04 Smooth muscles

Nitrates

  • Dynamite: nitrates (e.g. nitroglycerine)
  • Nitric oxide exhaust: nitrates are metabolized and release nitric oxide
  • Grump: nitric oxide causes an increase in cGMP in vascular smooth muscle cells
  • Chains constricting pants/shirts: MLCK usually causes vasoconstriction
  • Cut P lock off chain: increased cGMP causes myosin light chain dephosphorylation, preventing its interaction with actin.
  • Dilated blue pants: nitrates cause venous dilation and increased venous capacitance
  • Modestly dilated red sleeves: nitrates cause some vasodilation of large arteries, but minimal dilation of arterioles
  • preload: Nitrates decrease preload

  • Folded tongue: sublingual administration of nitroglycerine avoids first pass metabolism (for acute symptom relief)
  • Anvil: antianginal therapy
  • Angina anvil:nitrates treat chronic stable angina
  • Discarded oxygen mask: nitrates reduce myocardial oxygen requirements
  • Anvil medal: nitrates treat Prinzmetal angina
  • Broken heart strings: nitrates are useful in acute coronary syndrome (ACS) (unstable angina, NSTEMI, STEMI)
  • Emergency shut-off: IV nitroglycerine can be used in hypertensive emergency
  • Wet lung spots: nitroglycerine is an acute treatment for pulmonary edema

  • Mouth cave: oral nitrate preparations have a longer duration of action
  • Single nitro stick in cave: isosorbide mononitrate (oral)
  • Double nitro stick in cave: isosorbide dinitrate (oral)
  • Big pile of dynamite: oral nitrate preparations require larger dosing

  • Fainting: nitrates can cause orthostatic hypotension (venous blood pool in extremities)
  • Heart reflex hammer: nitrate induced hypotension causes reflex tachycardia
  • muted beta bugle: beta blockers help prevent reflex sympathetic activation
  • Nitrates can cause throbbing headaches and flushing
  • Oxidized iron wheels: nitrates can cause methemoglobinemia
  • No tolerance for 24 hr work day: avoid tolerance with daily nitrate free intervals
  • "Monday disease" - with workplace nitrate exposure, tolerance disappears over weekend (decreased drug exposure at work) causing headache and dizziness recur on monday

  • No right turn: nitrates should be avoided in right sided MI (reduce right ventricular preload, use IV fluid to enhance preload)
  • *Fill** station on blocked track: patients on PDE-5 inhibitors (e.g. sildenafil) should avoid nitrate therapy for 24 hrs, avoid severe hypotension
  • Obstructed heart smokestack: nitrates are contraindicated with hypertrophic obstructive cardiomyopathy (HOCM), worsens on decreased preload

Migraine

  • Pounding head shaped bell: migraine therapy
  • Three gems on hat: migraine pain due to activation of trigeminal nerve afferents in the meninges
  • Dilated sleeves: trigeminal afferents release vasoactive peptides (e.g. CGRP, substance P, neurokinin A) onto meningeal vessels -> vasodilation and protein extravasation

  • Sumowrestler: triptans (e.g. sumatriptan) are an acute treatment for migraines
  • "b" and "d" shaped fingers: triptans (e.g. sumatriptan) are 5-HT1b and 5-HT1d receptor agonists
  • Smiley face on headband: 5-HT1b and 5-HT1d receptors are located on the meningeal vessels
  • Tightening red headband: triptans (e.g. sumatriptan) cause vasoconstriction of cerebral and meningeal vessels. Decreases stretch of pain receptors
  • Sumo taking out the 3 gems: triptans also activate 5-HT1b and 5-HT1d receptors on the trigeminal nerve, preventing release of vasoactive peptides
  • Hair stem: triptans also activate 5-HT1b and 5-HT1d receptors in the brain stem, inhibiting pain pathways

