Warfarin INR Goals

⭐Test your knowledge and check your answers on the second slide!

Let’s talk warfarin INR goals 🤓⁠

💊 Warfarin is a vitamin K antagonist that requires INR (international normalized ratio) monitoring due to its narrow therapeutic index. Dosing is affected by many factors including diet, drug interactions, genetics, and close INR monitoring is required to decrease the risks of bleeding and/or clotting.⁠

🤔 Overall, direct oral anticoagulants (DOACs) are now recommended over warfarin in the majority of clinical situations unless there is a compelling reason for them to on warfarin such as valvular atrial fibrillation, severe renal dysfunction, patient costs, or close therapeutic anticoagulation monitoring required.⁠

🔑 Key points about INR monitoring:⁠

-Baseline INRs are recommended prior to initiating warfarin therapy⁠
-Warfarin requires overlap or ‘bridging’ with heparin or LMWH for 5 days and until INR is within goal for 24 hours (TIP: warFARin takes a long time to achieve full anticoagulation so think FAR into the future compared to other anticoagulants)⁠
-Changes in the INR is typically seen 2-3 days after administration of the dose (TIP: a physician I use to work with always said Jesus rose on the 3rd day and so will your INR 😅)⁠
-Prior to making a dose adjustment, assess for any missed doses, drug interactions, dietary intake or supplements, documentation of bleeding, or other changes that can affect the INR⁠

How many of the INR goals did you get correct? TIP is to memorize the outlier – the majority of the time, the INR goal is 2-3 except in high-risk patients such as those with mechanical valve replacements in the MITRAL position (goal is higher 2.5-3.5)⁠


💊 Clozapine is an FDA-approved atypical antipsychotic medication for treatment-resistant schizophrenia. ⁠

❌ Clozapine is not the first-line drug of choice due to its range of adverse effects including agranulocytosis (a serious condition with a severely low number of neutrophils – a type of white blood cell).⁠

⭐️ Due to this adverse effect, a patient must be enrolled in the clozapine REMS registry by a certified clinician in order to receive treatment. ⁠

⚖️ Clozapine is also associated with significant weight gain, diabetes type 2, diabetic ketoacidosis, and increased lipid levels-all due to increased insulin resistance.⁠


🔝 Beta-blockers are one of the top 200 drugs prescribed as they are indicated for many different cardiovascular diseases such as hypertension, angina, atrial fibrillation/flutter, and heart failure with reduced ejection fraction. ⁠⠀
⭐Generally, there are two types of beta-adrenergic receptors, beta-1 and beta-2 receptors.⁠⠀
-Non-selective beta-blockers block both beta-1 (β1) and beta-2 (β2) adrenoceptors. ⁠⠀
-Cardioselective beta-blockers are relatively selective for β1 adrenoceptors (remember you have 1 heart) and tend to be favored in patients with diabetes or COPD/asthma. ⁠⠀
-Some beta-blockers also cause vasodilation through blockade of vascular alpha receptors making them great for use in hypertension.⁠⠀
🧠 Use the mnemonic – Be (β1) selective about your MAN BABE to help you remember the beta-blockers that are cardioselective. ⁠⠀


💊 Lithium is a common ‘mood stabilizer’ used to treat the manic episodes of bipolar disorder, a mood disorder that is characterized by episodes of mania, hypomania, and depression. ⁠⠀
🤔 The exact cause of bipolar disorder is unknown but is highly linked to family history, genetics, and abnormalities in neurotransmitters. This makes it tricky to pinpoint exactly how lithium works to treat bipolar but there are many proposed mechanisms of action. ⁠⠀
🧠 Whenever you see the medication lithium, always think SALT as lithium (Li+) is located close to sodium (Na+) on the periodic table and they share similar structures. Because of this, lithium levels are often affected by salt and water balance as well as renal function (excreted mainly through kidneys). ⁠⠀
💦 Dehydration can cause lithium levels to increase while increasing sodium intake can cause lithium levels to decrease. Medications that affect water and salt balance (ex: diuretics, NSAIDs, ACEI) can also alter lithium concentrations. ⁠⠀
🗓️ The starting dose of lithium is 300 mg two or three times a day (The brand name is Lithobid to help you remember that it can be given BID or twice daily)⁠⠀
🤰🏻Lithium is considered teratogenic due to the potential for fetal cardiac defects. The risks and benefits should be discussed with a healthcare provider before starting it in women of childbearing age.⁠⠀
⭐ Lithium is a popular drug that often shows up on tests due to its narrow therapeutic index and many side effects. ⁠⠀

