Unknown Speaker 00:00 Hi, welcome Speaker 1 00:07 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. Dr. Sean Kane 00:28 And now on to the show. Welcome to week five of Rosalind Franklin University's top 200 drugs podcast. I'm your co host, Dr. Kane. Speaker 3 00:38 I'm Dr. Weatherton, and I'm Dr. Patel, and this week, Dr. Sean Kane 00:41 we have a grab bag of different medications, from muscle relaxants to stimulants to anticonvulsants. So we'll go ahead and start with the muscle relaxant category. We have a couple different agents, but they all share similar characteristics. Speaker 3 00:55 Yeah, an interesting thing about muscle relaxants is they don't really do anything directly to the muscles. Speaker 4 01:01 Yes, that is true, because these agents work in the CNS. Nobody knows the mechanism of action, but we think that it's probably a GABA mediated and probably related to sedation and CNS suppression. Speaker 3 01:14 So without further ado, let's hit 88 miles per hour and go baclofen to the future and talk about Lioresal. Speaker 4 01:22 So the easy way to remember this drug is, remember back, and if your back is hurting or spasming, you use baclofen. Dr. Sean Kane 01:30 Now the interesting thing about baclofen, compared to some of the other muscle relaxants, is that we have an intrathecal formulation of baclofen. Where is your fecal? So intrathecal means that it's injected into the spinal cord. Ouch. Typically, this is for patients who have some type of lesion in the spinal cord, or even multiple sclerosis, where they're more prone to these types of spasms, Speaker 3 01:53 and in that case of intrathecal administration, do patients just start and stop this willy nilly. Dr. Sean Kane 02:00 So it actually has a black box warning that in patients who receive the intrathecal formulation, really bad things can happen if they stop at cold turkey without titrating it down. And although the PO tablet formulation doesn't have this warning, it's probably good practice to taper that down as well, along with all of our other muscle relaxants. Speaker 3 02:20 Very interesting. So if these patients abruptly stop intrathecal use of baclofen or liorosol, what type of bad things can happen? Speaker 4 02:28 Well, patients can have fever or they would have altered mental status. Sometimes they will have rebound spasticity or muscle rigidity, and because these medications are kind of affecting your muscles, there could be muscle breakdown, a severe version of that that's known as rhabdomyolysis. Dr. Sean Kane 02:46 Then also with the tablet formulation, and patients who withdraw from it too quickly, we might even see something like hallucinations, which would be consistent with lack of GABA, like with alcohol withdrawal Unknown Speaker 02:57 as well. Very interesting. Speaker 4 03:01 So Dr. Weatherton, if you just heard me, I had a hiccup, and it's been going on for a while. Do you really think that I can use any other medications, just besides drinking lot of water and snacking on sugar food? Speaker 3 03:16 Well, very interesting. You asked that Dr. Patel, baclofen is used sometimes off label in patients with chronic hiccups, and it tends to help. Speaker 4 03:26 All right, I'll be sure to ask my doctor about this medication. Dr. Sean Kane 03:29 So our next medication is carisoprodol or Soma, and this is similar to baclofen, but it's labeled only for short term use, so two to three weeks for the treatment of musculoskeletal pain, Speaker 3 03:42 and unlike baclofen, carisoprodol is actually a DEA schedule for medication. It didn't used to be however, it's metabolized into a substance called meprobamate, which is a c4 medication. Dr. Sean Kane 03:56 One of the reasons that it became a controlled substance was patients were abusing it and misusing it because of its sedative effect. Speaker 3 04:04 So the next drug on the list has one of the coolest names out of any drug. Its generic name is metaxolone. Its brand name is Skelaxin, which I remember because it's relaxing your skeletal muscles. What do we know about this one? Dr. Kane, just Dr. Sean Kane 04:20 like all of our other muscle relaxants, this works the same way, and it's used for musculoskeletal pain. It causes CNS depression, just like all of the other agents. Really the only unique thing about it is that patients should consider taking it with food, because food will actually increase the absorption of the medication. Speaker 4 04:37 And this was actually one of the newer agent in this category. So for the longest time it was more expensive, but recently it has gone generic. Dr. Sean Kane 04:46 Our fourth and final muscle relaxant is Cyclobenzaprine, or Flexeril. Speaker 3 04:50 I actually have a story about Flexeril during finals week one year in pharmacy school, I had a studying related injury and that I was sitting in the library for 10 or 12. 