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Understanding the Mechanisms of Weight Gain in Psychiatric Patients · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  My
• 0:05
  friends,
• 0:06
  welcome
• 0:06
  to
• 0:07
  another
• 0:07
  episode
• 0:07
  of
• 0:08
  Pearls
• 0:08
  and
• 0:08
  Prep.
• 0:09
  We
• 0:10
  are
• 0:10
  going
• 0:10
  to
• 0:10
  talk
• 0:10
  today
• 0:11
  about
• 0:11
  three
• 0:12
  paths
• 0:13
  to
• 0:13
  weight
• 0:14
  gain.
• 0:14
  And
• 0:14
  we're
• 0:15
  going
• 0:15
  to
• 0:15
  talk
• 0:15
  about
• 0:15
  a
• 0:16
  mock
• 0:16
  patient
• 0:17
  named
• 0:17
  Johnny,
• 0:18
  who's
• 0:18
  a
• 0:18
  welder.
• 0:19
  He's
• 0:19
  30
• 0:19
  years
• 0:20
  old.
• 0:20
  And
• 0:21
  we're
• 0:21
  going
• 0:21
  to
• 0:21
  talk
• 0:21
  about
• 0:22
  why
• 0:23
  he
• 0:23
  may
• 0:23
  be
• 0:24
  gaining
• 0:24
  weight
• 0:24
  and
• 0:25
  how
• 0:26
  it
• 0:26
  is
• 0:26
  not
• 0:26
  enough,
• 0:26
  my
• 0:27
  friends,
• 0:27
  to
• 0:28
  just
• 0:28
  say
• 0:28
  to
• 0:28
  your
• 0:29
  patient
• 0:29
  that
• 0:30
  X,
• 0:30
  Y
• 0:31
  and
• 0:31
  Z
• 0:31
  medication
• 0:32
  causes
• 0:32
  weight
• 0:33
  gain.
• 0:33
  Maybe
• 0:34
  it
• 0:34
  is
• 0:34
  even
• 0:35
  better
• 0:35
  if
• 0:36
  you
• 0:36
  can
• 0:36
  get
• 0:37
  with
• 0:37
  the
• 0:37
  mechanisms
• 0:38
  behind
• 0:39
  their
• 0:39
  weight
• 0:39
  gain
• 0:40
  and
• 0:40
  you
• 0:40
  can
• 0:40
  have
• 0:40
  a
• 0:40
  deeper
• 0:41
  understanding
• 0:42
  as
• 0:42
  to
• 0:42
  what
• 0:42
  medications
• 0:43
  cause
• 0:44
  weight
• 0:44
  gain,
• 0:45
  why
• 0:45
  it's
• 0:45
  happening,
• 0:46
  and
• 0:46
  why,
• 0:47
  if
• 0:47
  you
• 0:47
  switch
• 0:47
  the
• 0:48
  medication,
• 0:48
  things
• 0:49
  could
• 0:49
  get
• 0:49
  a
• 0:50
  little
• 0:50
  bit
• 0:51
  easier
• 0:51
  on.
• 0:52
  On
• 0:52
  the
• 0:52
  patient.
• 0:52
  So
• 0:52
  that's
• 0:53
  what
• 0:53
  we're
• 0:53
  going
• 0:53
  to
• 0:53
  talk
• 0:53
  about
• 0:53
  today.
• 0:53
  We're
• 0:54
  going
• 0:54
  to
• 0:54
  talk
• 0:54
  about
• 0:54
  the
• 0:54
  three
• 0:55
  pathways
• 0:55
  that
• 0:56
  lead
• 0:56
  to
• 0:56
  weight
• 0:57
  gain.
• 0:57
  And
• 0:57
  you
• 0:57
  will
• 0:57
  see
• 0:58
  there
• 0:58
  are
• 0:58
  subtle
• 0:58
  differences
• 0:59
  between
• 0:59
  these
• 0:59
  three
• 0:59
  pathways,
• 1:01
  but
• 1:01
  they're
• 1:02
  all
• 1:02
  very
• 1:02
  important
• 1:03
  to
• 1:03
  be
• 1:03
  mindful
• 1:03
  of.
