DIP Episode 484 - Step 2 and 3 Drugs Series 1 (Pain Control)

Welcome, my name is Divine. This is episode 484 of the Divine Intervention Podcasts. In today's podcast, I'm going to be focusing on step 2 and step 3 drugs and I'm going to be focusing on pain control. Basically in this podcast I want to essentially deal with the drugs that are tested on step 2, step 3 from a pain control perspective. I'll talk about the ways they are classically tested, the things they are classically used for and the different ways they can try to throw them on exams. And if you're studying for any of your USMEL exams, step one or the way to step 3, I have a bunch of review courses that are coming up this month. They pretty much all start on the 19th of October with the testing course. That's for step 1 to step 3 and then I have a bias that's class also for step 1 to step 3 on the 20th and social sciences and ethics and quality improvement class. Also for step 1 to step 3 on the 21st of this month. Then I have a 20 hour step to step 3 review course taking place the week after that. That's a 20 hour course. Many people have taking these courses and done it extremely well. So if you're interested, just shoot me an email through the website, they'll over zoom and I can give you some more information. Okay, so let's jump right into these strokes. So what if they give you a question about a patient?

The patient comes in and they tell you that it's like a 19 year old male is brought to the hospital by his mom and his mom says that you know for the past 12 hours her son has been vomiting, her son has significant red or prochordal pain and then they give you a few labs and the child's AS Ts and AL Ts in the thousands and then they also tell you that this child has a history of tripping resistant depression and I'll try to commit suicide on many occasions and they ask what is your next best step in pharmacotherapeutic management? Well, I really hope you're saying oh divine, this sounds a lot like acetylaminophane toxicity and this child needs an acetylocysteine. So that kind of brings us to the first pain control medication we're going to talk about which is going to be acetylaminophane. Many people know it as teladol, people in the United Kingdom probably know it as paracetamol, people in Nigeria where I come from probably know it as paracetamol but it's a very important drug to them about and there are many things it is used for, right? And most times on the exams we use it to manage like fevers. For patients a fever acetylaminophane is pretty good for that. If a patient has febrile seizures, right? So if they give you a question about a child that has a high fever and they have a seizure that lasts for less than 15 minutes, that's a febrile seizure, that's going to respond to acetylaminophane.

When you see a person that has osteoathritis and you want to try out some pharmacotherapy, one of the things you can try out for osteoathritis to start is acetylaminophane. You can try it out for a while, see if it works, see if it helps, people's symptoms, if it doesn't and obviously you're going to transition to an insid. But acetylaminophane is also used for that purpose, right? So in general if a person has just fever, you really should be able to use acetylaminophane for that, right? I mean if a person if it has like, let's say they have this one or the other thing I was trying to think about here, besides just fever. But if a person has migraines, right? You know migraines many times you can use so much rip time for that, but honestly there are other things beyond so much rip time you can use. In fact, one thing you may weirdly see on your exam is the combination of like acetylaminophane and caffeine, right? Those things can actually control a person's migraine headaches acutely pretty, pretty well, right? But again, how do acetylaminophane work? Well we know that it works centrally. The thing is we don't fully understand how it works. We believe it may be a cox inhibitor that may work centrally, but if you notice the mechanism of acetylaminophane is really if ever tested on the on the exams, right? So what's the big big big thing to keep in mind with acetylaminophane in terms of toxicity? Liver liver liver toxicity. That's the big thing to keep in mind for step two.

