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Week 2 tutorial on quiz prep PART 3 — Transcript

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0:00Okay, we have just a few more questions
0:03to look at in this tutorial and one of
0:06them has to do with stimulant laxatives.
0:10Just recall what the stimulant laxatives
0:13were.
0:14Uh stimulant laxatives are a type of
0:17laxative that works by increasing the
0:19movement in the intestines.
0:23Now, that movement can it be increased
0:25by stimulating the nerves directly or by
0:29enhancing the response of the muscles to
0:32the nerve signals.
0:34In complex pharmacological terms, we're
0:37messing with the natural nervous system
0:40of the GIT.
0:42So, what would you expect to happen if
0:44we use those over a long period of time?
0:47Indeed, those are going to cause
0:50permanent damage to either the nervous
0:53system control of the motility of the
0:56GIT
0:57or to the GIT itself and or to the GIT
1:01itself, so to the colon.
1:04And uh that that happens if they're used
1:07for a long period of time.
1:09And as such, stimulant laxatives should
1:11really only be used when nothing else is
1:14working or as a preparation for
1:17endoscopy or surgical procedures.
1:21So, stimulant laxatives result in a
1:23rebound constipation
1:26that makes the person think that they
1:28need more and then when they use it for
1:32a long period of time, the stimulant
1:33laxatives damage the colon
1:36to the point where the person can't move
1:39their feces through the colon on their
1:41own.
1:42So, the question is going to say which
1:47of the following is incorrect and right
1:50now we've got three of the five choices
1:53showing.
1:54The first choice is stimulant laxatives
1:57include bisacodyl, sodium picosulfate,
2:00senna, and castor oil.
2:03And that is a correct statement. Each of
2:06those laxatives are termed stimulant
2:09laxatives.
2:10The next choice is uh stimulant
2:13laxatives exert a strong rebound effect
2:16causing even more constipation. And as
2:19we recall, that is correct as well. In
2:23fact, as I said before, it's suggested
2:26that the stimulant laxatives only be
2:28used in extreme situations
2:30and for short periods of time because of
2:33that fact that the GIT will get used to
2:35the medication.
2:37And it'll also damage the GIT and the
2:41nerves and so forth. So, we'll become
2:43dependent on it if it's used for a long
2:46period of time.
2:48The next choice is the one that can
2:51change, so pay close attention to this
2:54one. From the list of stimulant
2:56laxatives we investigated in module one,
2:59bisacodyl, sodium picosulfate, senna,
3:01and castor oil,
3:03it's the sodium picosulfate which is the
3:07only stimulant laxative that cannot be
3:10taken by suppository or enema.
3:13And as we see that choice there, it is
3:17correct. Each of those other stimulant
3:19laxatives can be
3:22used as a suppository. And if they are
3:25used as a suppository, they'll act in a
3:28matter of minutes to 1 hour, whereas
3:32uh normal is going to be about 6 to 15
3:35hours. But sodium picosulfate is a
3:38prodrug, and it's activated by
3:42intestinal bacteria.
3:44In order to be changed into the active
3:46form, it's going to actually have to be
3:48down there
3:50for a while. It's going to have to be in
3:52the area of the intestinal bacteria.
3:56So, sodium picosulfate is totally
3:59useless if it's taken as a suppository.
4:03And another choice is that stimulant
4:06laxatives can result in electrolyte
4:08disturbances.
4:10And that is correct as well. It's
4:12another one of the reasons that we have
4:14to be careful when using stimulant
4:17laxatives.
4:19And just think of the amount of fluid
4:21that's being excreted in short period of
4:23time, and that explains the fact that it
4:25results in electrolyte changes.
4:30The final choice is none of the choices
4:34are correct or choose this if all other
4:38choices are correct. And if the question
4:41appears exactly as we've just taken it,
4:44then the answer none of the choices are
4:48correct would be the best choice. But,
4:51as I said before, I reserve the right to
4:53change this one.
