawal pool)

Serotonin Drugs



• General • Serotonin- 5-HT (smiley face) • SSRIs and SNRIs are first line agents for: ○ depression treatment (happy and sad mask) § SIGECAPS- depression criteria ○ generalized anxiety disorder (anxious coworker) § used for long term treatment § no risk of addic1on or dependence § benzos are for immediate symptom relief ○ panic disorder (The Scream pain1ng on computer) ○ PTSD (ptsd dog tag guy) ○ OCD (obsessively neat guy) • SSRIs and SNRIs take 1-2 months to achieve maximum effect, not for acute treatment (2 month calendar)

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Selec1ve Serotonin Reuptake Inhibitors (expreSS tRIps) Fluoxe1ne (fly out poster) Paroxe1ne (parrot air poster) Sertraline (desert airline poster) Citalopram (the city poster) inhibit presynap1c reuptake of serotonin (keeping smiley post it out of the drawer) useful for: • bulimia (binge drawer lady) • social anxiety disorder (shy guy) side effects • may cause hyponatremia due SIADH (swea1ng water guy) • sexual dysfunc1on (girl rejec1ng advances) • weight gain (fat bellied guy) • drowsiness (sleeping girl) • serotonin syndrome- poten1ally fatal, hyperthermia, hypertension (angry, red boss guy) ○ differen1ated from NMS by hyperreflexia and clonus (hyperac1ve tapping foot) ○ can occur if therapy is combined with TCAs or MAO inhibitors (tricycle, mousetraps) ○ treated with Cyproheptadine, a 5HT-2 blocker ("rule 2 prohibited" paper) • discon1nua1on syndrome- flu-like withdrawal symptoms ("out with the flu" note)

Serotonin-Norepinephrine Reuptake Inhibitors (N and S compass map) Venlafaxine (fax machine) Duloxe1ne (dual copier/scanner) inhibit presynap1c reuptake of norepi and serotonin useful for: • Duloxe1ne- diabe1c neuropathy (guy with hand stuck in diaswee1es machine with frayed wire) • side effects • hypertension (angry coworker) • serotonin syndrome- poten1ally fatal, hyperthermia, hypertension (angry, red boss guy) ○ differen1ated from NMS by hyperreflexia and clonus (hyperac1ve tapping foot) ○ can occur if therapy is combined with TCAs or MAO inhibitors (tricycle, mousetraps) ○ treated with Cyproheptadine, a 5HT-2 blocker ("rule 2 prohibited" paper) • discon)nua)on syndrome- flu-like withdrawal symptoms (“out with the flu” note) • • • •

TCAs

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Tricyclic An1depressants (tricycle) Imipramine (imprint on face) and deriva1ves Desipramine, Clomipramine • Desipramine is a secondary amine (ball hisng secondary school sign) Amitriptyline and Nortriptyline (tripping girl) • Nortriptyline is a secondary amine (ball hisng secondary school sign) inhibit presynap1c reuptake of serotonin and norepi (smiley and compass ball) only given to pts that are unresponsive to other agents due to adverse effects useful for: • treatment resistant depression (resistant door, happy and sad masks) • diabe1c neuropathy (kid with hand stuck in diaswee1es machine with frayed wire) • migraine prophylaxis (pounding head bell) • OCD (obsessively compulsive marble kid) side effects • sexual dysfunc1on (woman rejec1ng advances) • inhibits muscarinic acetylcholine receptors (tea party) similar to Atropine side effects ○ dry mouth, cons1pa1on, blurred vision, urinary reten1on ○ symptoms less prevalent with secondary amines (kid hiding under secondary sign) • contraindicated in elderly due to seda1on, delirium, and risk of falls (confused old guy) ○ urinary reten1on points to an1cholinergic toxicity • block H1 histamine receptors (bee swaSer) ○ increased appe1te and weight gain (fat kid ea1ng) • block alpha-1 receptors (ex1nguished alpha candle) ○ orthosta1c hypotension (passed out girl) cardiotoxicity induced arrhythmia is most common cause of death in overdose (broken heart cookies) • ○ TCAs block cardiac fast Na+ channels (peanut buSer jar) ○ widened QRS complex (cracked heart sign) ○ can induce torsades (twisted streamers) § treat with sodium bicarb (baking soda girl) • serotonin syndrome (pile of smiley balls) • 3 C's ○ cardiotoxicity (heart cookie area) ○ coma (sleeping kid) ○ convulsions (shaking kid)

MAO Inhibitors



• General • MAO types ○ MAO-A (albino mouse) usually breaks down serotonin, norepi, and dopamine (mice ea1ng smiley face, compass, rope) § usually breaks down tyramine in GI tract (white mouse ea1ng GI meat) ○ MAO-B (black mouse) usually breaks down dopamine (mouse ea1ng rope) • • • •