12 hours a day and developed back spasms. And when they gave me Flexeril, they helped my back spasms, but more so it made me drowsy for about eight hours after every time I took one. So when I think of Flexeril, the big thing I think of is drowsiness. What other side effects can patients expect from Flexeril? Speaker 4 05:18 Because the chemical structure of this agent is like the tricyclic antidepressants. Patient might have anticholinergic like side effects, such as dry eyes, dry mouth, constipation and also CNS, depression like side effects, as Dr. rutherton already mentioned, Drowsiness is one of them. Dr. Sean Kane 05:37 And then, like Dr. Patel mentioned, Flexeril or Cyclobenzaprine is chemically related to our TCAS tricyclic antidepressants. Because of that, it carries some warnings that the TCA class as a whole carries. This would include you can't use it within two weeks of an Maoi, and also, it shouldn't be used in patients who are at risk for certain types of arrhythmias. Speaker 3 05:58 What's an Maoi is that that city in Hawaii, Maui, Dr. Sean Kane 06:02 so Maoi stands for monoamine oxidase inhibitor. It's very old school way of treating depression that has a ton of different drug interactions, including SSRIs, SNRIs and TCA. Speaker 3 06:17 All these muscle relaxants are making me drowsy. Can we talk about some stimulants? Absolutely. Dr. Sean Kane 06:22 The next drug category that we'll be discussing are CNS stimulants, used for ADHD and narcolepsy. Speaker 3 06:29 Now these agents do have some common features as a class. They are all stimulants, and they are all potentially habit forming. They shouldn't be used in combination with monoamine oxidase inhibitors or MAOIs, they can potentially exacerbate anxiety and agitation, as well as they can bring the blood pressure up. So they shouldn't be used in uncontrolled hypertension. In addition to that, if patients have recently had a heart attack or have structural abnormalities in their hearts, giving them amphetamines or other stimulants can precipitate cardiovascular events. So we need to be cautious with that. Speaker 4 07:02 There are a lot of side effects that they cause, such as headache, insomnia, irritability and jitters. Patients might have decreased appetite and nausea. There is a greater abuse potential, and that's why these agents are categorized as DEA schedule two drugs. Dr. Sean Kane 07:20 So keep in mind, da schedule two means that these can't be phoned in as a prescription. The patient has to bring these in. They can't have any refills. So from a patient perspective, it's kind of a hassle compared to other prescription drugs, to go to the pharmacy with a c2 prescription. So I kind of think of the adverse effect profile of these agents similar to caffeine, so you're going to get tachycardic, hypertensive, little jittery, and it's really a dose dependent effect, so the higher dose, the more jitteriness you're going to feel. As far as patient counseling points for our CNS stimulants, I think it's important to obviously tell the patient to take it in the morning. Probably a good idea to avoid alcohol. And the reason is that it's kind of like mixing a Red Bull and vodka. You don't want the patient to be awake at a point in time where they're too far intoxicated when they're normally pass out. The same principle goes with caffeine and other stimulants. You really don't want to mix stimulants together, because you're going to have an additive effect of the jitteriness and things like that. Speaker 3 08:18 I think they call that the Four Loko effect. So the first agent on the list here is methylphenidate, which has a couple brand names, including Ritalin and Concerta. This agent comes in a lot of different dosage forms, doesn't it? Speaker 4 08:30 That is true. So we have this from this drug available in immediate release and extended release form. There is Metadate CD and Ritalin LA, and these can be also sprinkled over the apple sauce. And if that wasn't enough, a new patch formulation that is out in the market. The brand name is Daytrana. And then we also have chewable tablets and oral solution Dr. Sean Kane 08:54 that's a lot of different dosage form. As far as the patch is concerned, I think it's a good patient counseling point that the patch lasts about nine hours. So they can take it off earlier if they want, but the full effect is about nine hours long, so after that time period, they really should be removing the patch. Speaker 3 09:10 Nine hours sounds like just about the amount of time it would