ACE-inhibitors ⁠

 Let’s talk about ACE-inhibitors ⁠⠀
💊 Angiotensin-converting enzyme (ACE) inhibitors are a class of drugs mainly used in the treatment of hypertension and heart failure with reduced ejection fraction (HFrEF). They are one of the top 200 drugs prescribed and because of that, they are an important class to know. ⁠⠀
⭐ Drugs in this class end in the suffix ‘-pril’ such as: ⁠⠀
❗Do not use this medication in patients who: ⁠⠀
-Have a hypersensitivity to ACE inhibitors or any of their components⁠⠀
-Pregnant or breastfeeding: box warning for patients who are or may become pregnant as it can cause fetal toxicity⁠⠀
-History of angioedema, bilateral renal stenosis, and concurrent use with aliskiren in patients with diabetes⁠⠀

Chronic Kidney Disease

 Renal adjustments in CKD and AKI 

😏 Acute kidney injury is not very cute ⁠

💧 Most drugs, particularly water-soluble drugs and their metabolites, are eliminated largely by the kidneys in urine. ⁠

⭐️ It is important to know which drugs require dose adjustments to prevent accumulation and toxicity in patients with chronic kidney disease (CKD) as well as those with acute kidney injury. ⁠

🤔 Things to keep in mind when renally adjusting medications: ⁠

👉🏻 Use estimated GFR or CrCl to determine drug dosing⁠
👉🏻 If the patient is on hemodialysis, the type of HD will also determine drug dosing⁠
👉🏻 CrCl should be monitored periodically in patients with AKI to determine if doses need to be adjusted when CrCl improves⁠
👉🏻 Some medications require individualized therapy (ex: serum drug level monitoring, vital signs, adverse effects) when dose adjusting⁠


🌧️ Major depressive disorder (MDD) is a mood disorder characterized by persistent feelings of sadness and loss of interest that interferes with normal daily functioning.⁠

⭐️ The exact chemical basis for depression is poorly understood but is thought to be linked to decreased levels of the neurotransmitters, serotonin, dopamine, and norepinephrine. This cause is also known as the monoamine hypothesis.⁠

👉🏻 Because of this, the drugs developed to treat MDD selectively target the reuptake of serotonin and norepinephrine, increasing levels of these neurotransmitters in the synapse and enhancing NT signaling.⁠

⭐️ SSRIs are generally first-line due to their improved tolerability compared to the others (TCAs and MOAIs) and relative safety in cases of overdose.⁠

⭐️ Studies have shown equivalent efficacy among antidepressants, therefore the initial choice is made empirically based on patient factors and the nuances of each drug.⁠

5-HT3 Inhibitors

💊 5-HT3 Inhibitors (ex: ondansetron) ⁠

🤢🤮 Nausea and vomiting are two of the most common presenting complaints ⁠

5-HT3 inhibitors (such as ondansetron) are one of the top 200 drugs prescribed and are used for the prevention of:⁠
🌟 chemotherapy-induced nausea and vomiting⁠
🌟 radiation-induced nausea and vomiting⁠
🌟 postoperative nausea and vomiting⁠
🌟 off-label for nausea and vomiting associated with pregnancy

Vancomycin ⁠

💊 Vancomycin belongs to a class of antibiotics called glycopeptides. Drugs in this class are composed of a cyclic peptide bound by two sugar molecules (glycogen), hence the name glycopeptides! ⁠

🌟 MOA: binds to D-alanyl-D-alanine on the outer surface of cell membranes preventing cross-linking. This interferes with cell wall synthesis and results in bacterial cell death. ⁠

