Speaker 1 00:00 Rob, welcome to Rosalind Franklin University, College of Pharmacy top 200 drugs podcast. Speaker 2 00:12 This podcast is produced by the pharmacy faculty members to supplement study material for students learning the top 200 drugs we're hoping that our real life clinical pearls and discussions from practicing pharmacists will help you study for your next drug quiz. Speaker 1 00:29 No participants have any conflicts of interest to disclose. This podcast is for educational purposes only and is not intended to treat a particular patient. This information should not be used in lieu of the judgment of a health care provider. Dr. Sean Kane 00:41 This podcast is copyright Rosalind Franklin University of Medicine and Science, and now on to the show. Welcome to Episode One of the Rosalind Franklin University top 200 drugs podcast. I'm your co host, Dr. Kane. Unknown Speaker 00:55 I'm Dr. Weatherton, and I'm Dr. Patel. Dr. Sean Kane 00:57 So without further ado, we're going to go ahead and get started with week six of our top 200 drugs podcast, and we'll go ahead and get started with metronidazole or Flagyl. Speaker 3 01:07 Dr. Patel, is it okay for patients to drink alcohol on Flagyl? Dr. Khyati Patel 01:11 Oh, no, I don't think that's a good idea at all. If your patient drinks while taking metronidazole, then they're gonna have a reaction called disulfiram, like reaction where A patient's gonna just throw up violently. Dr. Sean Kane 01:24 That sounds horrible. I've even heard that little small amounts of mouthwash that has alcohol in it could even cause this reaction with Flagyl. No kidding. So really, total avoidance of alcohol is necessary and a great counseling point with metronidazole or Flagyl. When do we use Flagyl? Speaker 3 01:42 We use Flagyl because it covers anaerobes and protozoal infections. Dr. Sean Kane 01:47 Okay, amoeba is protozoal. Dr. Khyati Patel 01:49 Whenever I think of metronidazole, I think of diaphragm. Diaphragm down. So all the abdominal infections as well as STDs, are also covered by metronidazole. Dr. Sean Kane 01:59 As far as adverse effect scope for the most part, it's going to be the typical antibiotic adverse effect profile, nausea, vomiting, upset stomach, things like that. But it has actually some unique adverse effects. What comes to mind when you think of unique adverse effects with Flagyl, metallic taste in the mouth? Definitely, that's the one I think of. Is metallic taste. They may need to get some Listerine for that bad taste Speaker 3 02:20 in their mouth, right? Oh no. Oh no. Listerine with Flagyl, we want to avoid that disulfiram adverse reaction, Dr. Khyati Patel 02:26 yeah, and I'm thinking of like peripheral neuropathy kind of symptoms as well, yeah, especially with long term use peripheral neuropathy, it is also one of the first line medication for treating mild to moderate C. diff infection. And what is C. diff? C. diff is an organism that causes watery diarrhea Speaker 3 02:45 and speaking of things that go wrong in the gut when people have parasitic infections, often those parasites have flagella, which sounds a lot like metronidazole's brand name, which is Flagyl. Dr. Sean Kane 02:57 Moving on to our next antibiotic that can actually cause C. diff, clindamycin or Cleocin. Typically, this is, you know, for anaerobic infections in the mouth. We see it for gram positive infections on the skin, Dr. Khyati Patel 03:09 or even aerobic gram positive coverage, where patients are not tolerating or cannot take penicillin. Speaker 3 03:15 When I think of Cleocin, I think of clear skin, clindamycin has a topical form that can be used for acne, and again, it's very effective at treating various different types of skin infections. Dr. Sean Kane 03:25 So kind of continuing on with our antibiotics for the skin, doxycycline, and it has a number of different brand names. The one that we're going to go with today is Vibramycin. Unlike the previous two antibiotics that are kind of on their own with respect to their drug class, this one is actually part of a broader class of drugs, which is the Speaker 3 03:43 tetracyclines, including other antibiotics such as tetracycline and minocycline. When do you guys see doxycycline Unknown Speaker 03:49 commonly used? Doxycycline Dr. Khyati Patel 03:51 has a broad spectrum of coverage. Mostly we have seen it used for patients who have had acne, infections as well as pneumonia, Lyme disease, rickettsial infections and plague. Dr. Sean Kane 04:06 Did you say plague? Oh, yes, I did. So are