It hurts when I do this...'

Hello. I know it has not even been 24 hours since I last posted, but I had a Spanish class unexpectedly cancel on me today, so I thought I should take advantage of the time.

It seems that things are going along ok. I am currently tied for 3rd place amongst the interns. I need to get some surveys going so that I can get above the rest. But, that is ok, because this weekend, as long as they don't call me into the hospital, I can get some more surveys. FINALLY the laptop battery I bought online showed up and is working just fine, so I can harrass people at work and be up another 100+ surveys in a few hours worth of effort.
That is the plan anyway. The hospital has been really busy the last few weeks, so I am hoping that Saturday it will be slow enough that I can get some of this stuff done.

Anyway, it is now time to unveil this weeks 'DotW' feature.
This week I have decided to focus on another neurological medication.

I am going to write about Tegretol today. This is another medication that I have had personal interaction with. In previous posts I have mentioned that I worked in a group home with the developmentally disabled and have personally administered some anti-convulsants and other medications. Tegretol was one of those medications that I would personally assist with.

However, I am not going to talk about it as a medication for seizures I am going to focus on it as a medication that is used for chronic nerve pain.
The Tegretol molecule looks like this
(Actually when I was looking up the information for this molecule I ran across a picture of someone who had tatooed a Seratonin molecule on their hip. Not relevant to this blog, but interesting nonetheless. It was a well done tatoo):

Tegretol is also known as Carbamazepine, in fact, like most of the drugs I have reviewed I knew them by their brand names and not their generic name. Tegretol works by blocking the sodium gateways in nerve channels. It halts or slows the rapid firing of neuron transmission. Basically it stops the nerves from being able to send signals. This makes Tegretol useful for both seizure activity and for neuropathic, or simply - nerve - pain.
(http://www.neuroskills.com/tbi/ac.shtml)

Personally I have only seen this medication prescribed for seizure activity. When I have dealt with neruopathic pain in a healthcare situation I have seen Neurontin prescribed. I spoke about Neurontin in a previous blog post, and I feel that that medication works fairly well.
In fact, I would say that there are 3 major medications that come to mind when dealing with both nerve pain and seizure activity. Those medications are, in no particular order: Topamax, Tegretol and Neurontin.
I have seen these medications in both of my past jobs in which I have worked with seizure disorders and neuropathic pain, and I think they work fairly well.

We just need to wait until those whom I have contacted about doing surveys for their neurological medications find time to fill out some surveys and we can see what they think!

Thinking a loud.

Unfortunately due to time constraints I won't be able to do a full post tonight, but I hope to be able to just talk briefly about some cool things that are going on.

I recently spoke with Cathleen Marshall who is one of the people in charge of the internship. She told me a really good idea, which was to find and speak with people who are in online groups and communities that deal with the medications that I am looking into. I did this today and I am happy to report that there seems to already be some progress.
I was worried about doing this because the last thing that I wanted to do was come off as a 'slimy' guy who was trying to capitalize on someone's illness. Like those awful lawyers who do commercials on tv telling people how much money they can get by taking people to court over traffic accidents - disgusting. But, it seems that people thus far have felt that my attempts were genuine. Cathleen also sent me the code lines so that I can link directly to surveys that have been completed. That will be a cool resource too.

I sincerely hope that those who look at www.rateadrug.com can get some answers and maybe give some as well. Especially in regards to those who suffer from chronic nerve pain. That can be so frustrating. I have taken care of kids who have this condition and just to touch their skin can be really painful for them. There is a surprising lack of knowledge on RAD concerning neurological medications. That is something I aim to correct.

In medicine there is often a lack of communication. Teams do not communicate with each other, doctors do no communicate with patients and patients do not communicate with doctors. There are of course the usual questions and relay of basic information, but there needs to be something more. Finding the right diagnosis is not just a matter of getting the right answer it is often a matter of asking the right questions.

