NAMES Health, San Diego, CA (2026)

04/27/2026

Medication Monday: Lisinopril

Brand Names
Zestril. Prinivil. Qbrelis.

Mechanism
Lisinopril is a competitive angiotensin-converting enzyme (ACE) inhibitor used primarily to manage hypertension and heart failure. ACE normally converts the inactive decapeptide angiotensin I into the potent vasoconstrictor angiotensin II. Lisinopril inhibits this process by competitively binding to the zinc ion within the ACE active site. This decrease in angiotensin II reduces systemic vascular resistance and suppresses aldosterone secretion. This suppression decreases sodium and water reabsorption in the distal tubule and collecting duct, while slightly increasing serum potassium levels. Further, because ACE is also responsible for the degradation of bradykinin (a vasodilator), lisinopril increases circulating bradykinin levels, causing increased vasodilation. However, this accumulation of bradykinin is also associated with the common side effect of a dry cough and an increased risk of angioedema.

Indications
FDA-Approved Indications:
- Hypertension
- Heart failure (adjunctive therapy)
- STEMI (if given within 24 hours)

Off-Label Uses:
- Diabetic nephropathy
- Proteinuria
- Post-transplant erthryocytosis

Contraindications
- Hypersensitivity
- Hyperkalemia
- Hx of angioedema
- Renal failure with prior lisinopril use
- Bilateral renal artery stenosis
- Concomitant use with Aliskiren in patients with diabetes mellitus
- Nephrilysin inhibitor use within the last 36 hours
- Pregnancy

Routes
- Oral

Source
https://www.ncbi.nlm.nih.gov/books/NBK482230/

04/13/2026

Medication Monday: Theophylline

04/07/2026

What Is Lyme Disease?

04/06/2026

Medication Monday: Tiotropium Bromide

Brand Names:
Spiriva.

Mechanism
Tiotropium Bromide is a long-acting muscarinic receptor antagonist that primarily targets the M1, M2, and M3 muscarinic acetylcholine receptors (mAChRs) in the lungs. It is also a quaternary ammonium compound, making it difficult to absorb across the alveolar-capillary beds, making its effects localized to the respiratory tract.

Once inhaled, Tiotropium Bromide competitively and reversibly binds to M1, M2, and M3 mAChRs (however, it quickly dissociates from the M2 receptors, which is actually positive since M2 receptors further help inhibit the release of acetylcholine). Its primary therapeutic effect occurs at the M3 receptors on airway smooth muscle and mucous glands. By antagonizing these receptors, it inhibits the Gq-phospholipase C pathway, preventing the intracellular calcium influx required for muscle contraction. This results in prolonged bronchodilation, reduced mucus secretion, and potential anti-inflammatory effects in the lungs.

Indications
FDA-Approved Indications:
- Long-term treatment/prevention of bronchospasm and COPD exacerbation
- Maintenance therapy for patients with COPD, bronchitis, or asthma (if older than 6 years of age)

Off-Label Uses:
- Add-on therapy to inhaled corticosteroids and other maintenance therapies for patients 6-11 years of age

Contraindications
- Hypersensitivity to Tiotropium, Ipratropium, Atropine, lactose, and milk protein
- Narrow-angle glaucoma
- Acute bronchospasm
- Not intended for rescue use

Use With Caution
- Discontinue use if paradoxical bronchospasm occurs

Routes
- Inhalation

Source
https://www.ncbi.nlm.nih.gov/books/NBK541127/

03/30/2026

Medication Monday: Salmeterol

Brand Names:
Serevent Diskus.

Mechanism:
Salmeterol is a long-acting beta-2 adrenergic receptor agonist with essentially the same mechanism as Levalbuterol (see our post about Levalbuterol for mechanism). Where Salmeterol differs from Levalbuterol is its molecular structure and exact binding location.

Salmeterol has an elongated lipophilic side chain and binds to an exosite near the receptor. This allows the active portion of the molecule to repeatedly bind to and activate the beta-2 receptor over a longer period, when compared to Levalbuterol (approximately 12 hours instead of 6 hours). Additionally, Salmeterol is roughly 5 times more potent than Levalbuterol.

 Indications:
- Concurrent therapy for maintenance and prevention of asthma attacks (typically with corticosteroids) when short-acting beta-agonists are ineffective
- Prevention of bronchospasm
- Long-term maintenance of airflow obstruction in COPD

 Contraindications:
- Hypersensitivity to any ingredient in the preparation, including lactose and milk protein
- Concurrent use of other long-acting beta-agonists
- Status asthmaticus or other acute asthma episodes (Salmeterol is not intended for rescue use)

Use With Caution:
- Salmeterol should not be used as a monotherapy in asthma patients
- Existing cardiovascular disorder, convulsive disorder, hepatic impairment, diabetes mellitus, or hyperthyroidism/thyrotoxicosis
- Use of CYP3A inhibitors
- Hypokalemia

 Routes:
- Inhalation

References
https://www.ncbi.nlm.nih.gov/books/NBK557453/

03/26/2026

Primary Open-Angle Glaucoma (POAG) and Primary Angle-Closure Glaucoma (PACG)

What is POAG?
- POAG is a condition in which intraocular pressure (inner eye pressure) increases. Under normal circumstances, the fluid that flows throughout the inside of the eye (aqueous humor) is able to drain through a tissue called the trabecular meshwork, which is located at the angle where the iris and cornea meet. With POAG, however, a draining issue occurs beyond the point of the trabecular meshwork entrance. This results in a slow, gradual build-up of intraocular pressure (sometimes building up for several years). This increase in intraocular pressure puts additional pressure onto the optic nerve, slowly damaging it and cause a gradual loss in vision. POAG is the most common type of glaucoma, accounting for around 90% of all glaucoma cases.