take to go to a day at school, huh? Dr. Sean Kane 09:15 Funny. You should mention that many of these agents are actually formulated with school children in mind. And when Ritalin first came out, one of the issues with it was that it was bid dosing, so the school child would have to visit the nurse in order to get their second dose, which is one of the reasons why we have so many different dosage forms that are this extended release, long acting formulation. Speaker 4 09:37 Do these oral pills have any recommendation in regards to take with food or take without food? Speaker 3 09:43 Good question. Dr. Patel, and that really depends on which agent you're talking about. Some of them need to be taken 30 to 45 minutes before food. But Concerta can be taken at any time without regard to food. Dr. Kane, I understand there's a boxed warning on methylphenidate, is there? Dr. Sean Kane 10:00 Correct there is so the box warning with methylphenidate or Ritalin Concerta de trano is that it should be prescribed and given cautiously to patients who have a history of drug dependence or alcoholism, because it is an abusable medication. Speaker 3 10:14 It's usually very important to refer to most drugs by their generic name in addition to their brand name, depending on who you're talking to, I, for one, tend to always refer to drugs as their generic name, except in the case of this agent, because its generic name, the generic for Adderall is amphetamine aspartate, amphetamine sulfate, Dextroamphetamine saccharin and Dextroamphetamine sulfate. That is a mouthful. It sure is. So what we find is that most people will refer to it using the brand name and just call it Adderall. Dr. Kane, what do you know about Adderall? Dr. Sean Kane 10:50 So Adderall comes in two different formulations. We have the immediate release and the extended release formulation. And one interesting thing about Adderall, which is because we have so many different types of salt forms in the preparation is it's a once daily form. So as I mentioned earlier, when Ritalin first came out and it was bid, dosing Adderall was a huge advantage, because it could be taken in the morning before a child went to school. There was no need to coordinate with a nurse or pull the child out of a class to get their second dose. Speaker 3 11:19 That does sound handy, being that it's so long acting Dr. Patel, do we have to give it at certain times a day? Speaker 4 11:25 As Dr. Kane said that there is an advantage of one's daily dosing. We prefer that the x star form be given before noon, and again, it can be opened and sprinkled over the applesauce, Dr. Sean Kane 11:37 and like Ritalin or methylphenidate, we also have the abuse potential black boxed warning with Adderall, but we also have an additional boxed warning, which is the risk of sudden cardiovascular death if the agent is misused. Speaker 3 11:53 So although it's inconvenient for patients to have a c2 I think you can start to see that there's good reason why these agents are C twos. Speaker 4 12:00 The next agent on the list is lisdexamfetamine. Brand name is Vyvanse, Speaker 3 12:06 so lisdexamfetamine, that sounds kind of like amphetamine. Is there any relation of this drug to Adderall? Dr. Sean Kane 12:13 So it's one of the salt forms within Adderall. And what they did was they added a lysine amino acid so that it would be longer acting and it wouldn't have as big of a peak effect when taken because it has to go to the liver first, because it's a pro drug. Speaker 4 12:27 What's the reason behind adding the lysine amino acid? Dr. Kane, so Dr. Sean Kane 12:31 the patent expired on Adderall. The patent did expire, and their their reasoning is that there may be less abuse potential with lisdexamfetamine Because it is a pro drug, and it may have a smoother peak and trough effect compared Speaker 3 12:45 to Adderall. So this is a capsule, but a lot of the target audience might be younger kids who aren't great at swallowing pills. Is there an easier way for them to take lisdexamfetamine? Yeah. Dr. Sean Kane 12:57 So unlike some of our other longer acting agents, where you sprinkle them over apple sauce. lisdexamfetamine can actually be placed in a glass of water, dissolved and drank immediately. How do the Unknown Speaker 13:08 warnings and ADRs compare to Adderall? Speaker 4 13:11 The warnings and the adverse side effects are pretty much similar to the agents we discussed before, such as Adderall and concerto. Speaker 3 13:19 Can we talk about some anti epileptic drugs. So the first agent in this class that we're going to talk about the anti epileptic drugs is phenytoin or Dilantin. What sort of seizures is this used for? Dr. Sean Kane 13:29 So there's