Pharmaco "Kinetics" (05:12)
Drug information is constantly being updated as new products are released. There are now 150,000 preparations in use; learn the top 10.
Pharmaceutical Money Makers (12:12)
The top thirty most profitable drugs are adalimumab, etanercept, Advair Diskus, infliximab, rituximab, insulin glargine, bevacizumab, trastuzumab, rosuvastatin, sitagliptin, aripiprazole, duloxetine, imatinib, pregabalin, pegfilgrastim, glatiramer, lenalidomide, ranibizumab, tiotropium bromide, esomeprazole magnesium, Prevnar 13, Atripla, valsartan, budesonide/formoterol, celecoxib, epoetin alpha, tenofovir/emtricitabine, interferon beta-1a, telmisartan, and NovoRapid.
Drug Development and Billion Dollar Drugs (06:34)
It takes 7-10 years to develop a new drug and patents last seven years. Barbara Bancroft discusses sofosbuvir, dimethyl fumarate, ado-trastuzumab emtansine, ibrutinib, dolutegraviry, Stribild, obinutuzumab, apremilast, vortioxetine, Breo Ellipta, and Anoro Ellipta.
Game Changing Drugs: HCV and Cirrhosis (06:43)
Bancroft discusses new Hepatitis C drugs; coffee improves liver outcomes. VSL#3, an over the counter probiotic, taken daily for six months improves liver function and reduces hospitalization and hepatic encephalopathy risk.
Fatty Liver (NAFLD) (06:41)
Nonalcoholic fatty liver disease is the most common cause of chronic liver disease in the U.S.; learn causes and risk factors. Nonalcoholic steatohepatitis (NASH) triggers neutrophils, fibrosis, and scar tissue, and can lead to cirrhosis. Aramchol reduces liver fat in obese and diabetic patients.
Game Changing Drugs: Heart Failure and Hyperlipidemia (06:54)
Neprilysin is a kidney produced protease that normally degrades vasoactive peptides. Bancroft discusses sacubitril/valsartan and Ivabradine. PCSK9 inhibitors evolocumab and alirocumab have been approved for homozygous familial hyperlipidemia and statin intolerant patients.
Dendritic Cell Vaccine (02:41)
Glioblastomas harbor a CMV strain not found in surrounding neuronal tissue. The dendritic cell vaccine combined with the tetanus vaccine uses the patient's dendritic cells to signal the immune system to mount an attack. Survival time doubles.
New Potential Antibiotic (01:08)
Teixobactin is on a fast track for approval. From a novel class of peptidoglycan synthesis inhibitors, it is effective against gram positive bacteria.
New 9vHPV Vaccine (07:34)
Gardasil-9 prevents human papillomavirus. It targets HPV 16 and 18, the most oncogenic types. View statistics for HPV induced cancers. Oropharyngeal cancers are increasingly caused by HPV.
Nivolumab/Opdivo turns on a part of the immune system suppressed by non-small cell lung cancer. It does not cure, but prolongs survival rates.
Game Changing Drugs: Alzheimer's Disease and Diabetic Foot Ulcers (07:55)
Aducanumab and solanezumab decrease amyloid plaque formation in the brain and have demonstrated positive improvement in cognitive scores. Heberprot-P can cure diabetic foot ulcers, and has been unavailable in the U.S. due to Cuban-U.S. sanctions.
Drug Timing Acronyms (02:11)
Drug timing acronyms include SR (sustained release), XL (extended length), CR (controlled release), CD (controlled dosage), ER (extended release), LA (long-acting), DS (double strength) and HS (half strength or at night).
Drug Timing: Anti-coagulants and Statins (05:39)
Once a day drugs work best in the first 12 hours. The liver makes clotting factors and LDL-cholesterol at night; warfarin and most statins should be given in the evening. Rosuvastatin and atorvastatin have longer half-lives.
Drug Timing: Anti-hypertensives (05:21)
Learn about hypertensive "dippers" and "non-dippers." A disproportionate amount of African-American patients are non-dippers and at higher risk of heart disease, renal disease, and stroke. Medication should be administered in the evening or via split dosage.