Signs/Symptoms of POAG
- Typically no symptoms in the early stages
- Blind spots in peripheral vision
- Worsened vision in later stages

What is PACG?
- PACG is a condition in which intraocular pressure rapidly increases due to a bulging iris partially or completely blocking the entrance to the trabecular meshwork, preventing the drainage of aqueous humor. This blockage can occur suddenly or gradually.

Signs/Symptoms of PACG
- Hazy or blurred vision
- Severe eye pain
- Severe headache
- Nausea/vomiting
- Halos or colored circles around lights
- Sudden loss of vision
- Eye redness

Risk Factors for POAG and PACG:
- Age over 55
- Family history of glaucoma
- Family heritage
- High intraocular pressure
- Eye anatomy
- Eye injuries
- Eye surgery
- Certain medical conditions (such as diabetes, migraines, hypertension, and sickle cell anemia)
- Corticosteroid use
- Nearsightedness or farsightedness
- Refractive error (need for glasses or contacts)

Management/Treatment of POAG and PACG
- Laser surgery
- Minimally invasive glaucoma surgery
- Conventional surgery
- Eye drops
- Medications to reduce intraocular pressure

03/23/2026

Medication Monday: Levalbuterol

Brand Names:
Xopenex.

Mechanism
Levalbuterol is a selective, short-acting beta-2 adrenergic receptor agonist. When inhaled, it binds to the beta-2 receptors on airway smooth muscle cells, stimulating the enzyme adenylyl cyclase, which then catalyzes the conversion of adenosine triphosphate (ATP) to cyclic adenosine monophosphate (cAMP). This increase in cAMP activates protein kinase A (PKA), which phosphorylates certain proteins in the cell and inhibits myosin light-chain kinase (MLCK). This cascade results in the reduction of calcium-dependent contractions, resulting in smooth muscle relaxation and bronchodilation.

Additionally, increased cAMP levels inhibit the release of inflammatory mediators from mast cells in the airways, reducing the inflammatory response in the lungs and airway.

While Racemic Albuterol contains both (R) and (S) enantiomers, Levalbuterol only has the (R) enantiomer. The (S) enantiomer is believed to be associated with paradoxical airway hyperreactivity and slower metabolic clearance, so by removing this from Levalbuterol, it may have a more favorable side-effect profile.

Indications
- Treatment of bronchospasm
- Prevention of bronchospasm (in cases such as exercise-induced bronchospasm, reversible obstructive airway disease, etc).

Contraindications
- Hypersensitivity to levalbuterol, racemic albuterol or any other component of Xopenex HFA Inhalation Aerosol

Use With Caution:
- Discontinue use if paradoxical bronchospasm occurs
- Existing underlying cardiovascular disorders
- Watch for hypokalemia or blood glucose changes
- Concurrent use of other short-acting sympathomimetic aerosol bronchodilators and adrenergic drugs
- Concurrent use of beta-blockers
- Concurrent use of diuretics
- Concurrent use of Digoxin
- Concurrent use of monoamine oxidase inhibitors (MAOs) or tricyclic antidepressants.

Routes
- Inhalation

03/21/2026

Not even summer yet and already over 100 😭

03/19/2026

.golding talks about the issues he noticed during the COVID-19 crisis and how they inspired him to create NAMES.Health.

03/16/2026

Mediation Monday: Phenylephrine

Common Brand Names:
Sudafed PE. Neosynephrine.
 Mechanism:
Phenylephrine is a selective α1-adrenergic receptor agonist that primarily binds to α1 receptors in the vascular smooth muscle. Upon binding, it initiates the following cascade:
1. Stimulates the Gq protein, which activates the enzyme phospholipase C (PLC).
2. PLC causes the hydrolysis of PIP2 into inositol trisphosphate (IP3) and diacylglycerol (DAG).
3. IP3 triggers the release of calcium ions from the sarcoplasmic reticulum (storage and release site for calcium ions), increasing intracellular calcium concentration.
4. Elevated calcium levels facilitate the interaction between actin and myosin, leading to smooth muscle contraction and systemic vasoconstriction.

Phenylephrine also binds to α1 receptors on the iris dilator muscle, causing mydriasis (pupil dilation). This is primarily used for ophthalmic procedures.

As a nasal spray, Phenylephrine constricts the arterioles within the nasal mucosa. This reduces mucosal edema and is commonly used for nasal congestion.

 Indications: FDA-Approved Indications:
- Severe hypotension due to vasodilation (IV)
- Uncomplicated nasal congestion (IN)
- Mydriasis and vasoconstriction of conjunctival blood vessels (OTC)
- Additive to topical hemorrhoid medications (OTC)

Common Off-Label Uses:
- Adjunct to neuraxial or peripheral nerve blockade to treat priapism
- Treatment for ischemic priapism
- Anesthetic vasopressor

 Contraindications:
- Hypersensitivity

Use With Caution:
- History of bradycardia, severe cardiac dysfunction, hypovolemia, severe arteriosclerosis, angina, or autonomic dysfunction
- Concurrent use of sympathomimetic drugs

Common Routes:
- Intravenous
- Oral
- Intranasal
- Ophthalmic
- Re**al
- Topical

Source: https://www.ncbi.nlm.nih.gov/books/NBK534801/

03/15/2026

Except for last shift, I surprisingly got some good downtime!

03/13/2026

When it comes to C. diff, I don’t mess around

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