Step two and step three, because remember it generates a quinolone derivative known as NEPQI and that can cause liver damage. So we can prevent that, we can treat it in acetylostean. Not prevent, treat it within acetylostean. In acetylostean, it will help you regenerate growth of fion and now fix the problem. Kind of important to know. And remember, I said, I mean often for the most parties, pretty pretty safe in pregnancy. It's something that you can give to a pregnant woman and you can also give it to a child as well. Okay? You can also give it to a child as well. Okay? So what if they give you a question about a 39 year old male and they tell you that, you know, for the past one week, he has had decreased urinary output and that he has asia diabetes and back crudic back pain. And you know, he has been on some medications. He has been on ibuprofen for his chronic back pain and was recently placed on an e-sinhibitor and, you know, he has had decrease urinary output and he gives him some labs and he gives him like a, like a, a, like one month ago versus now, you know, when do you put him on an e-sin hibitor or whatever. And you notice that many creatinians jumped up a lot. When you see that, I really hope you're thinking about an inset, right? Interactive with an e-sinhibitor and causing problems. Let me explain. This person has back pain. Back pain, right? Yeah, taking an incest, taking an incest, taking an incest.

Well, incest, you know inhibitors of cycloxygenase, then he be clock, cox 1 and 2. When he be cox 1 and 2, that's going to lower your synthesis of burst agglantines and burst agglantines, and visual dilators. When you know where the synthesis, you're going to have constriction of your afternoon material. That's going to cause decrease renormal perfusion, right? And that can kind of lower your GFR and raise your creatinine. But then if you add another problem on top of it like an e-sinhibitor, e-sinhibitors are efferent arteriola dilators. When you dilate the e-friend material, you're going to crush the hydrostatic pressures, you're going to mirror capillaries. That's going to lower the person's GFR and bring up the creatinine. So that interaction is kind of a nice interaction to know for, for exams. So obviously here we're going to be talking about the insets. The big one I'll talk about is aspirin. Remember, aspirin is different from the other insets. In that aspirin is an irreversible coxone and coxone inhibitor. But your regular insets like ibuprofen, naproxen, ketoroelac, ketoroelacism of an IV medication, those ones are reversible coxone and coxone inhibitors. And then many probably remember cello-coxib, those coxone inhibitors, apparently they're the ones that help, right? So you don't have GI issues, which is kind of helpful to know, right? Like cello-coxib, I think horrific coxib is another one. Those ones don't have the GI effects.

Because remember, between coxone and coxone, that's responsible for the GI bleeding associated with the insets. So usually we're going to use insets for a variety of reasons on exams, right? We can use them to money just to arthritis. If I said a malefin is not working, we can use them to close the doctor's arteriosus, right? We can use them to treat juvenile rheumatoid arthritis. You can use them as first line for gout. You can use them as first line to get out with coaches in for acute paracoditis. In fact, you can use them as topolytics, right? So if someone goes into premature labor, at least after 32 weeks, you can use an inset like endomethocin for that purpose. Also, if a person has primary dysmenorrhea, painful mancy, remember those things arise from prostaglandin meditated, myometrial contractions. So if you give something that needs prostaglandin synthesis, like an inset, it's great for primary dysmenorrhea. So it's pretty good for many of those, many of those purposes. I remember aspirin. We use it as part of the dual antipletlith therapy after a person has had an MI is also the first drug you give in an acute MI situation, right? Or if a person has a stroke from chronic stenosis, we're going to give aspirin as a first line drug because it also has antipletlith, antipletlith properties, right? So there are many ways you can really use an inset on exams.

I remember for the first six months after an MI, you try to avoid using like a straight-up inset because again, that can cause issues with like myocardial rupture. So we try to be careful about that. So insets are used in many different lights on exams, even Kawasaki's disease. Remember, we're going to treat our aspirin and IVIG. That's the only probably situation we give aspirin to a little kid because we're trying to avoid this whole right syndrome business, right? And remember the big toxicidodensets is that they can cause GI bleeding, GI, GI, GI bleeding. Again, because of that inhibition of Cox 1 effect, I remember aspirin was a right syndrome and you know, aspirin can also cause tenitis and cause ringing in the ears. So that's something you want to know. aspirin is also an oncoplane agent, right? So it can cause people to become hyperthermic and many people know this whole business with salicylic toxicity where it's going to you know, drive a pure respiratory, so you have a respiratory acetylucleosis because you're blowing off CO2 and then literally aspirin is called acetyl cellic acid, so because it's an acid, it can also cause a high anion gap in a polygacidosis. Please note, it causes both of those problems at the same time, not only one or the other. That's a common thing you see in many resources, but that's absolutely wrong. I mean, causes both problems, okay? That's something I kind of want you to fix in your mind because it's both at the same time.