Anyway, thank you for coming and reading my thoughts aloud. Later this week I shall post my 'Drug of the Week' feature.
Stay tuned!
Same blogger address, same blogger channel.

Vide Alternam Partem.

Before I begin I have one more personal note, yesterday while at work I overhead one of the nursing staff talking about using an oral dose of Vancomycin. If any of you have been following my earlier posts I spoke about how oral doses of Vancomycin are used only to treat GI issues. Come to find out that this patient was at high risk for an overgrowth of bacteria known as C dificile and the Vanco was being used to pre-treat the issue. But, thanks to my research and blog I knew the context and the generally prescribed way in which Vanco is used. Go me.

The last time I 'blogged' I spoke about a drug being used called Racemic-Epi. That is going to be the subject of today's DotW feature.

Ok, first off I need to define a bunch of terms. I am currently enrolled in an Organic Chemistry course, and I am really enjoying it. The terms that I am going to use are from Organic Chemistry, as Epi or Epinephrine is an organic molecule.

Epinephrine looks like this:
It is more commonly known as Adrenaline. It is commonly known as Epinephrine because it is produced by the adrenal glands which are above - epi - the kidneys and in Greek nephro means kidney. So, epinephrine means above the kidney.

Technically speaking, epinephrine is a sympathomimetic catecholamine. It causes quickening of the heart beat, strengthens the force of the heart's contraction, opens up the airways (bronchioles) in the lungs and has numerous other effects. The secretion of epinephrine by the adrenal is part of the fight-or-flight reaction. Adrenaline is a synonym of epinephrine and is the official name in the British Pharmacopoeia.
(http://www.medterms.com/script/main/art.asp?articlekey=3286)

We now have a basic understanding of Epinephrine, or, Adrenaline.
So, what makes it so special if it is called racemic?

We have to do a few definitions before we can define it completely. A racemic mixture is a 50/50 mixture of what are known as R and S enantiomers. An enantiomer is a mirror image of a molecule; when you have enantiomers they can not be placed directly on top of each other. To understand enantiomers think about your right and left hands. They look like mirror image of each other, but they can't be placed directly on top of each other with out rearranging things.
To say that an enantiomer is R or S means that it has bonds around a carbon that rotate in either a clockwise - R - direction or counter-clockwise - S - direction.
In other words, a racemic mixture is a mixture that has carbons with bonds that are counted in a clockwise direction and bonds that are counted in a counter-clockwise direction.
This is important because the way in which bonding occurs on a carbon atom can really affect the way in which the molecule is able to act.

Racemic-epinephrine is commonly used in an aerosol form to treat airway problems. There is, however no standard for treating a respiratory ailment with racemic-epi.
Several studies¹ have shown that nebulized racemic epinephrine, which stimulates both α-adrenergic and β-adrenergic receptors, is as effective or superior to albuterol in relieving airway obstruction in patients with viral bronchiolitis. Some studies²³ have shown no significant difference in the effectiveness of nebulized therapy with epinephrine and albuterol in a hospital setting. But short-term benefits in respiratory rate, oxygen saturation, and clinical score have been observed with the use of epinephrine. A single outpatient, placebo-controlled trial⁴ noted a statistically insignificant but potentially clinically meaningful 12% decrease in the hospitalization rate in the epinephrine group. One study⁵ in an ED showed that patients treated with epinephrine were discharged significantly earlier than patients who had been treated with albuterol.
(http://www.chestjournal.org/content/129/4/1114.2.full)

It is significant to note that it is commonly not the practice for medicinal chemists to use a racemic mixture of any drug. The idea is to isolate either the R or the S enantiomer and study those effects individually before you throw them together. Putting R and S together without a solid knowledge of what each will do is kind of like a box of chocolates. You don't know what you are going to get.
In this case, however, it seems that the benefits are high and the general outcomes positive.
I will continue to explain more stuff about organic chemistry as I myself learn more.

