14 Burst results for "Air Christianson"
"air christianson" Discussed on Real Life Pharmacology - Pharmacology Education for Health Care Professionals
"Practice. Pearls definitely go to real life. Pharmacology DOT COM Pickup that free thirty one page. Pdf on the top two hundred drugs a great resource for anybody going through pharmacology I I lay out the most important clinical practice pearls from the top two hundred drugs which also tend to be very highly tested. Pearls on those drugs as well so Go Snag that resource for free. If you enjoyed the podcast today Leave us a rating review on itunes. Or wherever you're listening Those reviews are greatly appreciated allows us to get our educational message Out there even more By sharing those ratings reviews definitely feel free to email a link. Real-life ARMOR ECOLOGY DOT COM to a friend Colleague coworker fellow student And help share in pharmacology education. There's a huge gap. That is absolutely for sure. GonNa Track me down. You can find me at Lincoln. Air Christianson Pharm d be CPS GP You can also find me at rely. Pharmacology DOT COM. Shoot me an email there or one dot com as well and hit the contact button. Those emails should get to me. I do my best to try to respond to everything. So if you haven't heard from me within probably three to five days Definitely don't hesitate to shoot me another email. I might have missed it. Might went to junk Who knows what happened but I. I definitely do try to respond to all the emails that I get. So I'M GONNA sign off for today. Thanks so much for listening Take care have a great rest of your day..
"air christianson" Discussed on Real Life Pharmacology - Pharmacology Education for Health Care Professionals
"I'm your host Air Christianson Pharmacists. And if you want to get in contact with me linked but in a good way to to do that Air Christianson Farm D. B. C. G. P. B.. CPS You can find me. They're also through the website real real life pharmacology dot com. We've also got that free giveaway thirty one page. PDF On the top two hundred drugs in their pharmacology an a an important clinical pearls That you actually might come across in real life so definitely go download that for free and and obviously also get updates when we've got a new podcast or any other in full To share for you there so go check that out a real-life pharmacology dot COM for today. We're going to get into metro. Nisell the brand name of that medication is flat. Joel and this is an antibiotic for infection. Shen I do see it somewhat frequently. I guess definitely a good one to to know to pay attention to Being an antibiotic probably the most common uses for this medication Bacterial vaginal says historically C diff was probably probably a lot more common for its use We have had changes in the guidelines. And now at least at this point at the time I making it Vancomycin Oral Orleans is typically going to be preferred there but still remains an option If a certain other options aren't available there Intra abdominal all infections. In in general metronidazole 's got some good activity specifically against ANAEROBIC BACTERIA K.. Okay so that's an important little nugget to remember with regards the use where you might see Metronidazole used in kind of along with that that depending on the type and surgery The type of surgery and the location of surgery metros nasal might be used in prophylaxis again. You know if you're doing some sort of Gi surgery were a bacteria gut bacteria are going to be in play We might might use metronidazole because a lot of those bacteria are potentially susceptible to the drug now adverse effect profile. I think this this is definitely important with an antibiotic. You don't nausea vomiting stomach upset can potentially happen and Dan With I would say the majority of antibiotics. It is okay to take them with food and Mitch Metronidazole Certainly falls under that umbrella. So if you're having a patient reporting some issues stomach upset Feeling only had an office with their medication with taking metronidazole definitely encourage them to at least start to try to take with food if they aren't already doing so oh other adverse effects We you know I think the GI tract Continuing along those lines metronidazole. Oh can provide a unique taste To the mouth and for some patients that can be very very troubling and bothersome It's most patients report. Almost a metallic type taste in their mouth but Keep in mind if patients are noticing. Food tastes different or something else going on with with taste. Buds and eating Definitely could be Metronidazole Having that adverse effect there There are some rare things that can happen with metronidazole. One really unique thing That I have encountered in the the past again very very rare But CNS changes can happen with Metronidazole and one thing specifically with those CNS changes Is Peripheral for all neuropathy. So it's kind of an interesting NEUROLOGIC type of act that can potentially happen with metronidazole. Now we'll say that the risk ask of you know some of these issues or particularly the central nervous system issues is likely going to go up as we increase doses and and as we Extend that duration. I'm thinking along the lines of full neuropathy Probably not real likely to happen. You know for other patients only getting it for a very very short period of time you know a few days for example so keep that in mind as you think about the adverse effect profile file and as you see Metro nasal used now. That is more specific to Metronidazole. That's obviously going to be. I static simic oral use so Important to I think make that differentiation versus a topically applied metronidazole for for example. So let's take.
"air christianson" Discussed on Real Life Pharmacology - Pharmacology Education for Health Care Professionals
"Your host Pharmacist Air Christianson thank you all so much for listening today I'm going to see Over Mira Baghran The brand name of this medication is murder trick and it is important to note that this medication at this time as a brand name medication you have to have the expectation that it's going to be very expensive and in our medical system it may or may not not be covered by insurance initially so that's always a big big challenge and I think a lot of healthcare professionals don't understand and at least what the cash price for a lot of these medications are so just to give an example of Murga tricky whereas brand name medication That cost Ballpark is in the range of three hundred to five hundred dollars a month and so that's substantially significant and you know any patient that's taking this type of medication that always has to be part of our assignments so I just wanted to lay out that point because it is so important when it comes to patient adherence to recognize that cost is a huge huge role in depending upon that patient's insurance how well they're able to afford that medication they may be rationing it they made maybe skipping days on purpose they may be using that in a non approved or inappropriate way that might make that medication in less effective so just have to have to recognize when you're working with patients to ask those questions about the cost of medications and if they can afford medications so getting into the getting over that little rant there let's get into the the pharmacology of the drug actually how the drug works so it's classification it is a Beta three agonists and you may remember Beta receptors from thinking about betablockers to other Beta agonists and the really important point about Beta receptors is there's multiple sub types of those receptors so the the three main subtypes of Beta receptors where we have drug targets are Beta one two and three so one those subtype of receptors are typically found in the heart for example Beta two or on the lungs and Beta three at least as far as drug target let's go are primarily found in the bladder urinary tract system mechanistically how this drug works that Beta three receptor activation or that agonised activity it allows for the bladder smooth muscle lacks and when that bladder smooth muscle relax relaxes this allows for a greater capacity greater ability to Astore Urine so this means that those muscles they aren't constricting they aren't contracting and when you have that constriction and contrast action the patient what they're going to experience likely is that sensation for going to the bathroom so as you could imagine this man vacation is used to manage overactive bladder symptoms urge incontinence type symptoms now I did mention the cost just as being an important factor when it comes to reviewing and assessing patient adherence to medications one other important factor is does using if you've got a a medication that needs to be dosed multiple times per day the more often you have to dose that medication the more likely it is that patients are going to have a difficult time following that.