4:55And the way that I would actually change
4:57it would be that I would talk about the
5:01laxatives that cannot be taken as a
5:04suppository
5:06or by enema. So, for instance, if I said
5:10from the list of stimulant laxatives we
5:12investigated in module one, castor oil
5:15is the only stimulant laxative that
5:17cannot be taken by suppository or by
5:20enema. Of course, that statement would
5:23be the incorrect statement.
5:25So, just remember on this one, if I
5:27change anything about the question,
5:29it'll have to do with the ones that
5:31cannot be taken by suppository or by
5:34enema.
5:36I just don't want you to just remember
5:39that the question on stimulant laxatives
5:42is none of the answers is correct. I
5:45want you to know a bit more about them
5:48because of the safety issues
5:50around these medications.
5:55Okay, so unless we have any questions on
5:58that, what I'll be doing is going to
6:01another question.
6:03The antihistamines
6:05actually termed inverse agonists. That's
6:09their technical term. It's all explained
6:12a little bit in the modules well as
6:15well. So module one explained a inverse
6:19agonist.
6:20So the question has to do
6:23with inverse agonist obviously, but
6:25inverse agonist will be the closest to
6:29and you can see three different ones on
6:32your screen right now and there'll be
6:33another two. The ones that are seen on
6:36the screen are an inhibitor, an agonist,
6:40a partial agonist, and then there's two
6:43choices that are missing which is choose
6:46this if the inverse agonist does not
6:48resemble any of the other choices,
6:51and also an antagonist.
6:54Okay, so
6:55to understand this, I just need to
6:58explain what type of receptor an inverse
7:02agonist can bind to.
7:04When I explained it in module one, I
7:07used a receptor involved in an ion
7:11channel because it's the easiest way to
7:13picture it, but actually the ion channel
7:17receptor isn't normally the kind of
7:20receptor that can be involved in inverse
7:22agonist, but let's get that simplistic
7:25picture with that type of receptor. So
7:28normally when a receptor of any type is
7:31on a cell surface,
7:34there needs to be a binding of the
7:36natural ligand to the receptor in order
7:38for it to have any of those follow on
7:40effects that are associated with the
7:42ligand binding. In other words,
7:45when there is no binding of the natural
7:49ligand to the receptor, the receptor is
7:52functionally silent. It's just sitting
7:54there.
7:56And
7:57uh the thing is that for certain
7:59receptors, just the fact that the
8:02receptor is on the cell surface means
8:05that there's going to be some what we
8:07call constitutive activity.
8:11It cannot be fully turned off, so
8:13there's a little bit of activity all the
8:16time.
8:17And that type of receptor can be acted
8:21on by an inverse agonist. Now, an
8:24inverse agonist not only blocks the
8:27receptor, but it also decreases the
8:30constitutive activity that some of the
8:33receptors have.
8:35So, that's explained in this picture
8:38right here, but like I say, it's a
8:41better the better example is really the
8:43antihistamines because those are all
8:47inverse agonists. The reason is because
8:49the histamine receptor
8:52is a receptor that will, just in itself,
8:55just by the fact that it's on the
8:58uh
8:59surface of the blood vessel
9:02uh the blood vessel wall, it's going to
9:05result in a little bit of vasodilation
9:07and increased permeability. Just the
9:10receptor.
9:11Just simply the receptor. But then when
9:13we take an antihistamine,
9:15it's going to actually not only block
9:18the histamine from binding onto the
9:20blood vessel, but when it's on that
9:22receptor, it actually blocks that what
9:24we call constitutive activity. It
9:27actually uh
9:29yeah, is it's better than an antagonist.
9:32So, if you look at the question, an an
9:36an inverse agonist would be closest to
9:39which of the following? An inhibitor,
9:42well, we know that's not going to act as
9:45an inhibitor because of the fact that
9:47inhibitors act on enzymes and not
9:50receptors. So, that's categorically
9:52incorrect.
9:54An agonist, remember agonist would act
9:58like the natural ligand. So, that's
10:01incorrect as well. We're talking about
10:02medications like antihistamines.