  • Constricted coronary crown: triptans can cause coronary vasospasm
  • Anvil in the sumo's shadow: triptans are contraindicated in patients with angina
  • Anvil medals in the sumo's shadow: triptans are a known trigger of Prinzmetal angina

  • Lantern cluster: triptans (and inhaled oxygen) are also an acute treatment for cluster headaches
  • Fire extinguisher: NSAIDs are an acute treatment for migraine

  • Calci-Yum icecream nozzles: calcium channel blockers can be used for migraine prophylaxis
  • Muted beta bugle: beta blockers can be used for migraine prophylaxis
  • festiVAL PRO: valproic acid (an antiepileptic) can be used for migraine prophylaxis
  • Toupee: topiramate (an antiepileptic) can be used for migraine prophylaxis
  • Tricycle: tricyclic antidepressants (e.g. amitriptyline) can be used for migraine prophylaxis

Prostaglandins

  • Head and assistant coaches: COX-1 and COX-2 produce prostanoids (e.g. prostaglandins)
  • Pro slugger: prostaglandins

  • "E": PGE1 and PGE2
  • Dill pickle: alprostadil (PGE1)
  • Erect bat: alprostadil treats erectile dysfunction
  • Dilated red sleeves: alprostadil is a vasodilator
  • Opening air duct: alprostadil maintains patent ductus arteriosus
  • Closing air duct: NSAIDs (e.g. indomethacin) promote closure of ductus arteriosus
  • Missed swing: misoprostol (PGE1)
  • Gastric protective equipment: misoprostol promotes protective mucus secretion by gastric mucosa
  • Missed swing hitting fire extinguisher: misoprostol can prevent NSAID-induced peptic ulcer
  • Opening uterus bag: misoprostol promotes uterine contraction to facilitate labor or terminate pregnancy
  • Flooded bathroom: misoprostol can cause diarrhea
  • Dino helmet: dinoprostone (PGE2)
  • Opening uterus bag: dinoprostone promotes uterine contraction and ripens the cervix to facilitate labor or terminate pregnancy

  • "F": PGF2a
  • Cardboard box: carboprost (PGF2a)
  • Opening uterus bag: carboprost promotes uterine contraction to control postpartum hemorrhage or terminate pregnancy
  • LA tan sandals: latanoprost (PGF2a)
  • World traveler boots: travoprost (PGF2a)
  • Leaking eyeballs: latanoprost and travoprost treat glaucoma by increasing aqueous humor outflow (not production)
  • Brown sunglasses: latanoprost and travoprost can produce brown pigmentation in iris

  • High tension pulmonary rackets: pulmonary hypertension
  • Dilated pro-cycler: prostacyclin analogs cause vasodilation (e.g. iloprost, epoprostenol)
  • iLOW - ePRO setting: iloprost and epoprostenol (prostacyclin analogs) treat pulmonary hypertension
  • Fainting: iloprost and epoprostenol may cause flushing, headache, hypotension

  • FILL: -fill suffix of phosphodiesterase isoform 5 (PDE-5) inhibitors (e.g. sildenafil, tadalafil)
  • Don't phoster disinterest: phosphodiesterase isoform 5 (PDE-5) inhibitors (e.g. sildenafil tadalafil
  • Grump: PDE-5 inhibitors increase cGMP
  • Erect bat: PDE-5 inhibitors (e.g. sildenafil, tadalafil) treat pulmonary hypertension and erectile dysfunction

  • Boss man Stan: bosentan treats pulmonary hypertension
  • End o' the line: bosentan is an endothelin inhibitor
  • Dilated red sleeves: bosentan (an endothelin inhibitor) causes vasodilation
  • Liver spot: bosentan is associated with fatal hepatotoxicity