The Yellow Jersey

Before I begin, I need to talk about some cool new things.

#1 I have picked up my efforts for surveys. Hopefully I will be hitting that 200+ mark in no time. I am also waiting on a new battery for my wife's laptop so that I can walk around and bug people that way. I think the person-to-person contact will prove to be much more successful.
#2 One of the people who helps and supports the interns - Cathleen Marshall - has shown me a way to put a graphic of www.rateadrug.com on the top of my page. That is kind of cool, if you look to the left of this sentence you will see it there, it looks kind of like a pill, but it says rateadrug on it. That is a neat feature and I like being able to customize the thing.
#3 I learned - in my last post - how to enter text boxes so that I can make the text that I quote look a little better and be a little more compelling.
#4 At work the other night one of the nurses that I work with told me that a patient had received a drug known as Racemic-Epi. I know what that means! I understood what the name of the medication was and what it would do! That is thanks to this blog and internship, and thanks also to my Organic Chemistry course at school. I like learning, it's cool.
I think that Racemic-Epi will probably be the next DotW (Drug of the Week) feature, I will explain what that name means, and why I thought that was neat.
Hopefully by the end of this internship I will have learned even more stuff!

I have been pondering over the 'Drug of the Week' feature for this week, and I must admit I was somewhat stumped. Generally I focus on Neurological medications and functions/abnormalities as this is what I usually see; but, recently my unit at the hospital got a girl who was in renal (kidney) failure and was on Dialysis for it. I have known people who were on Dialysis for kidney failure, but I had never before seen the machine or seen the procedure. That got me thinking, I wonder if there are any medications that are actively prescribed for people who are undergoing dialysis or if there are any renal medications for that condition? This was the first time I had ever thought about this, and I needed to do some research about what, if any, medications someone on Dialysis might be required to take.
Not knowing much about Dialysis, I decided to do some research about that first, there are several different kinds of Dialysis and several causes for renal failure. After searching for some time though I came across a medication known as: Erythropoietin.

Erythropoeitin does not directly treat the kidney failure, instead it is used to treat symptoms of being in kidney failure and being on Dialysis. One of the big concerns about having this condition is the complications that go with it, and Anemia (loss of red blood cells) is one of those complications.

If you're undergoing hemodialysis for kidney disease or chemotherapy for cancer, you may be familiar with erythropoietin drugs that treat anemia — low red blood cell count. These medications are called erythropoiesis-stimulating agents, or ESAs. ESAs are genetically engineered forms of the human protein erythropoietin (uh-rith-ro-POI-uh-tin), which is important in the production of red blood cells.

...Erythropoietin is a hormone produced by your kidneys that stimulates bone marrow to make healthy red blood cells, which carry oxygen. The hematocrit level in your blood is a measure of the level of healthy oxygen-carrying red blood cells in your body. Anemia occurs when your hematocrit falls below the normal range. Usually, that's prevented by the kidneys making extra erythropoietin and prompting your bone marrow to produce more red blood cells.

One consequence of kidney disease is decreased production of erythropoietin. Chemotherapy also can cause decreased erythropoietin production and may decrease erythropoietin's effectiveness. In both of these instances, giving erythropoietin can increase red blood cell production, eliminating the need for blood transfusions and improving your well-being.

(http://www.mayoclinic.com/health/erythropoietin/DA00137)

I have often wanted to put a graphic that shows the concerted mechanism for the medication that I was discussing, but could not find one, or find one that anyone would let me use for free, but I found one for Erythropoietin:
Obviously a simplified mechanism, but cool nonetheless for understanding how this thing works in your body.
This is the organic molecule:

I must admit, knowledge of this thing is way outside of my understanding, but it is cool looking!
The use of Erythropoietin has come under fire since the 1980's when it was used as a simple and effective form of blood-doping among athletes. It was not until the Australian Olympic games of 2000 that a test was developed to combat this problem. EPO is used as a doping agent because it produces more Red Blood Cells (RBCs) which allows the blood to carry more oxygen and give an athlete an edge over their competition. It is especially rampant in professional cycling, the riders are tested for EPO regularly, but its use is still a problem.
(http://www.pbs.org/wnet/secrets/doping-for-gold/the-dangers-of-doping)

That is also another interesting area of discussion for medications, that of abuse. For any number of legitimate uses for a medication there are the same number of abuses. Perhaps another feature, before I finish my internship will be to discuss some of the common abuses of medications. I find there is so much that I want to learn about that there is not enough time to get it done in.