10:06A partial agonist is also incorrect. A
10:11partial agonist is the medication that
10:13produces a small percentage of,
10:16simplistically speaking, it's it
10:18produces a small percentage
10:20of the effect that a full agonist would
10:23have.
10:24One of the choices that's not seen is
10:28choose this is if the inverse agonist
10:30does not resemble any of the other
10:32choices. And at this point, that's the
10:35correct choice. But,
10:36uh question the other choice that's
10:39going to be seen is actually
10:42uh an inverse agonist is very much like
10:45an antagonist. The other choices that it
10:49will be act as an antagonist. And
10:52indeed, inverse agonists are very much
10:55like antagonists. The difference is that
10:59it's a little bit better than an
11:01antagonist and it blocks the
11:03constitutive activity.
11:06So, that one is important to know
11:08because a lot of medications are called
11:11inverse agonists. And then, I don't want
11:15you to go out there and and say, "Well,
11:17actually, we never learned about inverse
11:19agonists."
11:20So, does anyone have any questions on
11:24that one?
11:27Okay, then I'll slip in one of the two
11:29two-point questions that you will need
11:32to answer in the way that I presented
11:34here in the tutorial.
11:36The question that's going to be in the
11:38quiz is going to read like this.
11:40Explain what was described in tutorial
11:45as being the most important point to
11:47remember about pregnancy categories.
11:51Obviously, we're going to be talking
11:52about the Australian pregnancy
11:54categories and at the beginning of this
11:57tutorial, I said a few words about that
12:00already.
12:01The very first thing that you're going
12:03to have to put in your answer in order
12:07for it to be deemed as uh getting any
12:10credit is this right here. The
12:13Australian pregnancy categories are not
12:16strictly hierarchical.
12:18So, you would actually say that the
12:20Australian pregnancy categories are not
12:23strictly hierarchical. Please don't put
12:25it into your own words.
12:28I'm going to put that into the chat box
12:31right now.
12:33And you can copy it and paste it. Yeah,
12:36it's in the chat box right now. So, of
12:39course, what that means is that it's not
12:41arranged in order of safest to least
12:44safe drugs, but I need you to say the
12:47Australian pregnancy categories are not
12:50strictly hierarchical. The spelling of
12:52hierarchical is h i e r
12:55a r c h i c a l.
13:00So, just to explain that again, while
13:02pregnancy category a, c, d, and x get
13:07more dangerous to the fetus as it goes
13:10from a to x, there's not enough data on
13:14pregnancy category b drugs to know
13:16exactly where they will ultimately land.
13:20In the end, after there is adequate data
13:23on pregnant women and women who are
13:26breastfeeding,
13:27the pregnancy category B drug may end up
13:31being an A drug, or it may end up being
13:35a C drug. So, although those B category
13:39drugs don't have enough data on humans,
13:43the data that is available on humans
13:46indicates that there shouldn't be a
13:49problem for the mother or the fetus.
13:52But, once again, we're just not sure.
13:55So, we get additional information from
13:57animal studies, and as such, the B1
14:00drugs also include a note about the fact
14:03that the animal studies show no reason
14:06for concern in animals, and the B3 drugs
14:10actually causes harm in some animal
14:14studies.
14:18So, you can get all of that in about 50
14:20words.
14:22I don't want you to go over 100 words
14:25because you're not going to get any
14:26points for
14:28super explaining it, and I don't want
14:30you to run out of time for the other
14:33questions. So, you can go to the TGA
14:36website, and they're the ones that
14:38actually say that. They're They're the
14:40ones that say, "Australian pregnancy
14:42categories are not hierarchical."
14:45Um but uh but they say a little bit
14:47more, too. They say, "The Australian
14:50categorization system differs from US
14:52FDA categorization.
14:55The categorization of medicines for use
14:57in pregnancy do not follow a
14:58hierarchical structure." And then
15:00there's a few points below that. "Human
15:03data are lacking or inadequate in drugs
15:06in the B1, B2, and B3 categories.
15:09Subcategorization of the B category is
15:12based on animal studies."