• 1:04
  Johnny
• 1:04
  is
• 1:04
  a
• 1:04
  welder.
• 1:05
  He's
• 1:05
  30
• 1:05
  years
• 1:05
  old.
• 1:06
  He
• 1:06
  is
• 1:06
  a
• 1:06
  male
• 1:07
  with
• 1:07
  schizophrenia,
• 1:08
  and
• 1:09
  he
• 1:09
  has
• 1:09
  been
• 1:09
  stable
• 1:10
  on
• 1:10
  Zyprexa,
• 1:11
  also
• 1:11
  known
• 1:12
  as
• 1:12
  olanzapine,
• 1:13
  for
• 1:14
  about
• 1:14
  six
• 1:14
  months.
• 1:15
  So
• 1:15
  that's
• 1:15
  pretty
• 1:16
  good.
• 1:16
  He's
• 1:16
  stable,
• 1:16
  but
• 1:16
  he's
• 1:17
  gained
• 1:17
  about
• 1:17
  10kg.
• 1:19
  His
• 1:19
  BMI
• 1:19
  has
• 1:19
  gone
• 1:20
  from
• 1:20
  24
• 1:21
  to
• 1:21
  28.
• 1:22
  And
• 1:22
  he
• 1:22
  reports
• 1:22
  strong
• 1:23
  carb
• 1:23
  cravings,
• 1:24
  feeling
• 1:24
  sluggish,
• 1:25
  and
• 1:25
  difficulties
• 1:26
  with
• 1:26
  blood
• 1:27
  sugar
• 1:28
  control.
• 1:29
  And
• 1:30
  so,
• 1:30
  given
• 1:30
  the
• 1:31
  fact
• 1:31
  that
• 1:31
  he's
• 1:32
  stable,
• 1:33
  these
• 1:33
  side
• 1:34
  effects
• 1:34
  are
• 1:34
  deal
• 1:35
  breakers
• 1:35
  for
• 1:35
  Johnny.
• 1:36
  He
• 1:37
  wants
• 1:37
  out.
• 1:37
  His
• 1:38
  primary
• 1:38
  care
• 1:38
  doctor
• 1:39
  sent
• 1:39
  you
• 1:40
  a
• 1:40
  private
• 1:40
  message
• 1:41
  saying,
• 1:41
  hey,
• 1:41
  you've
• 1:42
  got
• 1:42
  to
• 1:42
  make
• 1:42
  some
• 1:42
  kind
• 1:42
  of
• 1:43
  change
• 1:43
  here
• 1:43
  because
• 1:44
  this
• 1:45
  is
• 1:45
  no
• 1:46
  bueno.
• 1:46
  We
• 1:46
  cannot
• 1:47
  handle
• 1:47
  the
• 1:48
  weight
• 1:48
  gain.
• 1:48
  The
• 1:48
  BMI
• 1:49
  going
• 1:49
  up.
• 1:49
  His
• 1:50
  metabolic
• 1:51
  panel
• 1:51
  is
• 1:51
  getting
• 1:52
  worse.
• 1:52
  His
• 1:53
  cholesterol,
• 1:53
  his
• 1:53
  triglycerides,
• 1:54
  Please
• 1:55
  do
• 1:55
  something.
• 1:55
  And
• 1:56
  so
• 1:56
  you're
• 1:56
  scratching
• 1:56
  your
• 1:57
  head
• 1:57
  going,
• 1:57
  oh,
• 1:57
  my
• 1:57
  God,
• 1:58
  this
• 1:58
  is
• 1:59
  my
• 1:59
  first
• 1:59
  day
• 1:59
  on
• 2:00
  the
• 2:00
  job
• 2:00
  as
• 2:00
  a
• 2:01
  psych
• 2:01
  np.
• 2:01
  What
• 2:02
  do
• 2:02
  I
• 2:02
  do?