Allergy and Pulmonary

Histamines

  • beehive: histamine sequestered inside the granules of mast cells
  • "Q" dandelion: H1 histamine receptor is coupled to Gq protein (mediates allergic inflammation)
  • Honeypot with 2 "S" handles: H2 histamine receptor is coupled to Gs protein, increased cAMP
  • Golden gastric honey looks like stomach: H2 histamine receptor mediates gastric acid secretion
  • Dripping nose sap: histamine increases nasal and bronchial mucus production (H1 receptor activation)
  • Dripping vascular sap: histamine increases vascular permeability (H1 receptor activation) (urticaria/hives)
  • Constricted lung branch: histamine causes constriction of bronchial smooth muscle (H1 receptor activation)
  • Brain tree: histamine functions as a neurotransmitter (H1 receptor regulates sleep and arousal)
  • fairy rubbing nose: allergic rhinitis

  • Bee swatter: H1 receptor blocker (antihistamine) treats allergy
  • Dragonfly fairy: diphenhydramine and dimenhydrinate (1st-generation H1 receptor blockers)
  • Color fairy: chlorpheniramine (1st-generation H1 receptor blocker)
  • Fairy cuiSINE: hydroxyZINE, mecliZINE, promethaZINE (1st-generation H1 receptor blockers)

  • Fairy dust and dander: histamine mediates type-1 allergic reaction -> hives, allergic rhinitis (H1 receptor blockers are first line therapy)
  • Seasick fairy sailors: 1st-generation H1-blockers treat vestibular nausea or motion sickness (lipophilic -> enter CNS -> act on vestibular system and brainstem)
  • Falling "extra parking" cone: 1st-generation H1-blockers treat extrapyramidal side effects caused by antipsychotics, e.g. acute dystonia (antimuscarinic effects re-establish dopaminergic-cholinergic balance)

  • Sleeping under brain tree: 1st-generation H1-blockers cause drowsiness (lipophilic -> cross BBB -> central effects)
  • Antimuscarinic tea party: 1st-generation H1-blockers antagonize peripheral and central muscarinic receptors (e.g. pupillary dilation, dry mouth, urinary retention, constipation, exacerbation of glaucoma, and delirium)
  • Cut smiley face cake: 1st-generation H1-blockers antagonize serotonin receptors in the CNS
  • Stuffed fairy: 1st-generation H1-blockers stimulate appetite and weight gain (antiserotonergic effects)
  • Extinguished single alpha candle, fainted fairy: 1st-generation H1-blockers antagonize alpha-1 receptors -> dizziness and hypotension
  • Delirious elderly man: 1st-generation H1-blockers cause cognitive impairment in the elderly (central antihistamine and antimuscarinic effects)

  • Fox, satyr, and rat: 2nd-generation H1-blockers: fexofenadine, cetirizine, loratidine
  • Fox, satyr, and rat stand outside of brain tree: 2nd-generation H1-blockers are less lipophilic -> do not cross BBB -> less sedating (also less antimuscarinic, antiserotonergic, or anti-alpha adrenergic properties)

Asthma Drugs

  • Dilated beta 2 tuba: selective beta-2 agonists (e.g. albuterol) treat bronchoconstriction in asthma
  • ROL call: "-rol" suffix of the selective beta-2 agonists (e.g. albuterol, pirbuterol)
  • "Do not disturb": terbutaline (a selective beta-2 agonist) treats bronchoconstriction in asthma
  • Inhaler: selective beta-2 agonists (e.g. albuterol) are available as metered dose inhalers for acute symptom relief
  • Moon face: inhaled corticosteroids (e.g. beclomethasone, budesonide, fluticasone) can be added as daily maintenance therapy for persistent symptoms
  • Moon eclipsing inflammatory sun: corticosteroids treat asthma by blocking later inflammation and cellular infiltration
  • Canadian snow: Candida albicans
  • Snow cone tongue: inhaled corticosteroids (e.g. beclomethasone, budesonide, fluticasone) can cause oropharyngeal candidiasis