15:14And another point is, "The allocation of
15:16a B category does not imply greater
15:19safety than a C category." So, those are
15:22kind of important points. You can look
15:24at those up at the TGA.
15:26But, basically, all you really have to
15:28do is say that the Australian pregnancy
15:31categories are not strictly
15:32hierarchical. And then something about
15:35the fact that while
15:37pregnancy categories A, C, D, and X get
15:40more dangerous to the fetus as it goes
15:42from A to X, pregnancy category B drugs
15:46are ones that lack that human data.
15:49So, is everyone very clear about that?
15:52The two-point question.
15:56And finally, the very last question
15:58that's going to be in this tutorial and
16:01that will be in the quiz has to do with
16:03the four pathways that lead to the
16:05vomiting center.
16:07So, let's just go over those really
16:09quickly and it was part of the condensed
16:12version of chapter five in module one.
16:17Uh in that module, I explained that
16:19there were five four different pathways.
16:22There's one pathway that goes from the
16:24higher brain center to the vomiting
16:26center and that's responsible for
16:28vomiting that's associated with extreme
16:31pain or psychological distress.
16:34And vomiting from that pathway is best
16:37treated with the benzodiazepines
16:40like the L
16:41alprazolam,
16:43uh lorazepam, diazepam, the azepam or
16:47azolam drugs.
16:50There's another pathway that goes from
16:53the vestibular area to the vomiting
16:55center and that one is the one that is
16:59going to use the histamine one and
17:01acetylcholine. That's the one for motion
17:04sickness. It's also the one that uh
17:07somebody from with Meniere's disease so
17:11would actually be using.
17:13When there's damage to the
17:16vestibular area
17:18uh there's vomiting that's involved.
17:21That is the pathway. It uses
17:23acetylcholine and histamine one.
17:26So, of course, the first generation
17:28antihistamines are the very best ones
17:30because they kind of block both. They
17:33block histamine one intentionally and
17:36they also block acetylcholine as kind of
17:39almost an unintentional action.
17:43And then there's also the strictly
17:47anticholinergic
17:49drugs like hyoscine and scopolamine.
17:54Those are
17:57really good if there's also some types
18:00of spasm in the GIT along with
18:05the motion sickness.
18:08So, those are the strictly
18:10anticholinergic
18:11drugs.
18:13Now, if a person is receiving
18:15chemotherapy, that's going to do a
18:17number of things at the same time.
18:18That's going to for instance, it's going
18:20to damage the stomach. It's going to act
18:23on the chemoreceptor trigger zone and
18:25other pathways. And all the pathways
18:28that are affected by
18:28chemotherapy-induced vomiting have a
18:31very specific type of neurotransmitter
18:34called
18:36serotonin three or 5-HT3
18:40as the neurotransmitter. So, of course,
18:42the very best medication for
18:45chemotherapy-induced
18:46vomiting is ondansetron or other SETRON
18:51drugs. Those 5-HT3
18:54receptor antagonists.
18:57And there is another neurotransmitter
19:00that's involved in vomiting that
19:02originates from the GIT or the
19:03chemoreceptor trigger zone. And that
19:06neurotransmitter is dopamine two. So,
19:09dopamine two antagonists
19:13are going to be effective in
19:14chemotherapy induced vomiting
19:17and they're quite inexpensive.
19:19But the problem is that dopamine two has
19:22a lot of actions in a lot of different
19:25parts of the body. So there's movement
19:27disorders and all sorts of problems that
19:30are associated with dopamine two
19:32antagonists
19:34like for instance a prochlorperazine
19:38and and yeah, they're they're simply not
19:42the first-line therapy
19:44for many people.
19:47Let's put it that way. So hopefully you
19:49understand the four pathways
19:51and now that we've reviewed those
19:55pathways, let's take a look at the
19:56question that will be seen in the quiz.
19:59The question is going to be choose the
20:03person who is about to receive the wrong
20:05medication for their condition.