"O. r. e. okay so finishing up on drug interactions and this is a little bit challenging not talking about each specific diffic- agent and again. I'm probably going to cover more benzodiazepines as i go along but i just wanted to really get out a general <hes> podcast asked <hes> with the basics of benzodiazepines <hes> but first off there is an absolute boxed warning <hes> with the use of opioids and the big risk with opioids in combination with benzodiazepine is patients aren't much much greater risk for sedation respiratory depression in ultimately death <hes> basically in a in a setting of overdose high doses <hes> these patients are are at risk of respiratory depression and there's other risk factors as well. <hes> you know obesity sleep apnea things like that <hes> breathing difficulties already as somebody likes that has c._o._p._d. For example that may exacerbate this risk as well <hes> but bengals in opioids are really a combination <hes> for all intents and purposes you really wanna try to avoid if you can if we're using both of these agents <hes> you definitely want to look at the doses high doses are <hes> that's going to kind of play into that risk and you also want to watch monitor these these patients closely and recognize if they're at risk <hes> for this respiratory depression and for things to happen so very very important opioids and benzes <hes> <hes> in general if we can avoid it absolutely <hes> should should be trying to do out other drugs <hes> that i wanted to talk talk about that you can really have some additive <hes> type effects on top of benzodiazepines so remember the z drugs so those are commonly used for insomnia. I don't think i've done a podcast on them yet but that may be coming up soon. These drugs essentially have a pretty similar mm-hmm alert mechanism <hes> to the way that benza days appears to work so you're basically going to double up on those <hes> sedative <hes> tight c._n._s. type side effects so keep that in mind <hes> you know if you see a patient on both of these remind the patient that these do work works similarly <hes> and probably two to avoid taking them together. <hes> you know obviously you got to do a little bit of background and see what the patient's currently doing in their background macaroni history <hes> but yes that those that class of drugs <hes> definitely can't have additive effects <hes> other <hes> c._n._s. suppressants that i wanted to to run through so you know you think your life and hydra means you're hydroxy zine jock zillions of those anti cholinergic <hes> those can certainly be sedating and added with a benz as a team. I can really ramp up that sedation melatonin something see used over the connor owner definitely ask and remind patients about over the counter medications if they are taking any <hes> some older skeletal muscle relaxants axles can certainly be dating. I think of cyclo benza preen <hes> maybe a backlog and things like that and then drugs of abuse this potentially <hes> so marijuana. That's obviously got some sedative type properties. <hes> you know when you combine some of these drugs you just for lack lack of a better term. You have no idea you don't know what's going to happen. <hes> in that setting <hes> alcohol's another one where you really you know pile on that that sedative sedative <hes> from the alcohol that sedative side effect that confusion side effect the mind altering effect of alcohol with benzoate as a team you they can can lead to challenges and additive type tape side effects and then of course we've got some older <hes> seizure medications search for a good example there <hes> that can feel barbara tall that can really have some sedative c._n._s. Type adverse affects wchs and you don't really need to be really careful and watch our patients that are taking these medications together so i think that's it's going to wrap up the benzodiazepine podcast today. If you enjoy the show leave us a rating review on itunes. I greatly appreciate those <hes> it really <hes> makes my day some days with some of the the nice comments and kind words and helps keep me going and motivated to try to help <hes> teach what i know and share pass along the information that that i pick up as i'm out there practicing as a pharmacist so yeah leave that rating view tunes wherever you're listening <hes> go snag that free free resource at real life pharmacology dot com that is a free thirty plus page p._d._f. Where you can get a hold of the top two hundred drugs and really highly testable things a great resource for young nurse young pharmacist young. You'll med student for example so go check that out as well now. I'm going to sign off for today. You can find me shoot me a message <hes> email at at med education wanna one at gmail.com in track track me down and linked in as well air christianson. <hes> pharm d b._b._c. g._p. C._p._s. and i will sign offer today. Thanks thanks for listening..
"I'm your host pharmacist air christianson and today. I'm going to cover the drug. Doll you tag revere so doll you take revere is an agent that can be utilized in the management of h._i._v. infection and oftentimes in h._i._v. infection treatment <hes> we do need to use multiple <hes> combinations of drugs drugs with multiple mechanism of action in the mechanism of action of dog tag. Revere is an integrase inhibitor so mechanistically how this works is the drug can interrupt the h._i._v. Life cycle by binding integrase and integrase is super important to the h._i._v. Virus <hes> because that integrates is an enzyme that allows how's the virus to <hes> air quotes for lack of a better term integrate its own d._n._a. Into the host cell and in humans h._i._v. targets <hes> those cd four t cells so that's how that that drug <hes> helps prevent the replication and the continuous cycle the evolution of the h._i._v. virus within the the body now now with that obviously the drug is is used for <hes> h._i._v. Treatment <hes> often in combination with other drugs dosing is typically once a day which is a big advantage many patients <hes> with <hes> h._i._v. treatment or needing h._i._v. Treatment <hes> pill burden can be a significant issue where patients have to take multiple different <hes> pills throughout the day that can lead to you know forgetting and not remembering remembering when to take them and how to take them and just getting busy with everyday life in having a poor adherence <hes> so that's most patients patients are probably going to be on fifty milligrams a day <hes> however there is a twice a day dosing for certain <hes> patients. Maybe they've been resistant in in the past or <hes> there's other clinical factors at play where we might use a higher dose there and i'll talk a little bit about that <hes> in the drug interactions section as well <hes> always important to remember that you know this information is time sensitive. Certainly a as i'm making this podcast all you take viewers certainly part of <hes> or the integration inhibitors in in general or certainly part of the h._i._v. treatment guidelines lines but <hes> those seem to change as often as i change my clothes so <hes> definitely keep that in mind with any h._i._v. guidelines now making sure that you've you've got the latest and greatest information there. I did forget to mention the brand name of dolly tag revere that's typically and and it's also important to note that there are some combination products with all you take revere in it as well as other anti-hiv agent so <hes> if you're unsure of what a brand name contains or is <hes> do like i do and go look it up and make sure you know <hes> which which mechanism of actions were using which is going to lead you down the road to recognizing <unk> side effects drug interactions and and all that sort of stuff so <hes> important to remember <hes> to look those up if you're not accustomed to working with patients with h._i._v. Adverse effect <hes> <hes> profile <hes> you may see some changes <hes> insomnia dizziness <hes> there's a possibility that it can raise <hes> blood sugars so patients patients with diabetes for example that that may be a concern or at least something to monitor <hes> if you've got a patient on tag revere <hes> those they're probably a little bit more frequent but obviously you know maybe not quite as severe as something like you know have paddock failure or a hypersensitivity reaction so those are a couple of rare adverse effects but <hes> ones that that have been reported with dog tag revere so let's take a quick break here and i'll finish up on <hes> drug interactions after a.