there any patients that really shouldn't receive doxycycline? Speaker 3 04:11 Doxycycline or Vibramycin is not a good choice for children under eight, and the reason for that is that doxycycline likes to bind with calcium, and in children that age, they're still forming their teeth, so they could have teeth and bone issues if they're given doxycycline at a young age. But it's also a good counseling point, even for adults, that they should separate doxycycline from any calcium or iron that they're taking, so that they don't bind together in the gut and affect absorption. Dr. Kane, what's the dose of doxycycline or Vibramycin if a patient has the plague, I think it's 100 milligrams B ID, but what's the dose if the patient has renal impairment, I'm pretty sure it's 100 milligrams B ID. What's the dose of doxycycline if the patient has Lyme disease? I'd have to look it up. But I believe it's 100 milligrams B ID. I think you're right on all. Those counts. Dr. Sean Kane 05:00 So as a final counseling point, what are some adverse effects that people can see with doxycycline? Dr. Khyati Patel 05:06 I would say photosensitivity is one of them. So you definitely want to advise your patients to use enough sunblock sun protection or avoid sun exposure altogether. And another minor side effect, I would say rather, is esophageal irritation. It can cause ulceration, too. So make sure to so ask them to drink a full glass of water, Dr. Sean Kane 05:26 probably not right before bed, right? Yeah, that's after all, they are dosing it, Unknown Speaker 05:31 BID, 100 milligrams. Dr. Sean Kane 05:33 All right, speaking of BID, the next medication, also an antibiotic, is nitrofurantoin, and it has two different brand names, Macrodantin and Macrobid. And the reason I said, speaking of BID, the brand name Macrobid, Macrobid being BID. That's how you take the antibiotic BID. Speaker 3 05:52 One of the things you'll also notice about the brand names for nitro furantuan Is that they contain the word macro. The reason for that is the crystals inside of the capsule are big, so they become absorbed slower. Before these were macro crystals, the medicine was absorbed faster, and it wasn't tolerated as well, so they had to formulate it differently to get people to take it. Dr. Sean Kane 06:14 So how often do you have to dose Macrodantin? Dr. Khyati Patel 06:17 So Macrodantin, if you can think it's a longer word. So it's a QID dosing, more frequent dosing. Dr. Sean Kane 06:24 So I'm no, you know, paid representative Macrobid, but I don't see any reason to use Macrodantin. I agree. All right, so when are we using this medication? It's claim to fame Unknown Speaker 06:35 is the UTI. Dr. Khyati Patel 06:37 Are there any patient population where you don't want to use this medication? Speaker 3 06:41 So it's good to stay away from nitrofurantoin or macrobid in elderly patients, and you definitely want to stay away from it in patients with really poor renal function when their creatinine clearance is less than 60. This drug is a no go. Dr. Khyati Patel 06:55 One of the side effects of nitrofurantoin is hemolytic anemia, and that's again, related to the enzyme G6PD deficiency. Another side effect is pneumonitis, and you can also see peripheral neuropathy. Dr. Sean Kane 07:10 Our next antibiotic is sulfamethoxazole, trimethoprim. It's got two brand names, Bactrim and septra. Bactrim being the more common brand name. We see this a lot with urinary tract infections, with skin and soft tissue infections, especially with MRSA in the skin, Dr. Khyati Patel 07:26 and we also use for PCP, which is the type of pneumonia that HIV patients are at high risk of getting, so both the treatment and the prophylaxis. Dr. Sean Kane 07:37 So Dr. Weatherton, what are some adverse effects that one might expect when taking Bactrim or septra, which is sulfamethoxazole, trimethoprim. One thing that's Speaker 3 07:46 very important to tell your patients is they can have photosensitivity with Bactrim. They need to wear sunscreen and be sure that they're covering up and staying out of the sun as much as possible. Dr. Khyati Patel 07:56 If you say sulfamethoxazole, if your patient has sulfa allergy, then definitely want to be, you know, avoiding this medication. Some patients are not aware that they have sulfa allergy and they would develop rash. So that rash could be a normal all over presentation, or it could be a serious reaction, such as Stevens-Johnson Syndrome too, Dr. Sean Kane 08:18 speaking of the rash, interestingly enough, when