three different types of seizures, generalized, partial and absence seizures. This is good for two out of the three. It doesn't cover absence but it does cover generalized and partial seizures Speaker 4 13:40 in what different dosage form is this medication available in? Speaker 3 13:43 I hear you can give it orally as a chewable tablet or an oral suspension. It also comes as a capsule and as an IV formulation. Dr. Kane, all those are probably just about the same, right? Dr. Sean Kane 13:55 Actually, if you attend my clinical pharmacokinetics class, you'll find that there's an 8% difference between the capsule and IV forms, which are phenytoin sodium, compared to the chewable tablet and the oral suspension, which are phenytoin acid. And it seems like 8% wouldn't be a lot, but it has a saturable metabolism, which means that at some point the liver starts to give up and it won't metabolize as much drug as quickly, and drug levels can go up very, very fast. Speaker 4 14:22 And since we are talking about pharmacokinetics of phenytoin, it is important to note that this drug falls under one of these narrow therapeutic window drug and so it is important to monitor the drug level. And another point, important point about pharmacokinetic is that it induces drug metabolism. So there is drug drug interactions that we should be looking out for. Dr. Sean Kane 14:46 Can you guys think of any common adverse effects that we might see with phenytoin or dilatin? Unknown Speaker 14:52 Did you say common or distinguished? Speaker 3 14:56 I hear that sedation is a big complaint of many patients as well. CNS, depression, symptoms and so patients should avoid alcohol. One of Speaker 4 15:04 the unique or distinguished side effect is nystagmus. So what is nystagmus? Dr. King, Dr. Sean Kane 15:12 so Nystagmus is when your pupil will shake as your eyesight goes to the periphery. So you can see this very commonly with sobriety tests, where the officer will ask you to follow his finger and he'll bring it all the way to your peripheral vision. When that happens, if you have nystagmus, which means you've had one too many to drink, or you've had phenytoin, your pupil will bounce back and forth very, very quickly. This bouncing effect is called nystagmus, very well explained. Another adverse effect that is well distinguished with phenytoin or Dilantin is Gingival Hyperplasia, which basically means that patients with chronic therapy, their gums will balloon out, and it can become painful. The gums can bleed, and it has cosmetic issues as well. Speaker 4 15:58 That is why it's important for patients who've been on phenytoin to have regular dental checkups. Speaker 3 16:04 I also understand that phenytoin can cause hirsutism. Is that correct? Absolutely. And hirsutism is hair growth. Is that correct? Unknown Speaker 16:11 That is correct, but I'll be right back Dr. Sean Kane 16:15 my that's a wonderful Afro you have now. Dr. Weatherton, Speaker 3 16:18 thank you. It's phenytoin. Fro so we're going to keep rolling with the phenytoin side effects, because there are a lot, but they're important as well. A couple that I think of are hepato toxicity and bone marrow suppression. I also understand phenytoin has some activities with folic acid. What's going on there? Speaker 4 16:35 So basically it interferes with the folic acid synthesis and it leads to peripheral so the absence of folic acid levels in the body leads to peripheral neuropathy, and it also causes vitamin D deficiency, this in turn, leads to lower bone density. Dr. Sean Kane 16:53 The other two adverse effects that I wanted to touch on are rash, which is actually fairly common, but sometimes it can be a very severe rash. And then also, in the hospital, we can sometimes use IV phenytoin. And there's some issues with IV phenytoin, where we can only give it so quickly because of what it's diluted in, it can cause cardiovascular collapse or even hypotension. And also, if the drug extravasates, which means that the IV becomes dislodged and the phenytoin goes into the tissue instead of the blood vessel, it can cause a lot of tissue necrosis and damage. Speaker 3 17:27 So you're saying that it's not the drug itself that limits the IV infusion rate, but the stuff that the drug is in, right? Speaker 4 17:35 Absolutely. So the next medication in the same class is divalproex, or the brand name is Depakote. And the only difference of divalproex to phenytoin is this one is used to treat all three different types of seizures, generalized, partial and absence. Wow. Speaker 3 17:55 So it's a fairly attractive choice. I guess we could call it Johnny Depakote. Dr. Sean Kane 18:00 So at least for me, because I don't use valproic acid