"Podcast. I'm your host and pharmacists air. Christianson. Thank you so much for listening in those of you who have left a kind review in writing Ma doing my best to, to make sure the, the content stays good and relevant. So today, we're going to cover sofas Salazie seen a brand name of this medication is offering, and it's category its pharmacological category is a five essay type compound in that stands for five amino salicylic acid derivative. Now what this medication is used for out in clinical practice. If you can remember that this drug is typically used for inflammatory type diseases autoimmune type diseases, you should be on the right track. Their most commonly, what I have seen in my practice is rheumatoid arthritis being used for that. Also definitely has a role or a have seen used in all stripped, colitis and Crohn's disease. So some bowel and GI type disorders there, and I have seen it used for psoriasis occasionally as well. So very common disease states that are definitely out there that you'll see in this drug can be used within the, the treatment algorithm. For those types of disease states. Mechanistically how this drug works and how it benefits a patient with these potential disease states. It's really not that well understood we recognize it can help to reduce inflammation, and it's theorized at least by a couple possible mechanisms so reduction, and inflammation is possible through tumor necrosis factor. In addition, again, this is theorized. It's not very well. Understood exactly how this drug works. Adverse effects, very important adverse effect. Very common adverse effect of a job said. So now Zia vomiting and because of this, this is one of the reasons why we try to divide up the dose in not give one big daily dose once during the day. So you'll often see this drug split up to is probably the most common spreading out of dosages that I see. So, you know, morning and evening, for example, in again, that's to kinda help ease that, that burden or that stomach upset that the medication can cause. There is a sofa component with this medication as you could. Well, guess, probably by the name, sulpha, Salazie, so rash, risk patients with assault allergy. We have to be aware of that at least in recognize and, and take a bit of caution with those type of patients that have maybe if had allergic reactions in the past, and, or skin reactions to other medications that may have a similar structure, similar component within them another adverse effect can reduce the absorption of folic acid. So if you remember full of acid, it's important for a bunch of different things, but definitely in the context of anemia full like acid deficiency can lead to development of anemia. They're so important to remember that aspect into think about that in a patient, who may be taking self cells Zine. There are some kind of rare or more serious unique adverse effects though. These don't happen very often, but they certainly can be pretty serious, so hypnotic issues. That's the first one I kind of think about so monitoring. LSAT's is going to be important there. Also rarely may see a plastic in Nimia and a granules toast us risk as well. Now, this can be exacerbated by patients who are on other medications, you know, I think of methotrexate as far as liver goes, a granules toasts us, you know, the drugs that can suppress the, the immune system, for example there. But again, for monitoring, we're gonna look at LSAT's for liver in CBC you might see a done periodically to monitor for those other things. Now a really, really important patient education, point that I do. See get missed once in a while is the onset of action of medications. And this is a drug that takes a while to work. So let's take that example of rheumatoid arthritis. This drug is not intended to treat and manage a rheumatoid arthritis flare, the onset of action is going to be usually multiple weeks. Three plus before you're going to start seeing some decent efficacy, and helping with those symptoms. So really early important educate your your patients saying, you know, this is not going to be a silver bullet. It's not gonna work right away. It takes some time to work. So good education point to remember, their fear of pharmacists or pharmacy student in the market for board. Certification material go check out method wanna one dot com slash.
"Hey, all thanks for listening. Welcome back to the real life, pharmacology podcast. I'm your host air christianson, pharmacists, and we have got a heavy hitter for a drug today drug called carbamazepine, and there is a ton of clinical pearls with this medication. So we'll just get right into at brand. Name of this medication is tech Raton, and its mechanism isn't totally well understood, and there's multiple possible mechanisms I would say the one that's most commonly associated with the Houston, this drug as binds, sodium channels and alters sodium transfer across cell membranes, which can ultimately slowdown prevent action potentials from happening and synapses and things like that. So kind of a little bit more of a challenging medication as far as the mechanism goes because there is kind of so much ambiguity. And it works in the brain, which makes. Things more difficult to research and understand. But that sodium channel aspect does seem to be important. Other things that, that can potentially cause can stimulate the release of age. So we'll talk about that a little bit adverse effect profile mildly anti corner GIC as well. I would say, in the grand scheme of things that probably isn't a huge, huge deal. But because there are so many different side effects and boxed warnings with this medication now getting into the uses in my clinical practice, probably the three most common, I've seen Tegel tall or carbamazepine used for is seizures BI polar disorder and tread. Jemele neuralgia and it's, it's really a, a messy messy drug as far as lots of drug interactions, which will cover. So that's really why you don't see a lot of provide. Offers using this medication. Because there's so much a monitoring in potential for hazards along the way with this medication. But obviously in a situation like seizures bipolar disorder or trigeminal neuralgia or you know, maybe we're limited options and or it's very serious condition. You may potentially see it. I did want to mention target concentrations, usual. Target concentrations, are four to twelve micrograms per mille. Now with that said in something like epilepsy. This is much more important to find kind of target goal level of, of where we want a patient to be in something like a tragic neuralgia where, you know, you're treating pain and you're treating symptoms. Obviously, it's probably not that big deal to find a target concentrations. Now, if you're recognizing some symptoms of toxic maybe some CNS problems, some GI upset things of that nature. After that might be a situation where you actually check a level. But, you know, in, in try jemele neuralgia for example, ongoing routine monitoring of levels is going to be much, much less important than when you're treating seizures with as medication one thing that always comes up or frequently comes up on exams is carbamazepine is an enzyme inducer, and it can actually auto induce its own metabolism. So kind of stimulates itself stimulates the breakdown of itself until it reaches a steady state, but this auto induction can take weeks maybe in the period of two to five weeks for this auto induction Kana to come to a steady state. So if you've got a patient, that's maybe very stable after, you know, a few days or week or something like that. It. There is potential that those concentrations could come down as kind of this auto induction ramps up a little bit. So what that means if a patient is starting on this medication, and we're doing drug levels and monitoring for efficacy, whether it's reducing seizures, or, you know, mood control by polar disorder we need to have that close monitoring within those, you know, maybe I one to two months that type of thing. Now, adverse affects we've got a boxed warnings with carbamazepine. And so the first one's actually genetic variation. So patients with the. Lille. H L, A B fifteen to, and I have seen that come up on test questions as well. These patients are at risk for severe skin reaction called Steven Johnson syndrome. So that's a good one to remember also warnings on a plastic anemia also a granular Saito, so lots of things to kind of unpack, and you could definitely understand how you don't monitoring certain labs, CBC and things of that nature would be important with this medication. Now talk city at did wanna talk about a little bit. So obviously these box warning things can happen. But in the realm of tax. Cecily due to do to too high of concentrations. I think you can think of it very similarly to, you know, alcohol Fenton, those kind of toxins where