• 2:03
  Well,
• 2:03
  if
• 2:03
  your
• 2:03
  school
• 2:04
  prepared
• 2:04
  you
• 2:04
  properly
• 2:05
  and
• 2:05
  you
• 2:05
  did
• 2:06
  some
• 2:06
  reading
• 2:06
  in
• 2:07
  your
• 2:07
  textbooks,
• 2:07
  you
• 2:07
  will
• 2:07
  know,
• 2:08
  my
• 2:08
  friends,
• 2:08
  there
• 2:09
  are
• 2:09
  many
• 2:09
  options
• 2:09
  and
• 2:10
  you
• 2:10
  will
• 2:10
  have
• 2:10
  a
• 2:10
  good
• 2:11
  understanding
• 2:11
  as
• 2:11
  to
• 2:11
  what
• 2:12
  is
• 2:12
  happening
• 2:12
  here.
• 2:13
  Now,
• 2:13
  Zyprexa,
• 2:14
  also
• 2:15
  known
• 2:15
  as
• 2:15
  Olanzapine,
• 2:16
  is
• 2:16
  kind
• 2:16
  of
• 2:17
  a
• 2:17
  triple
• 2:18
  threat
• 2:19
  because
• 2:20
  it
• 2:20
  works
• 2:21
  on
• 2:21
  three
• 2:22
  different
• 2:22
  receptors
• 2:23
  that
• 2:23
  are
• 2:23
  all
• 2:23
  implicated
• 2:24
  in
• 2:24
  weight
• 2:25
  gain.
• 2:25
  That
• 2:25
  would
• 2:26
  be
• 2:26
  the
• 2:26
  histamine
• 2:27
  antagonism.
• 2:28
  That
• 2:28
  would
• 2:28
  be
• 2:28
  the
• 2:29
  muscarinic
• 2:30
  antagonism.
• 2:31
  That's
• 2:31
  M3,
• 2:31
  the
• 2:32
  M3
• 2:32
  receptor,
• 2:33
  and
• 2:33
  then
• 2:33
  the
• 2:33
  5ht2c
• 2:34
  receptor,
• 2:35
  which
• 2:35
  we
• 2:36
  talked
• 2:36
  about
• 2:36
  in
• 2:36
  previous
• 2:37
  episodes
• 2:37
  with
• 2:37
  glorious
• 2:38
  analogies
• 2:39
  to
• 2:39
  help
• 2:39
  you
• 2:39
  never
• 2:40
  forget
• 2:40
  the
• 2:41
  5ht2c
• 2:43
  receptor.
• 2:43
  The
• 2:44
  mnemonic
• 2:44
  we
• 2:45
  used
• 2:45
  in
• 2:45
  that
• 2:45
  episode
• 2:46
  was
• 2:46
  clerk
• 2:47
  or
• 2:47
  cashier.
• 2:47
  I
• 2:48
  highly
• 2:48
  recommend
• 2:48
  you
• 2:48
  go
• 2:48
  over
• 2:49
  to
• 2:49
  that
• 2:49
  Zyprexa
• 2:50
  episode.
• 2:50
  We're
• 2:50
  going
• 2:50
  to
• 2:51
  use
• 2:51
  a
• 2:51
  slightly
• 2:51
  different
• 2:51
  mnemonic
• 2:52
  for
• 2:52
  5ht2c
• 2:53
  today
• 2:54
  as
• 2:54
  it
• 2:54
  pertains
• 2:54
  to
• 2:55
  weight
• 2:55
  gain.
• 2:55
  All
• 2:56
  of
• 2:56
  the
• 2:56
  mnemonics
• 2:57
  come
• 2:57
  together
• 2:58
  very
• 2:58
  nicely
• 2:58
  for
• 2:58
  you
• 2:59
  to
• 2:59
  have
• 2:59
  a
• 2:59
  crisp
• 3:00
  understanding
• 3:00
  of
• 3:01
  this
• 3:01
  material
• 3:01
  moving
• 3:02
  forward.