But, that about wraps up our discussion on EPO. Thank you for coming.

Doctor! I got the shakes so bad!

So, here we are again. I am certain that everyone who follows my internship blog with rapt attention is interested in learning what the new drug feature will be. I, myself, am also interested to learn what it will be.

On with the grand unveiling:
This week the featured drug belongs to a group of medicines known as anticonvulsants. Anticonvulsants are defined as, 'medications that are used to prevent seizures or stop a series of on-going seizures'. (http://www.medterms.com/script/main/art.asp?articlekey=20523)
This is in honor of a patient that I took care of not too long ago and I got to see again today. He is a cute little guy and he and I hit it off, but unfortunately we did not meet under good circumstances. This guy has a pretty severe seizure disorder and anticonvulsant medications are used to treat his seizures.
The anticonvulsant of choice shall be: Neurontin, or Gabapentin (we will just call it Neurontin for simplicity sake).

I also have another motive in discussing this medication as I have personal experience with it. In an old job of mine I worked with the developmentally disabled and one of my clients was on this particular medication. The rules in Utah are funny: if I were giving medication to an intellectually capable person it would have been far outside of my scope of practice, but as my clients were not fully capable of understanding what was going on, it was suddenly appropriate for me to give them the medicine, and they took it. The days when this client either neglected or was not able to take his medication he had a great deal more seizures, so at least in his case, it proved effective.

The Neurontin molecule looks like this:

This molecule is considerably less complex than some we have looked at before. I wanted to find a space-filling molecule, but information on this drug is surprisingly lean. I was able to find, though a series of graphs from a clinical trial of Neurontin on nerve pain,

'The proportion of responders (those patients reporting at least 50% improvement in endpoint pain score compared with baseline) was calculated for each study' (http://www.healthyplace.com/other-info/psychiatric-medications/gabapentin-neurontin-full-prescribing-information/menu-id-122/

I was also able to find this 'chart' which shows the side-effects of Neurontin as compared to a Placebo. Some points of clarification as to the chart:

'The most commonly observed adverse events associated with the use of Neurontin in adults, not seen at an equivalent frequency among placebo-treated patients, were dizziness, somnolence, and peripheral edema.

In the 2 controlled studies in postherpetic neuralgia, 16% of the 336 patients who received Neurontin and 9% of the 227 patients who received placebo discontinued treatment because of an adverse event. The adverse events that most frequently led to withdrawal in Neurontin-treated patients were dizziness, somnolence, and nausea.

Table 2 lists treatment-emergent signs and symptoms that occurred in at least 1% of Neurontin-treated patients with postherpetic neuralgia participating in placebo-controlled trials and that were numerically more frequent in the Neurontin group than in the placebo group. Adverse events were usually mild to moderate in intensity.'