you're really gonna have, you know, that CNN's depression, maybe dizziness, maybe a taxi difficulty walking, you know, maybe nausea vomiting, some GI upset confusion things of that nature is what you're going to see if those drug levels get elevated now couple other adverse effects again. I said, this is very dirty drug. I always think about highpoint trivia, I absolutely have seen cases of SIA, D, H and hype. Nate tree Mia from carbamazepine that risk tends to go up as we're on more agents that can also cause highpoint trivia, he think about, you know, loop diuretics or diuretics in general. Also think about SS arise and medications of that nature as well. So definitely important to keep tabs on sodium with this medication liver. Toxicity is possible LSAT's are in with that CBC monitoring as well as sodium monitoring an important aspect that you're gonna wanna follow in a long, you know, with the L F teas that, I mentioned, you got to think about other agents that might be damaging to the liver as well. Obviously in combination with another agent like carbamazepine that can cause some liver problems. That's something to certainly be aware of as you're looking at that patients, maybe poly pharmacy medication list. So with that. Let's take a quick break from our sponsor admitted one one dot com slash stores. Proud sponsor, the real-life pharmacology podcasts, just love the podcast. Enjoy the free material go support met at one one dot com slash store. Tons of resource. You can even get a couple of free ones. If you've never had an audible book, so definitely go, check out those links take advantage of that. If you're pharmacists, or pharmacy student looking for board certification materials. Absolutely. That is a good place to go. Check out what we've got at mid one, one dot com slash store drug interactions. So probably the biggest thing I think of with carbamazepine is it is an inducer and you always gotta remember what an inducer is versus what an inhibitor is. So a sip three four inducer is going to stimulate these enzymes in the liver to clear the body of drug or metabolize drugs. More quickly. So if a drug not carbamazepine is metabolized by CYP three a four and we use carbamazepine. That drug is going to basically be chewed up faster, and it's a facts aren't going to last as long in a patient, who is not on carbamazepine. So it's kind of a simple as simple as I can make explanation to try to understand what happens to these drugs that go through CYP three four and here's some examples, so a picks Aban river rock. Som also warfronts anticoagulant. So if those concentrations fall because we're using carbamazepine that's a pretty big concern. You know, depending upon what you're using it for you're looking at increased risk of DVD p potentially a risk of a stroke. If we don't have adequate anticoagulant, concentrations to help prevent those strokes. So definitely a big deal there, again, gray. Good example, why we try to steer clear from using carbamazepine, if we can avoid it era. Pip Zola lands opinion, a couple of anti psychotics I think of there's anti-hiv drugs. So I think of the protease inhibitors, as well as some, some other oddballs that can be reduced concentrations, and reduce the effectiveness there, alternately, dill, tie them Rapa. Mel again couple of medications you may see amused for hypertension. May see him used for maybe migraine prevention. Maybe atrial fibrillation. A few different uses you can use that type of class for gin, those concentrations could be reduced by adding carbamazepine some of the as all antifungal, you gotta think about contraception. So estrogen contraception could be chewed up a little bit quicker. And that might leave a pair. At more risk for becoming pregnant when maybe they don't necessarily want to be, so that's an important one there as well. Also, some other oddballs hydro Koto and that's got some CYP. Three four metabolic breakdown today. Phil, another example, with the fast food restaurants. Five inhibitors there drug for rectal dysfunction. So very, very important to think about other drugs, whenever carbamazepine I think that's the, the bluntest most simple point. I can can tell you, and I would encourage you, if you see this drug being used to run an interactions check look it up and see what we're going to be affecting. 'cause if you've got a patient on three or four or five, plus medications, and carbamazepine odds are probably pretty favorable that one of might be affected. So very, very important. There. Couple of things I did want to mention, so a grapefruit juice. So that is known to be a sip three or four inhibitor. So this can actually raise concentrations of carbamazepine, so grapefruit, juice with carbamazepine may put a patient at risk for carbonates being toxicity, how important to remember that one. I do wanna I kinda hinted at the teas, you know, thinking about drugs that, that may cause liver function problems, and you add on remains a PM could be potentially an additive effect type of thing. And then I also think of the SAD h which I think I mentioned, a couple of examples there of other drugs that could 'cause that adverse effect, and that low sodium,
"And changing things with a patient's medication regimen. So without further ado, avoiding use of river ox ban is recommended in patients on dual p glycoprotein inhibitors and CYP three or four and. Hitters so a few examples here, and these drugs aren't used crazy often, but just wanted to provide you a few examples Kitakata Zoll Ichikawa's own retirement of your are few examples of those agents, and that is recommended to absolately avoid using those agents with river oxypan three four inducers is an another class there. Carbamazepine I do see that drug use occasionally, whether it's you know, tried jemele Raja occasionally for seizures. Maybe a rare case bipolar disorder. We've got to look out for that. Because these inducers will actually lower concentrations of the river rock man, and potentially lead you down the path of a treatment failure, increasing the risk of stroke by not having adequate concentrations there so cover maze of him. Reform plan antibiotic. That's that's used Caisley not terribly often. Saint John's worts something I have seen patients try four depressions over the counter supplement, so definitely strongly educate your patients about that one of their ever considering taking over the counters couple of other things to think about that. I definitely think about is Ruth revising classroom. Aisin these are through CYP three four inhibitors. They have been shown to potentially increase concentrations of river oxygen. So again may lead to situation where we're at higher risk of bleed and said, they can you don't inhibit those platelets. They can cause issues there potentially aiding the effect of a GI bleed. So definitely we need to look out for that. I strongly encourage patients, you know, to avoid these medications over the counter anti platelet Medicare. Nations. So we got clip integral and aspirin. There has been some some updates on guidelines in patients who have recently at a heart attack and a stent, and they also have each fibrillation. So you might wanna go take a peek at that. If you're a prescriber, and or clinical pharmacists that may need to be be aware of that. I'm not going to go through that today. So definitely those drugs that can increase the risk of lead. We we've got to keep tabs on those anti platelets in end sends are commonly commonly used and when you to pay attention to that one other one I I did want to mention estrogen therapy so patients with hot flashes menopausal type symptoms that may be on estrogen therapy. Remember, they can increase the risk of blood clots, and may kind of oppose the effects of some of these newer Orel anticoagulant like river ox ban. So I think that's going to wrap it up for today. Thanks so much for listening. If you love the podcast, get some some Pearl some clinical info out of it. I'm greatly appreciated if you'd leave a review rating on I tunes, or wherever you're listening that certainly appreciated you have the opportunity go support the podcast at one one dot com slash store. You can see all those resources there. See if anything fits with what what you're wanting to look at and learn there so without going to sign off. Thanks so much for listening all the kind words greatly appreciated in emails. Appreciate it as well. We do have that free giveaway as well. Real life, pharmacology dot com. Top two hundred study guide thirty one page PDF for highlight really important things with each drug in that study guide great resource for students young professionals that may be taking board exams at anytime in the near future, or pharmacology classes, of course, signing off. Thanks again, air christianson pharmacists, track me, down at linked in as well have a great rest of your day.