🧠 Another way to think of it: cell walls are like LEGO pieces linking together. The more that are linked, the stronger the structure is. Vancomycin prevents this cross-linking leading to an unstable structure. ⁠

🌟 Vancomycin = think mainly gram-positive coverage including MRSA! (gram-negatives do NOT have a thick cell wall and lack the D-ala-D-ala sequence, making vancomycin useless against them)⁠

🌟 NOTE: Recently, the term “red man syndrome (RMS)” has been replaced and is now recognized as “vancomycin flushing syndrome” or “vancomycin infusion reaction”. 

Anion Gap Acidosis -

Mind the Gap- HAGMA

⭐️ High anion gap metabolic acidosis (HAGMA) occurs when the body produces too much acid, or when the kidneys are not removing enough acid from the body.⁠
💊 Several drugs and toxins have been implicated as direct or indirect causes of HAGMA. The three most common ones to consider are methanol, ethylene glycol and salicylates.⁠
🌬️ Symptoms are generally non-specific, with dyspnea being common secondary to stimulation of the central respiratory center. Screening for toxic ingestions, including over-ingestion of aspirin and acetaminophen, is important. ⁠
🌟 Additionally, screening for features suggestive of diabetes (e.g., polyuria, polydipsia, polyphagia) or renal failure (e.g., nocturia, pruritus, anorexia) is essential.⁠
🌟 Primary treatment of high anion gap metabolic acidosis requires correction of the underlying cause



⭐ This is a great way to remember the names of antiretrovirals ⭐ Antiretroviral medications are used to treat HIV by blocking different stages of the virus’s life cycle (e.g., blocking entry into the host’s CD4 lymphocyte, inhibiting viral DNA from replicating, etc.)⁠ ⁠😖 However, learning the names of antiretroviral medications is horribly difficult. There are lots of drugs, with a dizzying array of names, abbreviations, and combination tablets.⁠ Hopefully, this will help you not to completely BLANK on which drug belongs to which type of antiretroviral! 🤓

IV Fluids Review

💦 ⁠ IV fluids – What the tonic?

✏️The human body is composed of 60% water 💦 ⁠
-Two-thirds of it is available INTRAcellularly (space INside cells)⁠
-One-third of it is stored EXTRAcellularly (EXTERNAL space in blood vessels and around cells)⁠

⭐ There are different types of fluids with varying chemical compositions of salt and electrolytes that are designed to bring fluid into cells or keep fluid within the bloodstream.⁠

🔑 Key Tips:⁠
-Water flows where sodium (or particles) goes!⁠
-Solutions want to have the same ratio or balance of solvents (water) to solute (particles such as salt)⁠
-Water will flow from an area of low particles to an area of high particles⁠
-Semi-permeable membranes allow water to pass through but not particles⁠

⭐ First, think of the starting point as the space within blood vessels (or intravascular space) since IV fluids are infused directly into the bloodstream 🩸⁠

⭐ ISOtonic fluids: “ISOlated in the vasculature”⁠
-Equal amounts of water and particles so there is no movement between the compartments⁠
-Water from IV fluids stay ISOlated in the vasculature – used in situations where there is fluid loss and replacement is needed (ex: hemorrhage, diarrhea, vomiting)⁠
-Examples include: 0.9% sodium chloride (normal saline), dextrose 5% in water (D5W), lactated ringer (LR)⁠

⭐ HypOtonic fluids: “Out of the vasculature”⁠
-Low amounts of particles compared to water⁠
-Water flows OUT of the vascular into the cells⁠
-Used in situations where we have intracellular dehydration (ex: DKA, HHS)⁠
-Examples include: 0.45% sodium chloride (1/2 normal saline), 2.5% dextrose in water ⁠

⭐ HypErtonic fluids: “Enter the vasculature”⁠
-High amounts of particles compared to water ⁠
-Water ENTERS the highly concentrated vasculature from cells⁠
-Used in situations where there are swollen cells (ex: cerebral edema) or hyponatremia⁠
-Examples include: 3% sodium chloride (hypertonic saline), dextrose 10% in water (D10W) ⁠