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Mao Inhibitors (mouse trap) Tranylcypromine ("try a sip of wine") Phenylzine (funnel in wine boSle) Isocarboxazid (boxed wine) Selegiline (sledge hammer hisng black mouse) • selec1ve MAO-B inhibitor • increases dopamine levels in CNS ○ useful in demen1a irreversible and usually non-selec1ve (trap with mouse skeleton) used in treatment resistant depression (resistant wine boSle, happy and sad mask) side effects • must avoid tyramine containing foods like aged meat, cheese, and wine (wine and cheese pile) ○ tyramine will enter circula1on and act as sympathomime1c agent (trap releasing compass cheese) ○ tyramine toxicity- hypertensive crisis (hypertensive lady) • serotonin syndrome (pile of smiley face cheese) • avoid concurrent use with other serotonin increasing drugs like SSRIs, SNRIs, TCAs (tricycle)

Atypical An1depressants

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Bupropion ("net dat ball pro") inhibits the reuptake of norepi and dopamine • inhibits Norepi Transporter (NET) and Dopamine Transporter (DAT) similar effects to amphetamines • CNS ac1va1on (aroused guy) used for tobacco dependence ("pros dont smoke") does not cause sexual dysfunc1on (kissing couple) less likely to gain weight ("stay fit" sign) side effects • seizures (shaking athlete) ○ increased risk with history of seizure ○ contraindicated in bulimia (binge snacker) ○ contraindicated in anorexia (skinny athlete) ○ lowers the seizure threshold Mirtazapine ("mirth and misery" sign) alpha-2 antagonist (ex1nguished alpha-2 light) increases presynap1c release of serotonin and norepi also blocks 5HT-2 and 3 receptors ("52 and 53" jerseys) H1 histamine receptor antagonist (bee swaSer) • seda1on (sleeping fan) can cause weight gain (fat guy) useful in pts with depression and insomnia does not cause sexual side effects (couple kissing on screen) Trazadone (trombone player)

• a serotonin modulator • antagonizes 5-HT receptors (smiley face drum) • inhibits 5-HT2 uptake (smiley face drum) • minimal norepi and dopamine effects • alpha-1 antagonist (exBnguished alpha-1 lighter) • H1 histamine antagonist (bee swaDer) • side effect • priapism- painful erecBon lasBng 4 or more hours (erect trombone ○ "trazabone" • orthostaBc hypotension (fainted coach) • sedaBon (sleeping girl) • avoid in elderly and pts on other CNS depressants • sexual dysfuncBon (rejected advances) • serotonin syndrome (smiley face ball pile)

Lithium + Mood Stabilizers

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Lithium (lithium li^) a mood stabilizer (stabilizing ski poles) treats acute manic events and prophylaxis of manic/depressive events in bipolar disorder narrow therapeu1c index, monitor drug levels ("narrow window" sign) thiazide diure1cs (speedo kid) and NSAIDs reduce renal clearance ("low clearance sign"), increasing risk for toxicity • due to a decrease in GFR side effects • lithium toxicity ○ nausea, vomi1ng, diarrhea (nauseous looking guy) • tremor (trembling girl) • neurologic symptoms- confusion and ataxia (falling kid) • hypothyroidism (undone bow1e on penguin) ○ weight gain, hair loss, cons1pa1on, dry skin (he^y snowboarder) • nephrogenic DI (pee fountain) • teratogenic (tarantula hat) ○ causes Ebstein's anomaly (malformed snowmen)

Other Mood Stabilizers • Valproate ("winter fes1VAL" sign) • treats acute manic episodes, with maintenance • Carbamazepine (classic car) • treats acute manic episodes, with maintenance • Lamotrigine (llama hat) • treats bipolar, maintenance only • 1st and 2nd gen an1psycho1cs (psycho1c pain1ngs on peak) • treat acute mania

Broad An1epilep1cs



• General • par1al (focal) seizure ○ simple- clonic jerking of an extremity, no loss of consciousness ○ complex- lip smacking, swallowing, loss of consciousness • generalized seizure ○ tonic clonic ○ juveline myoclonic spilepsy (shaking arms kid) • • • •

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Broad Spectrium An1epilep1cs treat par1al seizures (shaking arm guy) treat generalized seizures (full body shake guy) most are metabolized by CYP450 (chrome P450 canon) Valproate ("welcome fes1VAL" sign) • useful in all seizure types ○ first line in tonic clonic • binds voltage gated Na+ channels to prolong inac1va1on (salty peanut baskets) • increases GABA levels in CNS (taxi decal to remind you of Cab-A sketch) • side effects ○ nausea and vomi1ng (nauseated king) ○ increased appe1te and weight gain (fat king) ○ tremor (tembling weapon guy) ○ hepatotoxicity (hepa1c liver spot on cow) ○ pacrea11s (pancrea1c sponge) ○ teratogen (tarantula on shields) with neural tube defects (brain hat) Topiramate (toupee in helmet) • useful in all seizure types • binds voltage gated Na+ channels to prolong inac1va1on (salty peanut baskets) • increases GABA levels in CNS by allosterically binding to GABA-A directly (binding to "taxi" guy) • side effects ○ somnolence and fa1gue (fa1gued soldiers) ○ cogni1ve slowing (confused soldier) ○ weight loss (thin canon guy) ○ kidney stones (kidney shaped wheels with canon ball stones) ○ acute angle closure glaucoma (high pressure eye keSle) Lamotrigine (llama) • useful in all seizure types, including absence • binds voltage gated Na+ channels to prolong inac1va1on (salty peanut baskets) • side effects ○ steven-johnsons syndrome (sloughed red mask) ○ diplopia (crossed llama eyes)