"Hey, all thanks for listening today or christianson here, host of the real life pharmacology podcast. I am a pharmacist and people have certainly asked how to contact me reach out to me with questions or sponsorships or other things. Like that linked in as a great way to track me down so air christianson farm DU contract me down there as well. As through the website real-life, pharmacology dot com. So that's probably the easiest way to get in touch. With me. Thank you to all those who have left a rating and review if you like the podcast, I would strongly encourage you to do. So that helps us an I tunes and rankings and all that good stuff and allows us to be found by more people. So with that, let's get into it. I'm talking about the nasal it today. The brand name of this medication is XIV. Ox in this medication is an antibiotic foreign faction, we've got oral and IV capabilities there that we can give this medication primarily, you know, it can be used for a variety of different infections some off label and things like that primarily probably skin and soft tissue infections and Monja are going to be the most common, but you may see it for various other things as well. So there's to at least really big bugs in in my experience that Lanese lid can help treat lineal it is kind of one of those down the line type of drugs due to cost and due to its coverage capabilities. So it's not gonna be. Typically, not going to be used for empirical therapy where you know somebody's coming in with pneumonia. Boom, you're going to give one as let. No, that's that's not typically how that drug is is going to be given. So the two specific bugs that it's really really helpful in managing and treating our VR e which is vancomycin resistant Enterococcus. So it's kinda right in the name. Right. Where if I if a Enterococcus bacteria is resistant to vancomycin vancomycin 's you don't considered one of our Goto drugs for certain gram, positive bacteria and Enterococcus is obviously one of those VR e is a very resistant bug in resistant to vancomycin so Liniers la- does have definitely a role to play there. And m are essay, so methicillin resistant staff aureus, so we may have certain situations where vancomycin maybe that specific bacteria is resistant to vancomycin maybe thank him icing. Can't be used for whatever specific reason. So m say in VR or two of the bigger kind of resistant bacteria that you may see Liniers lid used for now how exactly does the the drug work. Kind of the big blanket statement this drug inhibits the bacteria from producing synthesizing protein, that's kind of a big broad overview specifically, I it binds to the twenty three s Ravazzolo sub unit which is part of the fifty s sub unit and this blocks formation. Listen of this bigger unit called seventy s so it's kind of a detailed process as far as protein productions, and and Rivaz almo activity and things like that. So yeah. Primarily blocks binds in and blocks twenty three s which is part of that fifty s sub unit. One of the big reasons la- nasal ID isn't used incredibly often is because of adverse effects and drug interactions. Now. I'll talk a little bit about drug interactions after the break, but let's get into the side effects here a little bit. I so he mental logic side effects are kind of unique thing associated with Lynn as the lead so lower white blood cell count, lower platelets. And this is why we monitor things like CBC with typically with longer. Term us. Now, if you use the Nazlet for one day three days, and then you switch agents to another drug for some odd reason. Odds are likely in that short amount of time were probably not gonna run into reduced white blood cell count. Okay. So typically, this is going to be in situations where this drug is given for a longer period of time. Maybe a few weeks something of that nature, another potential side effect kind of unique Tila nasal it is neurologic side effects, and there is potential for these neurologic side effects to impair vision cause optic neuropathy. So that is obviously very very concerning. When you start talking about vision loss as a potential side effect, again more likely with extended course extended duration treatment with Lena's lead. But it definitely is something we need to be aware of and one of the downsides to initially using this drug. Lower can I guess lower risk side effects. But maybe more common. You may get some a GI upset things of that nature and particularly kinda ties in with the the mechanism of action. Linnea does have some Amei. Oh, I activity now if you remember MA wise, they can be used in depression, for example, but they are a last line agent because they cause all sorts of side effects, and they have a ton of drug interactions and really kind of a messy class drug. Well, l- nasal does have some of that activity as well. So this is something we need to be really careful really cautious about. And like I said I'm going to talk about that in the drug interaction section now for monitoring parameters same kind of mentioned that CD CBC complete both so count there visual. So if you're you've got a patient where they're on longer term when as lead you may wanna do some visual Susman's nervous system assessments monitoring for a neuropathy, and that type of pain, so those are a few important monitoring parameters, and again, you're going to monitor those things kind of the longer you go on with the the course of therapy. There may be a greater risk of of running into some of these things. Let's take a quick break here from our sponsor and I'll finish up with drug interactions. We've got a huge list of clinical pharmacy resources at med one on one dot com slash store. START we've also got certain Cheerios to help pass board exams. Like, nah, plex and BCP SPCA C p geriatric exam there as well. So definitely go take advantage of those resources. Very well priced all sorts of price ranges, if maybe you're a student or something like that. But lots of different pearls. You can pick up audible books. You can get your first audible book for free. So that's kind of a unique thing there. If you've never tried audible, you can go ahead and snag one of our books right off a med one dot com slash store. Let's finish up on drug interactions with Lenny's lid, and this is where things get really challenging in clinical practice. One of the things that that always comes up very frequently. With Lena's lead is patients who have depression, most patients drug of choice for depression is necessary high and they are probably going to be on. One. If they've got a history of depression. Now, it is generally recommended to avoid using the
"air christianson" Discussed on 850 WFTL
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"Safely so med one one dot com slash store. Go check out the list of resources, we have there. All right finishing up on drug interactions with hydraulic Zine. There aren't a ton of really notable drug interactions with any blood pressure medication, obviously, I think about other meds that can lower blood pressure. That's kind of a common sense type of thing. So oftentimes, we're using hydrology, and maybe with, you know, a calcium channel blocker something of that nature in patients that need multiple blood pressure lowering medications, so that can certainly happen. But we've got to keep in mind when we add on more pressure lowering medications, we are on the risk of of dropping that too far in getting into dizziness and orth stasis and things of that nature so other what pressure lowering drugs think about that. And not just specifically the anti hypertensive. You know, I think about cinema, you know, drug for Parkinson's that can draw blood pressure. The PD. Five inhibitors. So example, there still data Phil brand name Viagra. I those are a couple of good examples their drugs that can really cause significant syncope or you know, kind of those passing type episodes. You gotta remember the alphabet offers those can really draw blood pressure quickly. And obviously if used in combination with a drug like, hey, drowsy and Vasil dilated tight medication that can really drop that blood pressure to a significant amount. And then the the