'Body System/	Neurontin	Placebo
Preferred Term	N=336 %	N=227 %
* 'Reported as blurred vision'
Body as a Whole
Asthenia	5.7	4.8
Infection	5.1	3.5
Headache	3.3	3.1
Accidental injury	3.3	1.3
Abdominal pain	2.7	2.6
Digestive System
Diarrhea	5.7	3.1
Dry mouth	4.8	1.3
Constipation	3.9	1.8
Nausea	3.9	3.1
Vomiting	3.3	1.8
Flatulence	2.1	1.8
Metabolic and Nutritional Disorders
Peripheral edema	8.3	2.2
Weight gain	1.8	0.0
Hyperglycemia	1.2	0.4
Nervous System
Dizziness	28.0	7.5
Somnolence	21.4	5.3
Ataxia	3.3	0.0
Thinking abnormal	2.7	0.0
Abnormal gait	1.5	0.0
Incoordination	1.5	0.0
Amnesia	1.2	0.9
Hypesthesia	1.2	0.9
Respiratory System
Pharyngitis	1.2	0.4
Skin and Appendages
Rash	1.2	0.9
Special Senses
Amblyopia*	2.7	0.9
Conjunctivitis	1.2	0.0
Diplopia	1.2	0.0
Otitis media	1.2	0.0'

(http://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?id=3943&type=display)
This webpage, if I am not mistaken, is where government drug trials are reported. This was a great resource in terms of finding other information about this drug. There were even data tables discussing the differences between adult reported side-effects and pediatric side-effects. But, my space is short, so I picked only one of the graphs. A further look at this drug and the information found on that page is definitely worth it.

Neurontin has wide ranging uses. Sometimes it is administered as an anti-migraine medicine, sometimes for control of neuropathic pain, seizure control or it has even been used as a therapy for pain control after a case of the shingles has developed (http://www.neurontingabapentin.com/information.shtml).
(I would love to be able to use the opinions found on www.rateadrug.com for other insight into this medication, but there have been no surveys completed about Neurontin specifically. This is something I will have to work on with my co-workers. The more information the better!)

According to information from Pfizer, the maker of Neurontin,
'The mechanism by which gabapentin exerts its anticonvulsant action is unknown...' And, 'The mechanism by which gabapentin exerts its analgesic action is unknown...' It is, however, suspected that Neuronton acts in the way that it does by mimicking a certain transmitter known as GABA (gamma-aminobutyric acid), but it is not converted into it, nor does it react in quite the same way.

'In vitro studies with radiolabeled gabapentin [Neurontin] have revealed a gabapentin binding site in areas of rat brain including neocortex and hippocampus. A high-affinity binding protein in animal brain tissue has been identified as an auxiliary subunit of voltage-activated calcium channels. However, functional correlates of gabapentin binding, if any, remain to be elucidated.'
(http://www.pfizer.com/files/products/uspi_neurontin.pdf)

So, after searching the internet for some time I have found that Pfizer, the maker of Neurontin, openly admits that they do not fully understand how this drug functions. On the outset that seems to be a little disconcerting, but from personal experience I can assure you this drug does work. I have seen it administered for seizure activity and for neuropathic pain and it has been effective in both cases.

Regulate

I am coming to learn that it is difficult to get large groups of people to do things.

200 surveys does not seem to be a large number. In fact, if approached individually, 200 people is not that many people. The problem is one of how to reach the most people in the shortest amount of time.

My latest endeavor was to place fliers on people's cars telling them about www.rateadrug.com and all of the cool things that it has to offer the public. I know that these fliers are annoying to receive. I personally do not much like that this method has been used before, but it is a great way to reach people. I could contact 200 cars in less than 30 minutes and if only 25% of the people did surveys that would add another 50 surveys to my total. If nothing else the numbers are encouraging.

I have learned, however, that most places discourage this type of thing. After trying to go through the right channels so that I can contact people in this way it has come to my attention that most places don't like you doing that. In fact the university I attend will actually prosecute someone if they are caught doing this.

So, that plan was scrapped, but life goes on. I will also be contacting people in a more personal way by talking to the members of my science classes; I am not sure if I will extend this to my other non-science courses or not. I will also make some more fliers, those seem to have gotten a pretty good response. I should look for other areas of the community in which I can place those fliers though...
And I have finally gotten approval to be able to speak with my co-workers which I am very excited about.

So, the work continues despite minor set backs and I should be able to hit the 200 mark, if not a few more, by the time that May is winding down.