• Leve&racetam (elevator) • useful in par&al seizures • side effects ○ somnolence (sleeping woman on elevator)

Narrow An1epilep1cs

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Narrow Spectrum An1epilep1cs ("seize the night") useful in focal seizures and generalized tonic clonic (waitress with shaking arm) • can exacerbate other generalized seizures Carbamazepine (classic car) • useful for par1al and generalized tonic clonic • binds voltage gated Na+ channels to prolong inac1va1on (salty peanut bags) • 1st line for trigeminal neuralgia (3 gem sign) ○ presents with pain involving cranial nerve V, specifically V2 and 3 • inducer of CYP450 (chrome P450 bumper) • side effect ○ diplopia (crossed headlights) ○ ataxia (wobbly stack) especially in elderly ○ SIADH (water on head with ADH cup) ○ blood dyscrasias- agranulocytosis and aplas1c anemia (grainy sand 1mer) ○ DRESS syndrome- drug reac1on with eosinophilia and systemic symptoms (polka dot dress) ○ teratogen (tarantula on jacket) § neural tube defects (neural tube exhaust pipe) ○ stevens-johnson syndrome (sloughed red mask) Phenytoin (tow truck) • useful in par1al, generalized tonic clonic, and status epilep1cus ("order status" sign) • status epilep1cus ○ use Phenytoin for maintenance, Benzos for acute treatment (ben's diner) ○ use barbiturates for refractory seizure (barber shop) • binds voltage gated Na+ channels to prolong inac1va1on (salty peanut bags) • inducer of CYP450 (chrome P450 bumper) • side effects ○ ataxia (wobbly stack) ○ diplopia and nystagmus (crossed headlights) ○ folate deficiency leading to megaloblas1c anemia (spilled salad) ○ gingival hyperplasia (expanding gum bubble) ○ hirsu1sm (bushy beard) ○ drug induced lupus (lupus wolf) ○ DRESS syndrome (polka dot dress) ○ stevens-johnson syndrome (sloughed red mask) ○ teratogen (tarantula on jacket) § cle^ palate (cle^ trucker hat) ○ decreased bone density (fractured bone axle) Gabapen1n ("grab a pint" truck) • blocks voltage gated Ca2+ channels (closed ice cream cooler) • does not bind to GABA receptors • useful in: ○ peripheral/diabe1c neuropathy (diaswee1es machine with frayed wire) ○ fibromyalgia (fiber bars)

○ postherpe1c neuralgia from reac1vated VZV (zeus) • side effects ○ seda1on ○ ataxia (wobbly ice cream stack) especially in elderly • Vigabatrin (raised GABA V-cab) • irreversibly inhibits GABA transaminase to decrease GABA degrada1on (cab transmission) • Tiagabine (raised GABA V-cab) • inhibits GABA reuptake (stuck neck 1e)

Ethosuximide



Ethosuximide ("ethos") • an1epilep1c therapy for absence seizures ("seize the day", "absences" clipboard) • happens mostly in children • sudden momentary lapse in awareness accompanied by staring, blinking, or clonic jerks (inaSen1ve student) • last around 10 seconds • 3 Hz spike wave complexes on EEG ("3 spikes" poster) • blocks thalamic T-type Ca2+ channels (T-thermos, calci-yum chocolate milk) • side effects • GI distress (kid punched in stomach) • lethargy and fa1gue (sleeping kid) • First Aid side effects (EFGHIJ) ○ Ethosuximide causes Fa1gue, GI distress, Headache, Itching, and Stevens-Johnson syndrome • Valproate is effec1ve against absence seizures with history of addi1onal tonic clonic seizures (farm fes1VAL banner) • Lamotrigine is effec1ve against absence seizures