other thing I'm gonna cover with with drug interactions. Here is remember that opposite effect drugs that can't oppose the blood pressure lowering effect from hydrology. So I think of you know, drugs like stimulants. You know, maybe like Adderall and things of that nature. End. Saids are another example of medication that can kind of impact blood pressure in a positive direction as far as positive meaning higher. So that could potentially oppose the blood pressure lowering effect of hydraulic Zina's. Well, so it was just a few kind of opposition and similar type of fact drug interactions that you're going to have with hydrology other than those there really aren't a ton of drug interactions where concentrations are raised of drought causing or hydrology impacts other concentrations of drugs, so really it's kind of those additive or opposing type drug interactions that I covered there. So that's going to wrap it up for today at the enjoy the podcast leave us a rating review on I tunes or wherever you're listening to incredibly appreciative. You can find me at linked in air. Christianson pharmacist if you'd like to connect with me feel free to to track me down there. Snag your free top two hundred PDF simply I subscribing to the website, you get alerted to when we've basically got a new podcast out as well. So absolutely of of no cost to you in just a little resource, if you're potentially preparing for a board exam, or if you're looking to to share something maybe with a student who studying for exams or something like that can be a really really helpful tool. So go check that out real pharmacology dot com. Also, contact me there if you've questions comments all sorts of stuff like that. So sign offer today. Thanks for listening. Hope you enjoyed the podcast and and picked up a Pearl or today. Take care. Thanks for west. None.
"They all air christianson here. Host of the real life pharmacology podcast today. I'm gonna cover aspirin and specifically with aspirin. I'm I'm going to talk more. So about the anti platelet activity that the the drug house, and how we use that in clinical practice, and some factors that you might want to think about as well as mechanism of action. And and all that good stuff as well. So other brand names that aspirin goes by Eka Tren bear, it's in some excedrin products as well when and I think this brings up a really important point. When you when you talk with patients about over the counter medications, you have got to be sure you're on the same page with them, and, you know, take excedrin, for example, excedrins generally considered for headache. But if you go look at different excedrin products, they've all got different ingredients. So. So very very important to understand what's in a medication and over the counter medication and make sure that info is relate back to the patient as to what to look for as far as the active ingredients go on the back of that label because so many brand names have different variations of products. And I after I've often often have to look myself to make sure I'm getting what, you know, giving something to a patient that I think they should be getting because you can often be deceived by brand name over the counter products, and what's in them. So with that we've got the mechanism of action for aspirin in. I did talk about end saids. More broadly in a previous podcast. So definitely go. Check that one out more at talk about some of the concerns with ensigns as a whole but its primary mechanism of action as far as the anti platelet active. Vity goes aspirin like other ends heads can inhibit Cox one and Cox two, and I'm and primarily this is going to block the production of thrombosis seen eighty two and this thrombosis in eighty two is important because it stimulates basically blood clotting it initiates that process in stimulates platelets to aggregate together in and stop bleeding. So I think you can kind of understand by that mechanism that aspirins going to increase the risk of bleeding there. So it is classified as an end said in addition to that anti platelet activity. We do have some analgesic anti paramedic anti inflammatory properties. These are generally at much. Much higher doses. Than the anti platelet activity, the anti platelet activity. We're looking at, you know, eighty one milligrams to three twenty five some of sometimes you will see patients, it seems like it's more geriatric patients use aspirin as their go to headache medicine and things like that. Generally, not something I I recommend. But you will see patients do that over the color sometimes and in the headache pain relief. Anti inflammatory type of fact, it's generally going to take higher doses with that. So maybe open six fifty and in more in that range as far as the the milligram dosage, so yeah, primary use in clinical practice is going to be that anti platelet activity. This is what you're going to see patients on eighty one milligrams once a day in the morning, for example, maybe three twenty five depending upon the situation. And what we're using the higher dose for. But again, if you see a patient usually dose down at once-daily, it's probably not for pain. It's probably four courteous, vascular prophylaxis, preventing heart attacks strokes and things of that nature. But we always want to make sure to ask patients what were using something for to make sure they know as well. Now, there's been some controversies and pushing Paul on cardiovascular prophylaxis, what doses appropriate is eighty one milligrams fine is three twenty five fine. And I will say probably in the majority of situations. Eighty-one milligrams of aspirin is okay. But there are some risk factors and and patients who have maybe had multiple events. There are some clinical factors in situations where you may get a provider that wants to do a higher dose. So there can be a little bit of leeway. There can be some exceptions there. But Eighty-one milligrams is probably acceptable for most patients one for sure situation where we're going to use that higher dose. Maybe a three twenty five milligram tablet is in ACS type situation. So that's. Acute coronary syndrome. It's a situation where you're maybe a patients presenting to the emergency department, or you know, with EMS the ambulance comes in a heart attack is suspected. In aspirin three. Twenty five milligrams is recommended over in eighty one milligram tablet in that acute situation where a heart attack is suspected. So that's one clinical situation where you might see the higher dose used and preferred over the eighty one milligram dose surgical procedures. This is always a question that patients Askar that I've seen patients ask a lot, and it can be difficult to end. There's no good blanket answer for whether an aspirin should be held or should be not held because different clinical situations and the intensity the aggressiveness of the surgery in what we're doing the invasiveness of the surgery, and how much blood loss is an -ticipant did. Does dictate whether aspirin should be held. You know, if it's a a minor, you know topical skin procedure. Aspirin might be appropriate to continue in that situation. And what you're going to want to lean on his the surgeon and in what they're doing with the patient and their determination of what the bleed risk is in that situation. So if it's going to be held typically aspirins going to be held in that five to ten day range, I would say most commonly in practice. I've seen about seven days maybe up to ten days in rare situations, but seven seems to be the number that I've seen most common. So again, whatever we hold aspirin. You know, the obvious risk is that, you know, cardiovascular event, if that's what we're using the aspirin for does maybe have the potential to happen, or you know, that's the perceived risk at least of stopping a medication like aspirin. That's a preventative type medication. So always important to to think about the the risk of the surgery the risk of blood loss as well as the risk of stopping that medication for a period of time as well. I adverse drug reactions with aspirin. I I would say with a baby dose aspirin adverse effects, particularly other than bleeding or