Vasopressors and inotropes

Vasopressors and Inotropes⁠

Vasopressors and inotropes OH NO! 🙇🏻‍♀️ These medications are commonly used in the critical care setting in patients with shock (or those with extremely low blood pressure) leading to end-organ damage (acute kidney injury, increased LFTs, etc.). ⁠

👉🏻 Vasopressors are drugs that cause vasoconstriction, therefore increasing mean arterial pressure (MAP). Vaso refers to blood vessels and pressor means to put pressure on or constrict making up the word – VASO-pressor. 🩸⁠

Examples of vasopressors include:⁠

⭐ Norepinephrine⁠
⭐ Epinephrine⁠
⭐ Vasopressin⁠
⭐ Phenylephrine⁠

👉🏻 Inotropes are drugs that affect cardiac contractility (or the force of muscular contractions). They can also be used as chronotropes (drugs that increase heart rate). THINK: Ino = strength; Chrono = time. Some vasopressors may also have effects on contractility and are called inopressors. ⁠

Examples of positive inotropic agents include: ⁠

⭐ Milrinone⁠
⭐ Dobutamine⁠
⭐ Dopamine⁠
⭐ Isoproterenone⁠

🧠 With the many different types of vasopressors and inotropes, it is important to understand how they work to use them effectively. Choosing the wrong agent or using it inappropriately, can harm the patient. ⁠

Want to learn more? Check out this Vasopressor and Inotrope Mnemonic Workbook for a more in depth review!

IV chemotherapy agents with high emetic risks⁠

🌟 Chemotherapy agents are notorious for causing many side effects such as nausea and vomiting and are classified according to their emetic risk. 🤢🤮⁠

🌟 High-risk agents cause emesis in more than 90% of patients and require pre-treatment with medications such as 5HT3 antagonists (ex: ondansetron), neurokinin-1 receptor antagonists (ex: aprepitant), and dexamethasone. ⁠

🧠 A fun way to learn which IV chemotherapy agents have high emetic risk – think of this story: ⁠

‘The car had motion sickness and threw up, making splat sounds”⁠

🤔 Can you imagine it in your head? This story will help you remember the medications DACARbazine, Mechlorethamine, Streptozotocin, and ciSPLATin. ⁠

🌟 Other IV chemotherapy agents that have high emetic risk at higher doses or in combination with other medications include:⁠

-Carboplatin AUC>4⁠
-Carmustine >250 mg/m2⁠
-Cyclophosphamide >1500 mg/m3⁠
-Doxorubicin >60 mg/m2⁠
-Epirubicin >90 mg/m2⁠
-Ifosfamide >2 g/m2/dose⁠
-AC (any combo that contains an anthracycline + cyclophosphamide)


💊 Antipsychotics, also known as neuroleptics, are a class of medications primarily used to manage psychosis in schizophrenia or bipolar disorder, hence the name anti-PSYCHOTICS or anti-PSYCHOSIS (including delusions, hallucinations, paranoia, or disordered thought) 👹⁠

They are broken down into two generations which differ by their side effect profiles: ⁠

1️⃣ 1st generation also called typical antipsychotics are associated with significant extrapyramidal side effects (movement disorder). ⁠
2️⃣ 2nd generation also called atypical antipsychotics have decreased risks of EPS side effects as compared to 1st generation antipsychotics but are associated with significant weight gain and the development of metabolic syndrome.⁠

In addition, all of the antipsychotics block the following receptors with varying degrees leading to the common side effects seen: ⁠

⭐ Dopamine: EPS symptoms⁠
⭐ Alpha: hypotension⁠
⭐ Muscarinic: anticholinergic side effects
⭐ Histamine: sedation⁠

🧠 MOA: In schizophrenia, dopamine is tied to hallucinations and delusions. Certain areas in the brain that ‘run off’ of dopamine may become overactive leading to symptoms of psychosis. Both generations block dopamine receptors, but second generations tend to act on serotonin receptors as well.