Drug Timing: Ischemic Strokes (04:24)
There is a 4.5 hour window for giving tPA; ask family members when they last saw the patient as "normal." Bancroft discusses improvements in stroke management.
General Absorption Times (03:37)
Pharmacokinetics is the body's effect on a drug from administration to elimination. View absorption times for oral, IM, IV, SQ, topical, sublingual, inhalation, rectal, intra-arterial, and intrathecal routes. Learn why not to administer insulin subcutaneously in acidotic patients.
Oral Antipyretic Drugs (03:59)
Acetaminophen takes 71 minutes to lower temperatures, and does not relieve inflammatory pain. Ibuprofen is a central and peripheral prostaglandin inhibitor. Tylenol should not be alternated with ibuprofen in children.
Oral Absorption (07:15)
Oral drug routes are the safest and most convenient for most patients; dry mouth is an exception. Pharmacists determine whether to administer with or without food. A high fat meal can delay sildenafil/Viagra onset; learn about the drug's history.
Sublingual Absorption and Nasal Spray Absorption (04:29)
Sublingual nitroglycerin does not work in dry mouths; anticholinergic drugs decrease saliva. If an older patient has anginal chest pain and no saliva to absorb sublingual nitroglycerin, nasal nitroglycerin is appropriate.
Sublingual Immunotherapy (02:09)
The FDA has approved three sublingual therapies for allergic rhinitis. Oralair, Grastek, and Ragwitek should be started before symptoms to inhibit histamine release. Bancroft urges parents to allow children to get dirty, to build the immune system and avoid allergies.
Multiple Administration Routes: Estrogen (10:14)
Estrogen can be administered orally, vaginally, or by patch. Oral administration increases clotting risk but also increases HDL production. Women with aura migraines should not take estrogen due to stroke risk. Vaginally administered estrogen reduces UTIs and yeast infections.
Overactive Bladder and Menopause (03:38)
Many OAB drugs have anticholergenic effects. Estrogen in vaginal cream can cross the male urethra. New studies show that some women convert isoflavone to the "equol" metabolite with mild estrogenic activity.
HRT and Breast Cancer (12:47)
Top breast cancer risks factor include gender, family history, and previous breast cancer. Minor risk factors include early menarche, menopause age, number of children, children before 20, and birth weight. Bancroft cites studies showing HRT is not a major risk factor.
Nose and Airway Administration Routes (04:53)
Learn about administering intranasal DDAVP for enuresis in children. Oxytocin/Pitressin can increase feelings of monogamy. Inhaled medication include topical steroids, bronchodilators, and anti-cholinergics. Bancroft discusses a study using oxytocin nasal spray to increase socialization among autistic children.
Rectal Administration Route (04:28)
Rectal drug absorption is more effective than vaginal absorption. Corticosteroids are prescribed for distal ulcerative colitis. Enemas can reach the splenic flexure; hear indications for aspirin suppositories.
Fecal Transplants for C. Difficile Infections (03:32)
Chronic C. diff patients who have failed vancomycin and metronidazole are eligible for fecal transplants. Learn about the process of rebalancing the microbiome.
Stomach Drug Absorption (03:49)
Low stomach pH kills bacteria; GERD drugs decrease acidity and increase foodborne illness risk. Drugs like ketoconazole require an acid environment for dissolution and may have decreased bioavailability when used with PPIs. Acid is necessary for iron absorption.
Drugs and Enteral Feedings (02:35)
Most drugs are absorbed through the stomach or duodenum. Administering warfarin and iron in a jejunostomy tube risks poor bioavailability. Do not add medication directly to the enteral feeding formula.
Brain Drug Absorption (11:59)
The blood brain barrier resists drug absorption; drugs must be lipid soluble. Compare atenolol to propranolol absorption and learn the side effects of lipophilic beta blockers. Adding liposomes can increase absorption.