bruising typically, aren't that common? So if I do see a patient, that's. That's maybe having trouble with aspirin. I might be a little bit of stomach upset or things of that nature or bruising and bleeding. That's probably the most common thing. I see with patients, maybe even more. So with geriatric patients that maybe have a little more frail skin and things of that nature. The the bruising maybe really really bothersome to patients. This is something that you're probably gonna come across. So we're always kind of juggling that risk versus benefit of aspirin. And we can certainly monitor hemoglobin in Amata Krit t to make sure that the patients aren't losing blood aren't having a blood loss. Maybe through the stool or something of that nature. GI bleed out. We can also check platelets to make sure that you know, this patient doesn't have some sort of underlying issue or or anything else that's dropping their platelets further which may put them at higher risk. For bleeding another thing to to monitor look out for with that bleed risk is other medications. So I and I played Litz antiquated, and I'll I'll touch on that with drug interactions a little bit there. So Jay upset, you know, you might get some some mild issues there GI bleed bleed risk in general is probably the thing. I see most common with aspirin because of that anti platelet activity. And and really what we're trying to do with the drug in preventing some of those those blood clots are rare things that you might see on like a pharmacology exam. But I can't say you see him too often in clinical practice so ringing in the years tonight is can happen with the overuse of aspirin or high dose aspirin, again, not incredibly common. But, you know, something to think about if you've got a patient presenting with ringing in the ears. Tonight is definitely asked them about over the counter us because there is a small segment of patients out there that will take some aspirin on their own for and pains or as nati- inflammatory, and then rise syndrome is associated with aspirin. That's always kind of a classic test question. So generally aspirins going to be avoided in pediatrics due to that risk. So let's take a quick break. From our sponsor men at one one dot com has a growing list of resources, nap, lex BCP SBC GP ambulatory care as well as good books that are clinically oriented great for nurse practitioners, PA's med, students physicians. Just good information clinical real world information in education that you can stop by. And check out. They're so mad at one one dot com. Slash store finishing up on drug interactions here. When I think of you know, particularly low dose aspirin. I'm looking at drugs that are going to have additive of facts or put ten she ate that risk of bleeding or thinning the blood. So other anti platelet medications. So something like cl- integral Presa grow which is typically used with aspirin post 'em. I for example. But you've got to remember that when we start using multiple agents that do similar things you can have that additive effect and bleed Rhys does go up so very important to remember that as we add more those anti platelet agents. Same thing with anti-coagulants. There's lots of geriatric patients with atrial fibrillation who are on a pixel ban or friend river rock Sebastian. And they may also be on baby aspirin, or you know, maybe higher does aspirin as well. And you've got to remember that that risk as we add those anticoagulant medications of bleed Kengo up as well. End saids notorious for causing GI bleed, I generally cautioned my patients on that. If they're taking aspirin on a dose of aspirin. If you use an end said in over the counter medication like pro or naproxen, you've got to remember that this is going to increase that risk for things like GI bleed. So I think that wraps up the podcast for today. Hopefully, you picked up a few pearls. It reminded yourself of a few clinical pearls with
"Hey, all air christianson here with the real life pharmacology podcasts. Thanks for listening today. I remember to go. Check out the real life, pharmacology dot com website, snag your free. Thirty one page PDF. Great little resorts for pharmacy students nursing students med students. Just as kind of a quick study guide on important pearls with the top two hundred drugs. So certainly at no cost to you. And simply I subscribing to follow the podcast with that today. I'm gonna cover Memon Tyne pharmacology so brand name drug here is no meadow. And this drug is primarily used for dementia. Now in important factor with dementia in dealing with patients, and caregivers and these type of medications that work in Alzheimer's dementia. You've got to remember that patients sometimes have unrealistic expectations. Kate these drugs, do not stop dementia, and they do not reverse dementia. There may be some symptomatic improvements, maybe initially, but ultimately that disease progression with Alzheimer's will not be stopped in the long run. Now, it it may help maybe delay the progression. Or allow functioning a little more functioning for a period of time. But again, not gonna reverse not gonna stop. So very important to remember that now the mechanism of action with this medication. So it's classified as an an MD. A receptor antagonist and the big thing with the outer the theory is that glutamate which binds this receptor glutamate from that binding and activation can put ten -cially be a contributing factor or cause in contributing to Alzheimer's dementia. So that's a very important thing to think about that that glutamate might be causing that, and if we can block the activity of that glutamate by blocking the receptor an MBA that it binds to we're going to help hopefully, you know, prevent the worsening of some of those symptoms. So that's kind of a little bit of a background about the mechanism of action in clinical practice patients generally classified as moderate to severe. Veer Alzheimer's dementia, and I'm not gonna get into classifications in the this podcast, but patients with moderate to severe showed the best benefit in clinical trials. So that's why indicated in patients with moderate to severe Alzheimer's now, I definitely have seen a tried in patients with maybe less severe dementia yet off label I've seen combinations with the seat Aucoin, ashtrays inhibitors. And actually there's some evidence for use in combination with these local industries inhibitors drugs like dinette Bazil brand name era sept-, for example. So that that's definitely something. You're going to see in clinical practice. Now. If you're monitoring these patients on this medication and monitoring for efficacy it's going to be really hard to tell if it's working or doing any. Anything in? That's just the reality of the drugs. The only way we can tell is if we compare groups of patients in research trials now again, you might see you don't maybe some modest symptomatic improvement. I have seen that in my career, of course. But again, that's it's not generally the norm with Menton in in these type of agents and the dementia type of agents in general. Let's talk about side effects a little bit with Nemenzo. Primarily what I've seen in practice is central nervous system type side effects with this medications with this medication. If patients have them, so maybe some sedation, maybe some dizziness I have seen situations where it's actually maybe worsened symptoms potentially. And obviously in in that that type of situation the medication was just discontinued. So again, you know, I there may be changes in mood. I've I've seen that happen as well. And sometimes it's kinda difficult obviously, timing is very important when the medication started, and when you're seeing adverse effects, but with dementia is sometimes it's very very difficult to know, if it's part of the disease process, or if it's part of medications or something else going on as well. So can. A little bit challenging to identify side effects would say overall usually pretty well tolerated. I'm with one exception. I do want to remind you about and that's kidney function. So this drug is primarily eliminated through the kidney. So you've got to remember that if a patient