1st Gen An1psychs



1st Gen An1psycho1cs (Van Gogh) -azine suffix except Haloperidol ("starry gAZINg", halo around moon in pain1ng) inhibi1on of dopamine D2 receptors in CNS (2 torn D-ropes) have long half lives (long tapered flag) High potency drugs (kid trying to fly) • "Try to Fly High" Trifluoperazine, Fluphenazine and Haloperiol • specific side effects ○ extrapyramidal symptoms (extra pyramid newspaper hat) § acute dystonia, hours to days (cocked head guy) § akathisia- inability to sit s1ll, days to months (falling chair) § cogwheel rigidity from drug induced parkinsonism, days to months (cog wheel 1res) § tardive dyskinesia- orofacial chorea as a result of long-term an1psycho1c use, months to years (guy with tongue out) § treat with benztropine, diphenhydramine or benzos ○ hyperprolac1nemia (squir1ng milk guy) ○ neurolep1c malignant syndrome ("now more spicy" chicken bucket) § lead-pipe rigidity (guy holding pipe) § altered mental status with fever (red face) § autonomic instability § rhabdomyolysis (chicken with bite taken out) Chlorpromazine- corneal deposits (corn yellow paint) ○ ○ Thioridazine0 re1nal deposits (re1nal paleSe) • Low potency drugs (color pro and theory) • "Chea1ng Thieves are low" Chlorpromazine, Thioridazine • specific side effects ○ an1muscarinic effects leading to dry mouth, cons1pa1on, blurred vision, urinary reten1on (tea party pain1ng) ○ alpha-1 blockade leading to orthosta1c hypotension (passed out pain1ng) ○ H1 an1histamine ac1vity leading to seda1on (bee swaSer and bed pain1ng) • useful in: • posi1ve symptoms of schizophrenia (blocked shoulder angel), not nega1ve symptoms (non-blocked shoulder devil) • acute psycho1c episodes in many condi1ons (crazy roo^op kid) • acute agita1on or aggression (agitated roo^op kid) • toureSes 1cs (marioneSe) • general side effects • can cause torsades (twisted streamer) • increased risk of seizure because it lowers seizure threshold (shaking guy) • • • •

Atypical An1psychs

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•



2nd Gen/Atypical An1psycho1cs (atypical surrealist) cause less CNS side effects, more metabolic ones Que1apine, Olanzapine, Risperidone, Aripiprazole ("quiet please, only whispering is appropriate" sign) Ziprasidone (big dress zipper) Clozapine (closet) block D2 dopamine receptors in CNS (snapped 2 D-ropes) block 5-HT2A receptors (cut smiley face cake) block H1 Histamine receptors (bee swaSer) block alpha-1 receptor (ex1nguished candle) block muscarinic receptors (tea party pain1ng) useful in: • posi1ve and nega1ve symptoms of schizophrenia (angel and devil shoulder) • treatment resistant depression (happy and sad mask on wine boSle) • OCD with addi1onal SSRI therapy (obsessive pain1ng guy) • motor 1cs in toureSes (marionneSe) side effects • seda1on (H1 blockade) • orthosta1c hypotension (alpha-1 blockade) • mild an1muscarinic effects (muscarinic blockade) • weight gain (fat face in pain1ng • dyslipidemia (melted buSer) • hyperglycemia (lots of candy) • Clozapine ○ neutropenia and agranulocytosis (grainy sand 1mer) ○ myocardi1s or cardiomyopathy (surreal heart) ○ lowers seizure threshold (shaking clock) • extrapyramidal side effects, but less than 1st gen an1psycho1cs (extra paper hat) ○ Risperidone has highest risk (whispering guy) • hyperprolac1nemia (squir1ng milk) ○ Risperidone has highest risk (whispering guy) • neurolep1c malgnant syndrome ("now more spicy") • rhabdomyolysis (chicken with bite taken out) • can cause torsades (twisted streamers)

Parkinson's Drugs



Parkinson's Drugs (park & sons bank) • regular dopamine has trouble crossing the BBB (bank vault threshold) • Levodopa (L shaped rope crank) • can cross the BBB where it is then decarboxylated by DOPA to dopamine (unfurled rope) ○ some L-dopa is decarboxylated in the periphery (unfurled rope in the lobby) § causes: □ GI distress like nausea (nauseous guy) □ cardiac arrhythmias (arrhythmia rope) □ orthosta1c hypotension (passed out woman) • most effec1ve treatment for Parkison's • side effects ○ anxiety, agita1on, insomnia, confusion, hallucina1on (guy with rope wrapped around head) ○ long term use leads to § wearing-off reac1on- akinesia and dyskinesia re-emerge at the end of each dose (worn out rope) § on-off phenomenon- periods of akinesia alternate with periods of improved mobility (flash alarm light) § dyskinesias- choreoathetosis of face and extremi1es ○ therapeu1c window narrows as Parkinson's progresses (robbers watch) ○ contraindicated in psycho1c pts (damaged an1psychs pain1ng) • Carbidopa (police car outside) • blocks DOPA decarboxylase in the periphery • increases bioavailability of levodopa (robber pulling away other robber away from hostages/into the vault) ○ decreases peripheral side effects ○ can increase anxiety and agita1on since these are central effects • side effects ○ wearing-off reac1on- akinesia and dyskinesia re-emerge at the end of each dose (worn out rope) ○ on-off phenomenon- periods of akinesia alternate with periods of improved mobility (flash alarm light) ○ dyskinesias- choreoathetosis of face and extremi1es • COMT Inhibitors (interCOM phone) • Tolcapone (tall Al Capone gangster) and entacapone (Al Capone gangster by the entrance) • COMT converts L-dopa to 3-O-methyldopa in the periphery (cop shoo1ng crank) ○ COMT inhibitors block this conversion, increasing bioavailability of L-dopa • Tolcapone has peripheral and central effects, while Entacapone only has peripheral (tall Al Capone gangster block interCOM cop in bank vault)