Gastric Bypass Procedures (07:51)
Patients undergoing Roux-En-Y gastric bypass, distal bypass or "the switch" may have absorption issues. Learn about alternative administration routes. Patients should avoid NSAIDs, salicylates, bisphosphonates, and sustained release medications. Bariatric surgery may "cure" diabetes.
Bancroft discusses aging and senescence. After peaking at 30, tissue functional capacity declines by 1% annually. People become geriatric around age 75; drugs can cause renal and heart failure. Chronic disease and gender differences accelerate senescence.
Pharmacogeriatrics and Drug Distribution (09:55)
Learn about absorption issues and toxicity risk in geriatric patients. Bancroft uses diazepam/Valium half-life as an example.
Drug Distribution and Albumin Production (08:17)
Fluoxetine/Prozac is appropriate for children and teenagers because of its long half-life. Learn about bound and "free" drugs. Decreased albumin production in elderly patients results in competition for binding sites.
Drug Metabolism (10:28)
The liver metabolizes most drugs; some are metabolized in the stomach and small intestine. The cytochrome p450 enzyme family metabolizes drugs. Drugs and foods can induce or inhibit these enzymes.
Cytochrome p450 Enzymes in the Liver (04:56)
Tamoxifen used to treat estrogen receptor positive breast cancer metabolizes to endoxifen. Fluoxetine/Prozac, paroxetine/Paxil and St. John's Wort inhibit CYP2D6 and reduce tamoxifen effectiveness. Citalopram/Celexa and esitalopram/Lexapro/Ciprolax are safer SSRI antidepressants.
The kidneys excrete most drugs; the glomerular filtration rate decreases with age. Less excretion means more retention and toxicity; learn about Metformin and contrast dyes and view drugs potentially retained in the elderly.
Elderly patients tend to have multiple chronic conditions requiring multiple medications. Bancroft discusses drug interactions and potential toxicities. SSRIs inhibit platelets and lower sodium.
Metoclopramide and Sinemet (05:39)
Metoclopramide/Reglan/Maxeran is a dopamine blocker, helping bowels to move; it is lipophilic and crosses the blood brain barrier. Doctors prescribe Sinemet, an L-dopa negating the effects of both drugs.
OTC Alternative and Complementary Therapies (09:47)
Multivitamins and calcium supplements can decrease Synthroid effectiveness; St. John's wort interacts with 60% of drugs. Cinnamon can cause hypoglycemia in diabetics, red yeast rice can cause rhabdomyolysis, glucosamine and gingko inhibit platelet aggregation, and ginseng retains fluid and sodium.
Tolerance and Receptors (04:28)
Effectiveness of a drug can decrease with continued use. Drugs boost or block receptors. Tamoxifen is an agonist and antagonist; learn about its use for estrogen receptor breast cancer patients. Raloxifene/Evista is prescribed for osteoporosis.
Antidepressants tend to illicit a familial response, although depression is learned. Pharmacogenomics combines pharmaceutical sciences with common DNA variations in the genome. Drug response is linked to single nucleotide polymorphisms (SNPs) variations.
Genetic Drug Response (02:49)
Some drugs are not as effective in some individuals, due to SNP variations. The liver enzyme CYP2D6 converts codeine to morphine. Patients without CYP2D6 activity are poor metabolizers, while ultra-rapid metabolizers can have morphine toxicity.
Genetic Mutations and Drugs (05:00)
Most cystic fibrosis patients are Caucasian. Ivacaftor/Kalydeco treats 4-5% of patients with a specific mutation in their CF genes. Crizotinib/Xalkori treats ALK+ non-small cell lung cancer that has metastasized, 14% of pediatric neuroblastoma cases, and anaplastic large-cell lymphoma.
Drug Class Overview (08:20)
Drug companies create trade or brand names for easy recall and pronunciation, but generic names are easier for healthcare professionals to recognize. Bancroft identifies prils, afils, sartans, setrons, triptans, gliptins, prazoles, azoles, olols, dipines, tidines, statins, abans, and nibs.