very much in the hospital, I am absolutely confused with the types of dosage forms that are available. Speaker 3 18:08 All right, let's break this down. Depakote, brand name is composed of a substance called divalproex, which is both valproic acid and divalproex sodium that comes as a sprinkle capsule and as tablets, the tablets come in extended release and delayed release. And although that's confusing, they're not the same, but with three confusing dosage forms, that must be all of them, right? Speaker 4 18:34 No, that doesn't end it there. Dr. Weatherton, we have more formulations available. So the IV formulation, the generic name is Valproate sodium, the brand name is Depacon. And the capsule and syrup formulations are available of valproic acid, not the salt, and that one is sold as Depakene. Dr. Sean Kane 18:56 So let me get this straight. We have Depakote, which is both the acid and the salt form, there are sprinkles and tablets of the Depakote. So far so good. We've got Depacon, which is an IV form of the sodium salt, and then we have Depakene, which is the acid form that comes as a capsule and a syrup. Speaker 3 19:17 You are correct. Got it right? Dr. King, that was Depa confusing. All right, that's enough dosage forms. Now, what sort of adverse drug reactions are possible with the Depakote family? Speaker 4 19:30 Well, the list is just as long as phenytoin. I will start up with nausea, vomiting or GI discomfort, sedation and drowsiness to reduce the GI upset is suggested to take it with food and divide the dose throughout the day. And to also note that this GI upset is a dose dependent effect, Dr. Sean Kane 19:49 so unlike our CNS stimulants, which caused anorexia or loss of appetite and weight loss, valproic acid or Depakote can actually cause Speaker 3 19:58 weight gain. This. Can also cause alopecia, right? Dr. Sean Kane 20:02 So, unlike phenytoin, which causes hair gain, not always on the top of your head, valproic acid can cause alopecia or hair loss. Speaker 3 20:09 Well, who wants that? I also understand that divalproex can cause some blood abnormalities, including elevated ammonia in the blood, which generally is not a problem, and also low platelets, which can lead to bleeding. What other side effects are there? Speaker 4 20:25 This drug is also known to cause hepatotoxicity. In fact, there is a black box warning for hepatotoxicity, especially in the children less than two years old. So the recommendation is to monitor the liver function tests while patients on it. There is a rare side effect. It is also a black box warning of pancreatitis. And as we said, the list just keeps growing. Dr. Sean Kane 20:48 So kind of the opposite of phenytoin. Instead of inducing hepatic metabolism of other drugs, it actually is a mild or weak inhibitor of drug metabolism. So it's the opposite effect. But clinically, this inhibition isn't terribly relevant. Speaker 4 21:02 And so what about pregnant women? Can they take valproic acid? Speaker 3 21:07 Divalprox is pregnancy Category D, so it should generally be avoided in pregnancy. Dr. Sean Kane 21:13 So phenytoin is also pregnancy Category D, but for whatever reason, valproic acid has gained a boxed warning for use in pregnancy, and Speaker 3 21:22 and like phenytoin, we also need to monitor drug levels with Depakote. Speaker 4 21:27 That is correct. This drug is considered narrow therapeutic window drug, so just like phenytoin, we do monitor the levels, Dr. Sean Kane 21:34 and there will be more on that in clinical pharmacokinetics. Speaker 3 21:40 All right, that's enough prescription drugs for me today. Folks, can we talk about some over the counters? Speaker 4 21:47 Yes, I'm actually really excited, because I'm going to the tropics, and I want to talk about DEET. Do we even want to know the generic name? It's N,N diethyl meta toluamide. Speaker 3 21:59 Now what are you going to use DEET for? Speaker 4 22:02 Well, they're going to be in the tropics, and I don't know what kind of bugs are there, so I'm going to spray myself, but some deed to prevent insect bites. Good. Speaker 3 22:12 You should probably layer it on as thick as possible, right? Should I? No, you shouldn't. DEET is neurotoxic. ADRs don't happen very often, but they're possible, especially with excessive use. Is that right? Dr. Kane, Dr. Sean Kane 22:26 yeah, so in patients who ingest too much DEET, or if they just slather it on so much that they absorb a lot of it systemically, they can see adverse effects like restlessness, insomnia, altered mental status, all the way to slurred speech. And at really high doses, we can see hypotension, bradycardia and seizures. Speaker 4 22:46 Okay, that sounds like a vacation disaster. I