• side effects ○ Tolcapone can cause hepa3c failure (liver gun handle) • Selegiline (black mouse ea3ng rope with sledgehammer guy) • MAO-B inhibitor that blocks dopamine breakdown • can exacerbate L-dopa side effects due to increased dopamine • Ropinirole (double rope ladder in a roll) • a D2 dopamine receptor agonist • important in ini3al treatment of Parkinson's • can be used to treat restless leg syndrome (shaking legs guy) • increase in impulse control disorders like shopping, gambling, and hypersexuality (rock and roll taMoo) • Pramipexole (robber with sweet pecs) • a D3 dopamine agonist • important in ini3al treatment of Parkinson's • can be used to treat restless leg syndrome (shaking legs guy) • increase in impulse control disorders like shopping, gambling, and hypersexuality (rock and roll taMoo) • Aman3dine (manatee statue) • increases dopamine synthesis and release, while decreasing reuptake (statue breaking open box full of rope) • Benztropine and Trihexyphenidyl (tri-hex Benz car) • treat parkinsonism by block muscarinic receptors • improve tremor and rigidity, but no effect on bradykinesia (shaking car)

Antineoplastics

MTX, 5-FU, Hydroxyurea



• General • MTX, 5-FU, and Hydroxyurea block synthesis of thymidine (hexagonal pyrimidine plate) • dUMP is converted to dTMP (plate with dumplings, plate with "T" shaped chops1cks) ○ thymidylate synthase (guy moving carbon sushi off 4-leaf boat) catalyzes the conversion of methylated THF to DHF (sushi boat with 4 leaves and a c-shaped carbon sushi becoming a boat with 2 leaves) and methylates dUMP to dTMP (transferring the carbon sushi from the boat to the dumpling plate) ○ DHF (boat with 2 leaves) is then converted back to THF (boat with 4 leaves) by dihydrofolate reductase (sushi guy adding 2 leaves) ○ THF is then re-methylated (addi1on of carbon sushi) • UDP is the precursor to pyrimidine nucleosides (UDP sign) ○ DUP is converted to deoxy-UDP by ribonucleo1de reductase (guest list waitress) An1metabolites • Methotrexate (meat s1ck chef on right side) • a cytotoxic folate analog • aSacks rapidly dividing cells and inhibits prolifera1on of immune cells (torn an1body lantern) • blocks the conversion of DHF to THF by compe11vely inhibi1ng DHF reductase (meat chef blocking leaf-sushi guy) ○ leads to buildup of DHF (buildup of 2-leaf boats) and decreased dTMP levels, decreased DNA synthesis • blocks the S phase of the cell cycle (Sushi phase sign) blocking DNA synthesis (chops1cks blocking ramen-DNA on sign) • treats: ○ many types of malignancies (cracked crab) ○ used with misoprostol as an abor1on method ○ ectopic pregnancy (baby keychain) ○ molar pregnancy, trophoblas1c tumors and choriocarcinoma (mole falling out of backpack) ○ psoriasis (silvery scale kneepads) ○ rheumatoid arthri1s (bone lantern with flame) • side effects ○ folate deficiency (falling leaves) leading to megaloblas1c anemia (fireworks lantern) ○ myelosuppression with pancytopenia and increased risk of infec1on (depleted bone serving tray, immunocompromised cane) ○ pulmonary fibrosis (fibro1c lung bonsai tree) ○ hepatotoxicity (liver spot on apron) ○ alopecia (bald guy) ○ mucosi1s (guy poking meat s1ck into his mouth) ○ reverse toxic effects with Leucovorin (lucky feline) a folinic acid § does not require DHF reductase § displaced MTX from binding sites to restore normal folate levels • 5-Fluorouracil (full, 5-finger waiving guy in yellow) • a pyrimidine analog (empty hexagonal plate) • blocks thymidylate synthase (guy moving carbon sushi off 4-leaf boat) to block thymidine synthesis and DNA synthesis • blocks the S phase of the cell cycle (Sushi phase sign) blocking DNA synthesis (chops1cks blocking ramen-DNA on sign) ○ causes buildup of dUMP (buildup of dumpling plates) • used in many solid tumors (cracked crab)