  • AA league: arachidonic acid (AA) is the precursor of leukotrienes (and prostanoid) synthesis
  • Lacrosse Coach Lox: lipoxygenase (LOX) converts AA into leukotrienes
  • Lacrosse players: leukotrienes LTB4, C4, D4, and E4 are important regulators of inflammation
  • B4 attracting first-responders: LTB4 is a chemoattractant for inflammatory cells (e.g. neutrophils
  • First responders: neutrophils
  • Hand clamping lacrosse stick bronchi: LTC4, D4, E4 increase airway vascular permeability, mucus production, and bronchoconstriction
  • Lacrosse goal CysLT1: receptor for LTD4 (most potent bronchoconstrictor)

  • Monte the broadcaster: "-kast" suffix of LTD4-receptor antagonists (e.g. montelukast, zafirlukast)
  • Blocked D4 shot: LTD4-receptor antagonists (e.g. montelukast, zafirlukast) are an alternative therapy for mild persistent asthma
  • Dilated scarf: LTD4-receptor antagonists cause bronchodilation
  • Open mouth: LTD4-receptor antagonists are administered orally
  • Godzilla falling on Coach Lox: zileuton (a direct lipoxygenase inhibitor) is an alternative therapy for mild persistent asthma
  • Liver spot: zileuton has a risk of hepatotoxicity

  • ASA umpire grabbing Coach Cox: inhibition of COX shifts the AA metabolism to the LOX leukotriene pathway (exaggerated in aspirin-induced asthma)

  • Salute formation: salmeterol and formoterol (long acting beta-2 agonists) treat moderate or severe persistent asthma
  • Long tapering flag: salmeterol and formoterol (beta-2 agonists) have a long duration of action
  • Inhaler: long acting beta-2 agonists (salmeterol, formoterol) are administered as a daily controller inhaler
  • Higher moon face: an increased dose of inhaled corticosteroids treats moderate or severe persistent asthma
  • Xanthine energy drink: methylxanthines (e.g. theophylline) are an alternative therapy for mild to severe persistent asthma

  • Xanthine energy drink: methylxanthines (e.g. theophylline) are an alternative therapy for mild to severe persistent asthma
  • "flyin'": theophylline (a methylxanthine)
  • Caffeine: methylxanthines are related to caffeine
  • "Don't phoster disinterest": methylxanthines (e.g. theophylline) are phosphodiesterase inhibitors
  • "Camping'": methylxanthines increase cAMP, bronchodilation
  • Open mouth: theophylline is administered orally

  • Shaking kid: methylxanthines (e.g. theophylline) have CNS side effects including nervousness and tremor
  • Holding up heart watch: methylxanthines (e.g. theophylline) can cause tachycardia
  • Chrome bumper hitting energy drinks: methylxanthines (e.g. theophylline) are metabolized by the cytochrome P-450 system
  • Treat overdose with activated charcoal

  • Bee hive: mast cell degranulation is important to the pathogenesis of asthma
  • IgE gun shooting hive: antigen binding to IgE on mast cells causes degranulation and release of inflammatory mediators (e.g. histamine)
  • Limousine: omalizumab (an anti-IgE monoclonal antibody) is an adjunctive therapy for moderate or severe persistent asthma
  • Grabbing end of IgE gun: omalizumab is a monoclonal antibody directed against the Fc portion of IgE, preventing mast cell sensitization
  • chrome Lynn's bee control dispenser: cromolyn sodium
  • Bee sedating smoke: cromolyn sulfate inhibits mast cell degranulation (preventing release of histamine)

  • Beta-2 tuba: inhaled short-short acting beta-2 agonists (e.g. albuterol) treat an acute severe asthma exacerbation
  • Moon face: systemic corticosteroids treat acute severe asthma exacerbation
  • Ivy: corticosteroids are administered IV or orally during an acute severe asthma exacerbation
  • Cat-ipra-pillar: nebulized ipratropium bromide (anticholinergic) can be added to treat an acute severe asthma exacerbation
  • Epic: subcutaneous or intramuscular epinephrine can be used to treat an acute severe asthma exacerbation