Your PCO3 is going to get crushed, your bike cover is going to get crushed as well. It's going to cause a respiratory acetylucis with a metabolic acidosis at the same time. That's incredibly important to know for your, for your exams, okay? That's incredibly important to know for your, for exams. So again, don't forget the reno failure that you can get with the stuff. Don't forget the gastric GI bleeding you can get from the stuff and many people don't give incense, credit for this, but it's also a drug that causes photosensitivity. It's a photo sensitive drug kind of like the tetracycline or your cell phone amides or a mutorome. Just something you want to keep at the back of your mind as you study. And then again, again, I say we use it as a topoletic, but we're only using it at less than 32 weeks. If you're using beyond 32 weeks, that's not smart. You're going to be closing the doctors' arteriosus if you, if you do that. So just kind of be careful, kind of be careful about that. Kind of be careful about that. And then the, and then we've talked about the reno failure you can also get with, you know, taking an inset and aspirin like crazy, right? And again, think about it, these drugs cause a lot of bleeding because a lot of bleeding, right? So you want to be careful about combining them with other drugs that cause bleeding, right? So like other anti-bleteleid drugs, other anti-gwaugulants, not very smart, combining all those things together.

Now, one other thing you may see NSA's use for you, you can use it actually for rheumatoid arthritis, right? So you want to use it like when a person has, like just to acutely control symptoms of our control of the pain, you can use an NSA'd. Remember a long term, you're going to be using a a demarc like methyl trexid for, for example, it's kind of important to keep, keep a back of your, of your mind, right? And again, if you have a really, really bad kidney, you really shouldn't be taking NSA's. That's kind of an important thing to keep in mind. And again, if you're taking a lot of drugs that cause bleeding, think twice before you put that person on, on an NSA'd. Now, the final thing I'm going to talk about here in terms of being controlled with this series of the opioids, right? So, you know, the opioid is the love, love, love to test these things on exams, right? They're useful pain control, right? Things like codine, oxycodone morphine, hydromorphine, I think that's delauded, you know, fentanyl, things like that. Remember opioids can cause problems, right? But we use them for severe pain, right? If a person has like post surgical pain, they've had like big surgery, given an IV opioid is not a bad idea, right? If a person has cancer pain, right? Many times when a person has cancer pain, right? You can try to start off with like NSA's, but many times you're not going to control their pain, you're going to flip to an opioid.

And in those cases, you want to make sure that the opioids are giving with two softener, because opiates can cause constipation, right? And remember, opioids work by literally being meal receptor agonists, right? And we know the big toxicity, which is going to be respiratory depression, how you're going to manage that, where you're going to give an aloxone. An aloxone is a meal antagonist, so you can use it to reverse opioid intoxication. Please use now tricks on right now. Tricks on is more for alcohol use the solder. It's not to reverse opioid intoxication, just FYI. And the big big thing you want to keep in mind with opioids is that opiates, right? If you see an opioid intoxication, right? You're going to have respiratory depression, your e-gradient will be completely normal, because the problem is not in the lungs to bring problem. I got to see them become hypercapnic, so you're going to have awful ventilation. You're going to see them, they have pinpoint opioids, popularly meiosis, right? Because opioids reduce the synthesis of an rapid effort in the body, right? So they decrease the synthesis of a sympathetic hormone that will cause my dryness. So you're going to get meiosis, right? You're going to get constipation, you're going to get a person that's very confused, you're going to have abdominal pain and all these things, right? So that's pretty high, you know? So what do we use to reverse it again? As I've said, you're going to give an amoxone, right?