• side effects ○ loss of epithelium in intes1nes leading to diarrhea (brown stained pants) ○ photosensi1vity (flashing camera) ○ myelosuppression with pancytopenia and increased risk of infec1on (depleted bone serving tray, immunocompromised cane) § worsened with Leaucovorin (falling lucky feline) • Hydroxyurea (hydro-rock area in back le^) • blocks ribonucleo1de reductase (guest list waitress being pushed aside) • blocks the S phase of the cell cycle (Sushi phase sign) blocking DNA synthesis (chops1cks blocking ramen-DNA on sign) • blocks the S phase of the cell cycle (Sushi phase sign) blocking DNA synthesis (chops1cks blocking ramen-DNA on sign) • increases hemoglobin F (baby with hemoglobin coin) • treats CML, AML, head/neck cancer, melanoma, (cracked crab) • also treats veno-occlusive crises in sickle cell (zen sickle) ○ increases hemoglobin F (baby with hemoglobin coin) • side effects ○ GI upset ○ myelosuppression with pancytopenia and increased risk of infec1on (depleted bone serving tray, immunocompromised cane)

Azathioprine, 6-MP, Mycophenolate



• General • Purine synthesis ○ begins with PRPP (statue being built with 3 "P" hammers), which becomes IMP ("imp" gargoyle statue), which then becomes either AMP (gold "gramps" statue on le^) or GMP (gold "grump" statue on right)

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Azathioprine (azameralda the gypsy girl) and 6-mercaptopurine (CAPTive gypsy) prodrug of cytotoxic purine analog 6-mercaptopurine (CAPTive gypsy) • 6-MP is ac1vated by HGPRT (HiGh PRiesT poking gypsy) Azathioprine is metabolized into 6-MP blocks synthesis of IMP (kicked over imp statue) which blocks DNA and RNA synthesis works at the S phase of cell cycle (Stairs out and the stairs represent DNA) treats: • hematologic malignancies (cracked archer and knights on glass) • rheumatoid arthri1s (bone lantern) • immunospressive therapy (torn an1body lantern) like transplant rejec1on, SLE, autoimmune hemoly1c anemia • crohn's disease and ulcera1ve coli1s (inflamed colonic lanterns) side effects • myelosuppression with pancytopenia (empty bone tray) with increased risk of infec1on (golden cane) • pancrea11s (squeeze pancreas sponge) • hepa11s (liver stain) • pts on xanthine oxidase inhibitors like allopurinol and febuxostat increase the levels of 6-mp increasing risk of side effects (pure nuns with purine beads)

Mycophenolate mofe1l (quasi-mofe1l hunchback) • a IMP dehydrogenase inhibitor (hunchback kicking over GruMP statue) • decreased GMP synthesis leading to decrease in lymphocyte prolifera1on • treats: • rheumatoid arthri1s (bone lantern) • immunospressive therapy (torn an1body lantern) like transplant rejec1on, SLE, myasthenia gravis • side effects • GI distress like nausea, diarrhea and cramping (nauseous hunchback) • myelosuppression with pancytopenia (empty bone tray) with increased risk of infec1on (golden cane)

Cladribine, Cytarabine, Gemcitabine



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Cladribine (man clad in bear skin) a cytotoxic purine analog (purine shaped hammer) inhibits DNA polymerase (cracked map glass with replica1on fork) works in S phase (Stone phase sign) treats hairy cell leukemia (hairy caveman) side effect • myelosuppression (broken bone) with increased risk of infec1on (immunosuppressed cane)

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Cytarabine (saber toothed 1ger) cytotoxic pyrimidine analog (pyrimidine hexagons in fur) inhibits DNA polymerase (cracked map glass with replica1on fork) works in S phase (Stone phase sign) treats hematologic malignancies like AML and lymphoma (scratched out archer, knight, and crab cave art) side effect • myelosuppression (broken bone) with increased risk of infec1on (immunosuppressed cane)

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Gemcitabine (gems) cytotoxic pyrimidine analog inhibits DNA polymerase (cracked map glass with replica1on fork) works in S phase (Stone phase sign) treats hematologic and solid tumors (crabs etched into solid rocks) side effect • myelosuppression (broken bone) with increased risk of infec1on (immunosuppressed cane)

Cyclophosphamide, ifosfamide, busulifan, nitrosoureas

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Cyclophosphamide (cyclops) cross-links DNA at a non-specific phase of cell cycle (ankle chains) • halts cell division and causes apoptosis must be metabolized by CYP450 to be ac1vated (P450 license on horse) treats hematologic and solid tumors like leukemias and lymphomas (torn crab sail) used in immuno suppression (torn an1body lantern) side effects • myelosuppression (broken bone marrow club) • hemorrhagic cys11s (blood fountain) ○ prevent with mesna (maze) • increased risk of bladder cancer (golden crab belt buckle) • hyponatremia due to SIADH (ADH bucket on head) • infer1lity and premature menopause (dried up ovary tree) Busulfan (beau1ful sirens) cross-links DNA at a non-specific phase of cell cycle (ankle chains) • halts cell division and causes apoptosis does not require bioac1va1on used in condi1oning prior to bone marrow transplanta1on (depleted bone marrow bones) side effects • lung toxicity (lung paSern on shirts) ○ acute lung injury, inters11al fibrosis, alveolar hemorrhage • hyperpigmenta1on of skin (tan sirens) called Busulfan tan