20:08So the very first choice on that is
20:10well, the first choice that I'm giving
20:12you right now. Obviously,
20:14these are going to be seen in random
20:17order. Anvee has vomiting that results
20:21from extreme pain or the psychological
20:23stress of seeing something very
20:25disturbing and is most likely to benefit
20:28from the benzodiazepines.
20:31And that is actually a correct treatment
20:34for vomiting from psychological stress
20:36of seeing something very disturbing. The
20:39suffix azopam
20:41and the suffix azolam, those azopam and
20:44azolam drugs are benzodiazepines
20:47and those are the best medications for
20:50that type of vomiting.
20:52So the next client is Melissa and she's
20:54going on a boat
20:56and is very susceptible to motion
20:58sickness and is about to receive a
21:01first-generation
21:03antihistamine called diphenhydramine.
21:06And as we will see when we discuss the
21:09early antihistamines, a first generation
21:12antihistamine and the early
21:15antihistamines, the first generation
21:17antihistamines blocked both of the
21:20histamine and the acetylcholine
21:23receptors.
21:24So, because of that, uh diphenhydramine
21:27is probably the best motion sickness
21:30medication that a person could actually
21:32get as long as the person can tolerate
21:35it.
21:36Another client is Joe who has eaten some
21:39stale shellfish
21:41and uh that has bacterial toxins. And
21:44although ondansetron would probably stop
21:48the nausea and vomiting, it is decided
21:50that
21:51uh Joe Joe receives no medication so
21:55that the toxins are naturally expelled
21:57from the body.
21:58And it's also decided that he should get
22:01fluid and electrolytes and be monitored
22:04closely. And as that choice stands,
22:09here Joe is about to get the right
22:12medication. And if the question is
22:14exactly the way that appears there, then
22:17do not choose it because we're looking
22:19for the incorrect uh statement. But this
22:23one could actually change.
22:26So, take note of this because now Joe is
22:30about to receive ondansetron.
22:33Well, it would probably be effective at
22:36stopping the nausea and vomiting, but
22:40the problem is that all of those
22:42bacterial toxins and the bacteria
22:45themselves are going to start to
22:47proliferate. All of that is in the GIT,
22:50it remains in the GIT. We don't have our
22:54natural ability to get it out, and it
22:57could result in big problems for Joe,
22:59and he might have to actually go to the
23:00hospital.
23:01So, uh so if it is this choice, then
23:04that is definitely the incorrect
23:07statement.
23:08And another client is Jan, who is on
23:12chemotherapy and is about to receive
23:15ondansetron, the selective 5HT3
23:18receptor antagonist.
23:20And now that is the correct medication.
23:22Jan could also be prescribed, uh for
23:26instance, prochlorperazine
23:29as well. But uh ondansetron has the
23:32fewest side effects, and it would be the
23:35most effective. So, finally, the final
23:38choice on this one is choose this if
23:41each of the people on the list is about
23:43to receive the correct treatment for
23:45their specific type of nausea. And this
23:48is the correct choice if Joe is about to
23:51receive fluid and electrolytes. But, of
23:54course, if Joe is about to receive
23:56ondansetron, then that is the incorrect
23:59statement.
24:00So, does everybody understand that one?
24:04Okay.
24:06If you have any problems on any of these
24:09questions, then post them into the chat
24:12box.
24:13Uh or you could email me.
24:15And in the meantime, what you need to do
24:17is practice those activities. Remember
24:20the uh module one has a number of short
24:25lessons. And each one of the short
24:28lessons is is followed by an activity.
24:31Remember the way in which I get the
24:33questions for the multiple-choice
24:35questions is I I looked at each one of
24:37those activities and said, "Can I make
24:40this into a multiple-choice question?"
24:42If I was able to make it into a
24:44multiple-choice question, then I
24:46included it the multiple-choice question
24:49in the quiz. So, make sure that you go
24:52through those activities again, and
24:55you're going to do really well in this
24:57quiz.
24:59Okay, everyone.
25:00Um thank you for joining me here.
25:03And we're going to see you at the quiz
25:06on Friday.

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