Generic vs. Brand/Trade Name Drugs (05:53)
Generic drug equivalents produce the same therapeutic results in most cases; different fillers can impact bioavailability by 4%. Patients on anticonvulsants, antihypertensives and warfarin should not change generic manufacturers. Dosing may differ among generic drugs with different brand names, depending on indication.
Naming Drugs is an Art Form (10:12)
Learn about indications for Adderal, Pepcid, Adcirca, Rythmol, Premarin, Azmacort, Aleve, Zebeta, Brethaire, Astroglide, Pissenlit, Morphine, barbiturates, Lasix, Urospaz, Duvoid, Rapaflo, Flomax, and Viagra. Learn several easily confused brand names and warfarin's history.
New Drugs beginning with Q, X and Z (06:46)
The FDA requires new drugs have names that are not easily confused. See several examples.
OTC Zicam (04:14)
Zinc helps prevent colds and reduces virus length. Intranasal zinc caused permanent olfactory damage; zinc added to denture creams caused peripheral neuropathy. Learn about bimatoprost/Latisse, used for glaucoma and eyelash lengthening.
Primary Hypertension (03:38)
Many patients have increased renin-angiotensin-aldosterone, causing vasoconstriction and fluid retention. "Prils" or ACE inhibitors and "sartans" or ARBs are first line therapies. "Dipines" or calcium channel blockers vasodilate blood vessels.
"Prils" (ACE Inhibitors) (06:10)
Learn about the development of "pril" drugs produced with snake venom. Bancroft covers captopril, enalapril, fosinopril/Monopril, lisinopril, perindopril, moexipril, benazepril, quinapril/Accupril, trandolapril, and ramipril. Captopril, trandolopril and fosinopril cross the blood brain barrier and slow cognitive decline in dementia patients.
Kidney Physiology (05:15)
Arteriole baroreceptors "sense" blood flow volume and pressure; if low, the kidney releases renin from the JGA. Angiotensin II vasoconstricts and releases aldosterone, which saves sodium and water. Learn about other functions, including tissue remodeling.
ACE Inhibitor Function (03:00)
Angiotensin converting enzyme inhibitors are anti-hypertensive, anti-inflammatory and anti-thrombotic agents. "Prils" stop the kidney from releasing renin, angiotensin and aldosterone as a compensatory mechanism during heart failure. They can induce hypoglycemia in diabetics.
Angiotensin II in the Healthy Kidney (06:07)
Bancroft explains the filtration process. Hyperglycemia, hypertension and too much animal protein increase prostaglandin and angiotensin II, rupturing the glomerulus and damaging the kidney. Hear how ACE inhibitors work. Microalbumin in urine indicates disease.
ACE Inhibitor Use and Side Effects (15:58)
Angiotensin converting enzyme inhibitors treat hypertension, prevent diabetic nephropathy, decrease preload and afterload in CHF, and more. ACE inhibitors cause hypotension and hyperkalemia; patients should decrease potassium intake.
ACE Inhibitor Induced Angioedema (07:25)
Learn about the life threatening airway constricting condition. Treatment includes methylprednisolone and clemastine; intubation may be necessary. Icatibant/Firazyr is a new selective bradykinin B2-receptor antagonist. ACE inhibitors are also teratogenic, and are contraindicated in pregnancy.
Sartans (ARBs) and ACE (02:37)
Angiotensin II receptor blockers bypass ACE; Olmesartan/Benicar crosses the blood brain barrier and lowers blood pressure centrally. ARBs are generally safe for patients with ACE inhibitor induced angioedema.
Hypertension and Spironolactone (03:36)
Combining two synergistic drugs is five times more effective than doubling the dose of one drug. Beta blockers are only indicated for heart failure, angina, or tachycardia. Aldactone and eplerenone/Inspra influence the renin-angiotensin-aldosterone system.
Beta Blockers (04:16)
Beta blockers block the fight/flight response. Atenolol/Tenormin raises central blood pressure, increasing cardiovascular event risk. Bancroft distinguishes between metroprolol succinate/Toprol XL and metroprolol tartrate/Lopressor. Nebivolol/Bystolic boosts nitric oxide.