Nitrosoureas (centaurs) • -mus1ne suffix, Streptozocin (mustang horse body, striped body) • once ac1vated in liver, cross BBB to treat brain tumors (brain tree) • side effects • neurotoxicity (dizzy centaur) ○ convulsions, dizziness, ataxia

Cispla1ns

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Cispla1n, Carbopla1n ("pla1num" pla1num analogs cross link DNA (cross-linked necklace with double helix chain) used in solid tumors, leukemias, and lymphomas (crumbled crab bag) side effects • ototoxicity (gong shaped earrings) leading to 1nnitus and sensorineural hearing loss • peripheral neuropathy (black gloves) • nephrotoxicity (kidney purse) with acute kidney injury ○ also acute tubular necrosis with muddy brown casts (muddy drain tube) ○ Cispla1n has highest risk of toxicity of all the pla1ns ○ prevent cispla1n-induced nephrotoxicity with amifos1ne ("free amethyst" sign with jewels in kidney purse) § scavenges free radicals produced by cispla1n in kidney ("free" part of sign) ○ prevent with IV saline as well • carbopla1n especially causes myelosuppression (depleted bone jewelry box)

Bleomycin, rubicins, Ac1nomycin D

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Bleomycin (beluga whale) an an1tumor an1bio1c binds DNA and produces free radicals to cause breaks in DNA strands (oxygen bubbles, broken DNA seaweed) blocks G2 phase ("Galleon") treats hematologic and solid malignancies (cracked cancer crab) side effects • pulmonary toxicity (lung coral) ○ pulmonary fibrosis, pneumoni1s, pulmonary infiltrates • hyperpigmenta1on with striae (pigmented stripes) and rash • mucosi1s and stoma11s (sea urchin in whale mouth) • alopecia (big bald head of whale) Anthracyclines ("santa anthracycline) -rubicin suffix (chest full of rubies) generate free radicals (oxygen bubbles) intercalate, or insert in between DNA base pairs to block DNA/RNA synthesis (DNA seaweed with rubies) treats hematologic and solid tumors (cracked cancer crab) side effects • cardiotoxicity (dilated ruby sacks) ○ dilated cardiomyopathy ○ prevent cardiotoxicity with dexrazoxane, an iron chelator (skeleton on deck with razor holding ruby sack) • myelosuppression (empty bone shaped chest) • mucosi1s and stoma11s (sea urchin in whale mouth) • alopecia (bald headed skeleton)

Ac1nomycin D (doll ar1fact) • intercalate, or insert in between DNA base pairs to block DNA/RNA synthesis (DNA seaweed with ar1facts) • treats pediatric malignancies (child doll ar1fact) • side effects • alopecia (bald doll) • myelosuppression (empty bone shaped chest)

Etoposide, teniposide, topotecan, irinotecan



• General • topoisomerase II relieves DNA supercoiling during DNA replica1on • topoisomerase I makes single stranded nicks to relieve supercoiling

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Etoposide, Teniposide (side of tower) Etoposide clue (girl climbing from top of the tower) topoisomerase II inhibitors target topoisomerase II (2 hair strands) causing strands breaks (broken hair strands) and prevent religa1on of strands block S phase of cell cycle ("Stairs out" sign) and G2 phase ("Gone 2 forest" sign) treats hematologic and solid malignancies (torn crab flag) side effects • myelosuppression (empty bone marrow luggage) • immunosuppression (immunocompromised cane) • alopecia (loose hairs on ground) Topotecan, Irinotecan (toucan) topoisomerase I inhibitors (single ponytail on guy) block S phase of cell cycle ("Stairs out" sign) and G2 phase ("Gone 2 forest" sign) Topotecan treats ovarian and small cell lung cancer (torn crab flag) Irinotecan treats colon cancer (torn crab flag) side effects • myelosuppression (empty bone marrow luggage) • diarrhea (bird poop on glove)

Vincris1ne, Vinblas1ne, Taxanes

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Vincris1ne (yellow dress girl in vines) a vinca alkaloid binds β-tubulin and inhibit its polymeriza1on into microtubules, inhibi1ng microtubule produc1on and mito1c spindle assembly (breaking spindle vines) blocks the cell in metaphase of cell cycle (swinging monkey) treats ALL, mul1ple myeloma, hodgkin/non-hodgkins lymphoma, pediatric tumors (cracked cancer crab) side effects • neurotoxicity as a peripheral sensory neuropathy (yellow girl wearing stockings and gloves) • paraly1c ileus and cons1pa1on (plunger) • alopecia (bald monkey) Vinblas1ne (guy with gun) a vinca alkaloid binds β-tubulin and inhibit its polymeriza1on into microtubules, inhibi1ng microtubule produc1on and mito1c spindle assembly (breaking spindle vines) blocks the cell in metaphase of cell cycle (swinging monkey) treats lymphomas and solid tumors (cracked cancer crab) side effects • myelosuppression (broken bone marrow) "blasts your bones" • alopecia (bald monkey)