will remember just to apply a single layer Speaker 3 22:52 that's right, and only apply it once every eight hours, because it will last that long, even if you're going in and out of the water. Dr. Sean Kane 22:59 Interestingly enough, there's a number of different dosage forms that deep comes in. Speaker 4 23:04 Oh, I researched this because I was looking to see which one I can carry with me and my bag. So we have the topical, liquid lotion, and we have the aerosol or the spray. We also have towelettes available, and one of the formulation is also available in the control release form, and you can go out and buy these products in many different brand names. The most common one you probably have seen is off with the exclamation point or muscle Ultra THON cutter and more cool, Speaker 3 23:35 enjoy your vacation. Dr. Patel, now me, I've been researching athlete's foot, and I've heard about Tough Actin Tinactin, which I understand is also known as tolnaftate. What do we use tolnaftate for? For listening to John Madden's commercials for treatment of tinea pedis, which of course, is athletes foot, tinea cruris, which is jock itch, and tinea corporis, which is ringworm, do we treat for the same length of time for all these different indications? Dr. Sean Kane 24:07 So tinia cruris, the jock itch, you need to treat for two weeks, and then the other two you need to treat for four weeks. Speaker 3 24:14 Now, I thought we talked about terbinafine In the past, which was Lamisil AT and it was another Athlete's Foot treatment, but that one only required one week of treatment. Dr. Sean Kane 24:25 That's true. So we have Tough Actin Tinactin, two to four weeks, whereas Terbinafine, or Lamisil AT only requires one week of treatment. Speaker 4 24:33 Not so tough acting anymore Is it? Speaker 3 24:36 Now, this agent comes in multiple dosage forms, as you'll usually see, an aerosol, a powder, a cream and a solution. The thing about the aerosol is it contains a little bit of alcohol, and it should not ever be applied to broken skin, particularly in some of these more sensitive areas where it will sting like the dickens. Dr. Sean Kane 24:57 So our last over the counter agent is Eucerin Cream. Eucerin is actually a name for a company that has a lot of different products. Speaker 3 25:05 So what's so special about this Eucerin stuff? What's it used for? Dr. Sean Kane 25:09 So it's really just used for dry skin, and a lot of dermatologists will recommend Eucerin cream because it doesn't have any fragrances, it doesn't have any dyes, and it's non comedogenic. What does that mean? So non comedogenic means that it shouldn't clog your pores and form blackheads in your skin. Ooh, fancy. So that concludes week five of Rosalind Franklin University's top 200 drugs. The first drug we talked about was baclofen Speaker 3 25:34 or Lioresal. Then we talked about carisoprodol or Soma. Speaker 4 25:38 The next on the list was metaxolone, brand name, Skelaxin. Dr. Sean Kane 25:43 Then we talked about Cyclobenzaprine, or Flexeril, and Dr. Weatherton had a flashback moment of his pharmacy days. Speaker 3 25:50 Then we moved on to the CNS stimulants, and the first agent that we talked about was methylphenidate, which goes by many brand names, including Ritalin and Concerta. The next Speaker 4 26:00 one on the list was the mouthful, generic name of methamphetamine and Dextroamphetamine salts. Brand name is Adderall. Dr. Sean Kane 26:09 And then we had a similar drug, lisdexamfetamine, or Vyvanse. Speaker 3 26:13 And then we moved on to the anti epileptic drugs, the first one of which was phenytoin or Dilantin. Speaker 4 26:19 The next one on the list was divalproex, brand name, Depakote, or many others. Dr. Sean Kane 26:24 And then we had a few over the counter agents. The first was DEET, which goes by a number of different brand names, including off exclamation point. Speaker 3 26:33 The next was tolnaftate, which goes by the brand name Tough Actin Tinactin. Speaker 4 26:38 And the last one on the list was just basically Eucerin cream. Sad, no brand names. Dr. Sean Kane 26:44 So that concludes week five of Rosalind Franklin University's top 200 drugs podcast. I'm your co host, Dr. Kane. Unknown Speaker 26:50 I'm Dr. Weatherton And Unknown Speaker 26:51 I'm Dr. Patel. Study hard. Speaker 1 26:56 This has been an educational production by the Rosalind Franklin University College of Pharmacy. Dr. Sean Kane 27:00 This podcast is copyright Rosalind Franklin University of Medicine and Science. Speaker 1 27:05 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 healthcare provider. Theme music for this podcast is an excerpt of Metro Mix by sea salt released under Creative Commons.