Beta Blockers (09:44)
Cardioselective beta blockers block B1 heart receptors; non-selective beta blockers block B1 and B2 receptors. Cardioselective beta blockers reduce cardiac output, lowering heart rate and blood pressure. Learn several uses for beta blockers.
Calcium Channel Blockers (04:40)
Non-dihydropyridines decrease cardiac workload but cause constipation. Diltiazem/Cardizem functions as a peripheral vasodilator. Dihydropyridines include amlodipine/Norvasc; felodipine/Plendil causes most the peripheral edema and Isradipine/Dynacirc causes less peripheral edema.
Clinical Uses for "Dipines" (10:07)
Calcium channel blockers are prescribed for hypertension, vasospasm, and ureteral spasms. Nitroglycerin paste can be used to start an IV. Cocaine-induced vasospasm requires diltiazem/Cardizem and a "dipine." Researchers are considering using "dipines" as a male contraceptive.
Calcium Channel Blocker Side Effects (03:15)
Verapamil/Verelan causes constipation, and has many drug interactions."Dipines" cause peripheral vasodilation with headache, hypotension and peripheral edema. All CCBs inhibit calcium-induced contraction of the lower esophageal sphincter.
Atorvastatin/Lipitor and rosuvastatin/Crestor are high potency statins. They inhibit the HMG CoA reductase liver enzyme responsible for LDL cholesterol, which works at night.
LDL Cholesterol (07:17)
Low density lipoprotein puts fat into arterial walls. Particles are small and dense or large and loose. Diabetics have B pattern particles, increasing heart disease risk. Diet and statins change particle size.
LDL-Lowering Effects and Guidelines (03:24)
Atorvastatin/Lipitor and rosuvastatin/Crestor lower cholesterol by 50%. At risk groups include individuals who have experienced a cardiovascular event, individuals with LDL greater than 190, type 2 diabetes patients aged 40-75 with LDL between 70 and 189, and individuals with a 10 year cardiovascular risk.
Statin Functions (11:48)
Statins decrease total cholesterol, LDL cholesterol, and oxidation of LDL cholesterol. They shrink renal artery plaque, stabilize plaques and prevent rupture. They decrease mesangial proliferation and vascular inflammation, and boost neurogenesis.
Statin Side Effects (07:59)
Statins can unmask diabetes in predisposed individuals. Rhabdomyolysis is rare and liver toxicity are rare. Simvastatin has the highest drug interaction risk. Statins can slow MS progression; PCSK9 inhibitors are an alternative to statins.
The glucophage works by decreasing hepatic glucose production and increasing tissue sensitivity to insulin. It also lowers blood pressure and LDL, slows breast and prostate cancer, and prevents weight gain in patients taking anti-psychotic drugs. Metform increases flatulence by depositing glucose in the GI tract.
"Tides" or GLP-1 Agonists (05:23)
Glucagon-like peptide 1 triggers incretin release in diabetics; incretins are responsible for 60% of post-meal insulin secretion. Learn about its discovery in Gila monsters and development as a weight loss drug.
Incretin Mimetics (02:23)
GLP-1 agonists are generally added to type 2 diabetics receiving metformin, a sulfonylurea, or both. View a chart of "tide" drugs. Liraglutide/Saxenda was approved for obesity in 2015. Bancroft discusses weight loss psychology.
"Gliptins" or DPP-4 Inhibitors (03:00)
DPP-4 inhibitors inhibit dipeptidyl peptidase, an intestinal enzyme responsible for breaking down incretins potentiating post-meal insulin release. They reduce HbA1C by 0.5%, and are best used as add-ons to metformin. They may be linked to cardiovascular and pancreatic disease.
"Flozins" or SGLT2 (03:15)
Sodium glucose co-transporter 2 inhibitors lower HbA1c by 1%, reduce renal glucose reabsorption, and increase urinary glucose excretion with osmotic diuresis. Side effects include yeast infection, hypovolemia, euglycemic ketoacidosis, and increased cardiovascular event risk.