And again, what are a few quirks you need to know about opioids? In general, if a person has a bad kidney, you need to cut down the opioid dose they get. That's the truth. A person has bad kidneys, they're going to be able to metabolize opioids very quickly, and they can get in some very, very, very severe troubles. And some other weird things you kind of need to know, there are some opioids that have serotonergic properties. So combining them with another serotonergic agent can cause serotonin syndrome, right? It's going to be things like my buried in, things like fentanyl, thing twice before giving another serotonergic agent and people that are taking those stains, right? And then don't forget morphine. We use morphine for people that have a cancer, right? Or they have terminally ill, they have a shortness of breath. morphine is the drug of choice for that purpose, right? And then don't forget, co-dean kind of has this weird relationship, but co-dean, we say that a lot of cough syrups, right? But there's this genetic mutation, it's kind of weird, it's kind of high yield. The CYP 2 D6 mutation, it's pretty common actually in Caucasians. These people are not going to be able to metabolize co-dean, right? So they can get in a lot of trouble. So just be mindful of that, be mindful of that, right? Just don't forget the CYP 2 D6 issue.

You know, so just know the genetic mutation, but the big thing is they just support that have like mutation, and that's CYP 2 D6 business where they just convert co-dean to like huge amounts of morphine, right? Get like severe respiratory depression and all these problems, right? So just kind of be careful, careful about that. And that'll probably be in a Caucasian actually on your, on your test. So those are the different ways they test these different pain control medications. Again, I know this may sound like a short podcast, but I promise you, the stuff is pretty, pretty high yield to know for you, exactly. So just study it, know it. You're going to see it shopping many different way shapes and forms on your test in one way or the other. So thank you for joining me today. I will see you in a piece of 485. God bless you. I do offer 101 tutoring for all the USML exams. Again, I have review courses as I've mentioned already. And then I have these podcasts on the major podcast apps. I have a You Tube channel, Divine Intervention, USML podcast and videos. That's where I post the videos that I meet. And then I have another website called Divine Intervention Lifelessens.com. I post podcasts regularly there. We're from a biblical perspective, I address life lessons. I actually have a podcast on Apple podcasts, you know, so you do with that called the Divine Intervention Life Lessons podcast. Well, thank you for joining me today. I'll see you next time. God bless you. Bye for now.

Thank you.

Hepatotoxicity (Liver damage), due to the formation of a toxic metabolite called NAPQI.

NSAI Ds, as they can precipitate acute kidney injury by compromising renal perfusion and GFR.

It causes both a respiratory alkalosis (low PCO2) AND a metabolic acidosis (low HCO3), making it a mixed acid-base disorder.

Because their primary toxicity is severe respiratory depression, which requires immediate reversal to prevent hypoxemia and death.

CYP2 D6 deficiency/mutation; this prevents the conversion of codeine into its active metabolite, morphine, leading to ineffective pain control or accumulation of toxic metabolites.

Only for premature labor occurring before 32 weeks gestation (e.g., using endomethacin). Beyond 32 weeks, the risk outweighs the benefit due to potential closure of the ductus arteriosus.

Inhibition of COX-1, which reduces the synthesis of protective prostaglandins in the gastric mucosa.

Osteoarthritis (OA) and Gout.

Aspirin; monitor for GI bleeding, tinnitus, and the mixed acid-base disorder (respiratory alkalosis + metabolic acidosis).

NSAI Ds combined with ACE inhibitors.

Morphine, as it can help manage dyspnea (shortness of breath).

Opioids; they require an anti-constipation agent (like laxatives) due to their effect on gut motility.

Inhibition of COX-1, which reduces the synthesis of protective prostaglandins in the gastric mucosa.

Osteoarthritis (OA) and Gout.

Aspirin; monitor for GI bleeding, tinnitus, and the mixed acid-base disorder (respiratory alkalosis + metabolic acidosis).

NSAI Ds combined with ACE inhibitors.

Morphine, as it can help manage dyspnea (shortness of breath).

Opioids; they require an anti-constipation agent (like laxatives) due to their effect on gut motility.