we use Bactrim in patients who have AIDS, where we're using it to prevent that PCP or PJP pneumonia, they actually have a much higher incidence of rash compared to non AIDS patients, which you think would be the opposite, because they have an impaired immune system. Dr. Kane, what kind of patients shouldn't take Bactrim? So you kind of want to avoid Bactrim and neonates, and the reason is that they have higher bilirubin levels. And if you have Bactrim, it can compete with the same binding sites, and if it kicks off bilirubin from the proteins in the blood, you get what's called Kernicterus, which is essentially too much bilirubin in the blood. Dr. Khyati Patel 08:55 This medication also interacts with warfarin, and it's a it's a heavy interaction. So if your patient's on warfarin, you might want to think about another option. So kind Dr. Sean Kane 09:05 kind of switching gears a little bit, going from some oral stuff now to some topical items. We have mupirocin or Bactroban. Do you guys ever see this used in the community? Dr. Khyati Patel 09:14 Oh, yeah, all the time. I remember filling those 22 grams of mupirocin generic nasal tubes all the time, and interestingly, it's available as an ointment, which is for nasal use, and then a topical cream. Did you say nasal use? Yeah, it's weird. Sounds weird, but it is definitely used for nasal MRSA colonization. Dr. Sean Kane 09:37 All right. Moving on, we have two over the counter products as part of our top 200 drugs. The first is zinc oxide, the brand name Desitin, typically used for diaper rash dermatitis. Speaker 3 09:48 Zinc Oxide works by sort of drying out and shrinking portions of the skin. It's called an astringent. And it's also neat in that zinc oxide, or Desitin, has a very simple. Chemical name to remember. It's just z, N, O and Dr. Khyati Patel 10:03 Desitin, per se, is not used as a sun block, but if you add titanium dioxide in it, you can definitely use this product as a sun block as well. So if you think of soccer players, or if you're a cricket fans out there, you see that white patch on their face or nose. It's to protect their little noses from getting burned. Unknown Speaker 10:22 Zinc and titanium. I'm thinking of Iron Man. Dr. Sean Kane 10:25 The last item we have is polyethylene glycol, 400 the brand name here is Sustain. For Sustain eye drop. Many people call these artificial tears or just lubricant eye drops, obviously used for dry eyes. Speaker 3 10:39 When you're looking at over the counter eye drops, one of the biggest distinctions that you can make are the preservative free ones, which tend to come in single use vials, versus the agents with preservatives, which are the bigger three or five ml bottles that you see. The preservative free agents may be less irritating, but you also have to counsel patients that once they open that bottle they need to use it and throw it out immediately, or it can harbor bacterial growth. Dr. Khyati Patel 11:06 Yeah, with that same note, then you shouldn't touch the tip directly to the eye or with your hands. If your solution or the medication looks any cloudy or discolored, make sure you discard it. And if you are wearing contact lens, then make sure you remove the contact lens before you use the medication. So the Dr. Sean Kane 11:23 first drug we talked about was metronidazole or Flagyl. Speaker 3 11:27 The next one that we talked about was clindamycin or Cleocin. The third one Dr. Khyati Patel 11:30 on the list is doxycycline, Vibramycin, as we mentioned, it has many different brand names. Dr. Sean Kane 11:37 The next one was nitrofurantoin, two different brand names Macrodantin and Macrobid. Speaker 3 11:42 The next agent that we talked about was sulfamethoxazole combined with trimethoprim in a brand name product called Bactrim. Speaker 4 11:49 The next one on the list is mupirocin. The brand name is Bactroban. Dr. Sean Kane 11:53 So we had two over the counter agents. The first was zinc oxide, brand name Desitin, Speaker 3 11:57 and the next was polyethylene glycol. 400 also known as Sustain eye drops. Dr. Sean Kane 12:03 So that concludes week six of our first podcast for the top 200 drugs, presented by Rosalind Franklin University, Dr. Weatherton, Dr. Patel, always a pleasure, and I'll look forward to next week. Thanks. Dr. Kane, study hard. This has been Speaker 1 12:20 an educational production by the Rosalind Franklin University, College of Pharmacy. The theme music for this podcast is an excerpt of Metro Mix by Cecil released under Creative Commons. You.