Phosphodiesterase 5 inhibitors improve blood flow to the penis. Bancroft describes the "stamp test" for psychological impotence during REM sleep. Do not use "afils" with nitroglycerin. Learn about side effects.
"Osins" and "Sterides" for BPH (03:54)
Prostate smooth muscle cells enlarge with aging. Alpha-1 blockers include tamsulosin/Flomax, silodosin/Rapaflo, and doxazosin/Cardura XL. S-alpha reductase inhibitors prevent the conversion of testosterone to dihydrotestosterone.
Floppy Iris Syndrome and "Dronates" for Osteoporosis (06:12)
Cataract surgery is more difficult in patients that have taken Alpha-1 blockers. Bisphosphonates treat osteoporosis, Paget's disease, and hypercalcemia of cancer. Hormones maintain bone health and decrease with age.
"Dronates" Function (03:18)
Osteoblasts build bone and osteoclasts break down bone; after 45, we have more osteoclasts. Bisphosphonates induce bone cell apoptosis, boosting mass. Patients on them longer than five years develop brittle bones and fractures.
Proton pump inhibitors treat GERD by inhibiting hydrochloric acid from entering the stomach after a meal; they can relieve nighttime bronchoconstriction for asthma patients. Long term PPI use and acid suppression can increase risk of hospital-acquired pneumonia, food borne illness, osteopenia and osteoporosis, and more.
Clinical Implications of B12 Deficiency (06:42)
B12 deficiency can cause nutritional dementia, peripheral neuropathy, and macrocytic anemia. At risk groups include patients on metformin, people over 50, patients with malabsorption, and vegetarians or vegans. Learn administration routes.
"Poietins" and Azoles (04:14)
Renal patients once received packed red blood cells with negative reactions. Giving too much of erythropoietin stimulating agents can cause dialysis shunt access thrombosis. Bancroft lists antifungal drugs.
Bancroft relates a story in which she had trouble understanding a patient in North Carolina. Herpes lives on toilet seats for 45 minutes. Learn about "cyclovir" indications. A new vaccine will be 90% effective in preventing shingles.
Depression: SSRIs (07:40)
Bancroft discusses links between stress and depression. SSRIs produce a response in 50-70% or patients; they should stay on for 6-12 months. Sertraline/Zoloft’s short half-life is convenient for sexual dysfunction. Escitalopram/Lexapro has few drug interactions but paroxetine/Paxil should be avoided in elderly patients.
SSRI Side Effects (04:09)
SSRIs block dopamine, responsible for sexual drive. They can cause bruxism, restless leg syndrome, hyponatremia, and mucous membrane bleeding due to decreased platelet aggregation.
SNRIs, Depression Drugs, and Stroke Recovery (05:59)
Bancroft lists serotonin norepinephrine reuptake inhibitors. Antidepressants need at least 8 weeks to boost neurogenesis. Selective serotonin reuptake inhibitors are associated with less dependence, disability, neurologic impairment, anxiety and depression among patients recovering from stroke.
"Albans" or NOACs (01:44)
Novel oral anticoagulants are replacing warfarin/Coumadin. An antidote to reverse factor Xa is being developed. Indications include VTE, atrial fibrillation, and thrombosis prevention.
Top 5 Antibiotics Prescribed in Nursing Homes (10:39)
Bancroft discusses penicillin, 2nd generation dulfonamides, nitrofurantoin, and cephalosporins. Erythromycin reacts with other drugs. Clindamycin and fluoroquinolones cause C. diff.
"Mabs," "Nibs," and "Triptans" (05:07)
Monoclonal antibodies are targeted therapies. Learn about MABs targeting the immune system, tumors, and the heart. Bancroft discusses tyrosine kinase inhibitors and 5-hydroxytryptamine agonists.
Serotonin Antagonists for 5-HT3 (04:43)
5-HT3 in the chemoreceptor trigger zone of the brain stem is responsible for vomiting from chemotherapy and post-anesthesia. "Setrons" reduce anticipatory nausea and vomiting risk.
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