Taxanes (Tarzan) • -taxel suffix • enhance microtubule produc1on and stability to prevent degrada1on leading to improper mito1c spindle func1on (monkey stabilizing Tarzans vine) • blocks the cell in metaphase of cell cycle (swinging monkey) • side effects • alopecia (bald monkey) • neurotoxicity as a peripheral sensory neuropathy (Tarzan holding white glove) • myelosuppression (broken bone marrow)

The -nibs, Kinase Inhibitors



Kinase Inhibitors • -nib suffix (broken nib of pen) • •

•

•

•

Tyrosine Kinase Inhibitors -1nib suffix (inhibited 1re swing tree) Ima1nib (imita1ng pain1ng guy) • treats hematologic and solid malignancies (cracked crab bell) • treats CML (colorful packaging peanuts) ○ transloca1on of chromosome 9 to 22 ("922 Philadelphia" s1cker on box) • inhibitor of BCR-ABL protein ("breakable" s1cker on box) • blocks c-kit tyrosin kinase in GI stromal tumors (congress kit box, guy with fat belly and cancer crab buSons) • side effects ○ fluid reten1on with ankle and periorbital edema (baggy pantaloons on imita1ng guy) Erlo1nib (bri1sh Earl of Tinib in window) • inhibitor of EGFR tyrosine kinase ("Geoffry" on hat) • treats non-small cell lung cancer (cancer crab badge on lung-shaped lapel) • side effects ○ papulopustular acneiform rash (spoSy rash) ○ diarrhea (mud on pants) Suni1b and Sorafenib (rising sun and soaring eagle) • inhibitor of VEGF receptor tyrosine kinase (man inhibi1ng vegetable growth outside) • treat renal cell carcinoma (bilateral crab buckles) • side effects ○ hyperkeratosis and skin rash (callused and sunburned vegetable guy) ○ increased risk of hemorrhage (bleeding wound) Vemurafenib (snake venom in drawing) • inhibitor of BRAF kinase ("B. Fra" signature) • treats V600E BRAF posi1ve malignant melanoma (ink stains on jacket) ○ FA: VEmuRAF-enib is for V600E-mutated BRAF inhibi1on

The -mabs



The -mabs • -mab will always be a monoclonal an1body • monoclonal means all cells are from the same cell line and target the exact same an1gen • Rituximab (corona1on ritual) • chimeric, IgG monoclonal an1body (chimera sigil) • targets B cells by binding CD20 (archer with 2 X's to symbolize 20) • treats CLL, non-hodgkin lymphoma (worn out T and B cell tapestry) • treats rheumatoid arthri1s (bone lantern) • useful for immunosuppressive therapy in microscopic polyangii1s and wegner's granulomatosis (torn an1body lantern) • side effects ○ immunosuppression with increased risk of infec1on (immunocompromised cane ○ higher risk of progressive mul1focal leukoencephalopathy (white laurel leaves) ○ infusion reac1on- headache, fever, dyspnea, pruri1s, hypotension (fat red angel with ivy) ○ serum sickness within 7-10 days (red face and dropped drink) • Cetuximab (elephant tusks) • chimeric, IgG monoclonal an1body • targets EGFR (giraffe on blanket) ○ tyrosine kinase receptor (1re swing) • treats solid tumors (cracked cancer crab) • side effects ○ papulopustular acneiform rash (red spots on giraffes) ○ infusion reac1on- headache, fever, dyspnea, pruri1s, hypotension (fat red angel with ivy) ○ serum sickness within 7-10 days (red trunk and drink) • Bevacizumab (beverage lady) • IgG monoclonal an1body • inhibi1on of VEGF (chopped up veggies on table) especially in vascular endothelial cells to inhibit growth of blood vessels in tumors (chopped red veggies) • treats metasta1c cancers (cracked cancer crab) • treats wet macular degenera1on (wet spot on re1na pillow) • side effects ○ can cause bleeding (bloody aprons) ○ increased risk of clots (ice clot in pitcher) ○ GI perfora1on (perforated veggies in GI-like sac under table) • Alemtuzumab (guy with "alms" dish) • IgG monoclonal an1body • binds to CD52 on B and T cells to deplete them (pulling on archer and knight, "52" design etched into sword) • treats CLL (worn out T and B cell tapestry) • side effects ○ myelosuppression • Trastuzumab (tapestry weaver) • monoclonal an1body against HER2 (2 babies) "Tras2zumab for HER2" ○ a tyrosine kinase receptor (1re swing) • used in pts with HER2 posi1ve tumors ○ breast (cancer crab bra) and gastric cancers • side effects ○ cardiotoxicity § decreased le^ ventricular ejec1on frac1on § heart failure