has declining kidney function, which pretty much all patients do as they age this drug can slowly accumulate over time or more quickly. If it's more of an acute change in kidney function there where the Craton is rising and the Craton clearances falling that drug can accumulate and potentially caused some issues. So keep an eye for I o for dose adjustments on that medication dosage forms. I didn't want to cover this specifically. So there is an amendment Xsara formulation versus an amendment immediate release formulation the immediately says much cheaper. And you know in in my experience, I've. Scene. No potential clinical advantages other than the extent of releases once a day, but amend X are much much hundreds of dollars generally more expensive than the immediate release which is twice a day. So yeah, I typically recommend only the immediate release. If someone is going to use try one of these medications, simply due to the fact that is just one more pill and many patients, you know, with dementia geriatrics, they're oftentimes taking medications more than once a day. Anyway, so it's typically not going to be that much of an issue when you talk about possibly saving hundreds of dollars per month. So just a little note on a dosage forms their discontinuation. So there isn't a perfect algorithm. There is no perfect. Way to know when to stop these medications, obviously, if you're presented with a patient that has a very very short life expectancy there non responsive, you know, that type of patient where the the dementia medication is really providing no value that all is probably pretty easy and pretty safe to go ahead and maybe taper down and discontinue that medication. But you know, what you really think about each patient clinically individually some things that that I think about patient family preference. Really get them involved in that decision of you know, weaning off medications taking medications off the stage of their disease. You know, how close are they potentially to death, for example? Slowly, tapering off is something. I generally always recommend very seldom is there. A reason just to pull out the rug, and and take it all away. That's kind of a geriatric mantra start logo slow and that applies to reducing doses. As well. I if they've got you don't difficulty, swallowing difficulty taking Orel medications, I mentioned kind of minimum minimal responses. You know, that's probably a patient where the medication really isn't helping to improve them or delay anything if they're already at that kinda end stage type of symptoms. So those are just a few things I think about when considering when to actually discontinue dementia medications, let's take a quick break. From our sponsor met at one one dot com. Great resources for nap plex, if you're a pharmacy student, for example. Be CPS VCA C P NBC GP so geriatrics exams. Ambulatory care. Pharmacotherapy exam. Plenty of study material they're met at one one dot com slash stores where you can find the entire list finishing up on drug interactions here. I knew Amena is I guess what we would consider a pretty clean medication in that. It really doesn't have a ton of drug interactions. So that's always a great thing that we're not complicating things in causing concentrations to go up and down for other medications or amend itself so drug interactions. I typically don't worry about too much. There are a few rare ones. I generally think about drugs that might exacerbate dementia in contribute to the prescribing of dementia medication so Anti-cull Nirj sedatives drugs that can. 'cause memory impairment confusion. I think about those drugs in our dementia patients, and I watch and monitor those very closely to make sure we aren't doing more harm than good with that gonna wrap up today's episode again find that free PDF on real life, pharmacology dot com. Simply I subscribing have enjoyed the podcast think, it's helpful. So appreciative of all the ratings and reviews of you've got comments, certainly reach out to us from the website suggestions about different topics or medication you covered feel free to to shoot us. An Email there at real-life pharmacology dot com that gets sent straight to me. So thanks for listening. Take care of hope you have a great rest your name.
"air christianson" Discussed on Armchair Expert with Dax Shepard
"Bogged down in what the theory is behind certain things. At the expense of evaluating the outcome. Right. So for instance, there are many parts of AA that I think are either misogynistic because it was written in the thirties or way to God Centric for my taste. There's a whole batch of things in there. I maybe don't agree with, but then if I look at the results of this thing and the results are these people worried they're going to be dead in prison or in an insane asylum, and now they're healthy, thriving and have kids. Right? I could choose to continue to focus on these three elements that I disagree with inferior more. I can just look at the results in a little bit more about that. I guess a choice I get to make so awesome. I'm naturally not drawn assigned Scientology just because I don't. You know, this is one of the long debates we had in a car driving back from sess wedding. Do you remember this in this was one of my one. My one issues with it was. Okay. So there's a book Dianetics by L Ron Hubbard, right? It teaches you how to go clear, right, right. There is a bible, there's a bible. That's all the information there is on on Catholicism is in that bible, right? So why is there a priest? I don't understand whether it's a priest who has to tell me what the meaning of the words in that book is that that's always been my objection to Catholicism is high. Why is there a hierarchy when it's based on a text, we all have the ability to read the text. No one's a better or worse. Interpreter of tax. It's just, I mean, that's not true obviously. So people can't never what they all things being equal. The pope and I have the same intellect and the same reading comprehension level. Why on earth is that guy know more about the same book that we both read and why is he been elevated to a position of power and authority? I don't trust that totally allies on my criticism at one point of yours was, well, if this is based on taxed. Why on earth are there levels? Why is there a hierarchy? Why is there a. The, oh, whoa. The only things I think is absolutely miraculous about a is it's a completely structuralist organization. There is no presidents, there's no secretaries. There's no nothing. Nobody knows more than anyone else. Dude with today's sobriety as just a valid as Pinon as I do with their team. That's magic. The one thing I'll say is the coolest part of a right so. And then what was your defensive that when I was saying, I don't understand why you air christianson who I know is smart as motherfucker and has access to the tax. Why would you need instruction from someone else or why would you elevate or put faith in someone above you when it's based on a text while mostly I don't, and I don't remember what I would have said at the time because why recorded. Seven years ago. But basically you're, you're absolutely right. You read something and your relationship is with the information there and your observation of those things as true in the world around you or not. Now there is definitely the as far as the levels is just that you you don't take Trig. Like before you finished your arithmetic and and they're not gonna let you read it. They're going to say no finish your addition and multiplication tables before you get there. Right? Because it's not gonna make any sense. 'cause you're saying like level, let's say level seven has has six levels of prerequisite knowledge. Exactly. The that you couldn't even comprehend what you would be readings. Yeah, it's just sequence. Okay. Okay. Well, that makes sense. Yeah. But what was going? I started to say, then I, I got sidetracked with our debate, which is. I know a lot of Scientologists and I don't. I don't think I agree with many of the tenants or maybe the origin or I might not hold L Ron Hubbard in the same degree that you guys do any of that stuff almost unilaterally