• 3:03
  So,
• 3:03
  you
• 3:04
  know,
• 3:04
  that
• 3:04
  was
• 3:04
  more
• 3:04
  textbook,
• 3:05
  right?
• 3:05
  Here's
• 3:05
  the
• 3:06
  street
• 3:06
  stuff.
• 3:06
  There's
• 3:07
  a
• 3:07
  street
• 3:07
  answer,
• 3:07
  and
• 3:07
  there's
• 3:08
  a
• 3:08
  textbook
• 3:08
  answer
• 3:08
  to
• 3:08
  everything.
• 3:09
  My
• 3:10
  experience
• 3:10
  is
• 3:11
  personally
• 3:11
  with
• 3:11
  Zyprexa
• 3:12
  is
• 3:12
  that
• 3:12
  Zyprexa
• 3:13
  is
• 3:13
  a
• 3:14
  phenomenal
• 3:14
  medication
• 3:15
  at
• 3:16
  stabilizing
• 3:17
  patients
• 3:17
  who
• 3:17
  have
• 3:18
  severe
• 3:18
  psychosis
• 3:19
  or
• 3:20
  even
• 3:20
  mania.
• 3:21
  They
• 3:22
  need
• 3:22
  stabilization
• 3:23
  quickly.
• 3:23
  You'll
• 3:24
  see
• 3:24
  it
• 3:24
  frequently
• 3:25
  prescribed
• 3:25
  in
• 3:25
  inpatient
• 3:26
  psychiatric
• 3:27
  settings.
• 3:27
  It's
• 3:28
  very
• 3:28
  effective
• 3:30
  for
• 3:31
  psychosis
• 3:32
  and
• 3:32
  it
• 3:33
  can
• 3:33
  be
• 3:33
  very
• 3:34
  potent.
• 3:35
  The
• 3:35
  problem
• 3:36
  with
• 3:36
  Zyprexa,
• 3:37
  in
• 3:37
  my
• 3:38
  opinion,
• 3:38
  and
• 3:39
  borne
• 3:39
  out
• 3:39
  in
• 3:39
  the
• 3:40
  evidence
• 3:40
  and
• 3:40
  seen
• 3:40
  all
• 3:41
  over
• 3:41
  psychiatry,
• 3:42
  is
• 3:42
  that
• 3:42
  it
• 3:43
  can
• 3:43
  cause
• 3:43
  significant
• 3:44
  levels
• 3:45
  of
• 3:45
  weight
• 3:45
  gain.
• 3:45
  We're
• 3:46
  talking
• 3:46
  pretty
• 3:46
  rapid
• 3:47
  first
• 3:47
  month,
• 3:48
  very
• 3:48
  significant
• 3:49
  noticeable
• 3:50
  weight
• 3:50
  gain.
• 3:51
  You
• 3:51
  almost
• 3:51
  have
• 3:51
  to
• 3:51
  do
• 3:51
  a
• 3:51
  double
• 3:52
  take
• 3:52
  sometimes
• 3:52
  when
• 3:52
  you
• 3:53
  see
• 3:53
  your
• 3:53
  patients
• 3:53
  because
• 3:54
  it's
• 3:54
  just
• 3:55
  too
• 3:55
  much
• 3:55
  too
• 3:56
  fast.
• 3:57
  We
• 3:57
  always
• 3:57
  talk
• 3:57
  about
• 3:58
  on
• 3:58
  this
• 3:58
  podcast
• 3:59
  the
• 3:59
  fact
• 3:59
  that
• 3:59
  there
• 4:00
  are
• 4:00
  trade
• 4:00
  offs
• 4:00
  in
• 4:00
  psychiatry.
• 4:01
  And
• 4:02
  I
• 4:02
  think
• 4:02
  one
• 4:02
  of
• 4:02
  the
• 4:03
  biggest
• 4:04
  adjustments
• 4:04
  I
• 4:04
  had
• 4:04
  to
• 4:05
  make
• 4:05
  going
• 4:05
  from
• 4:06
  an
• 4:06
  RN
• 4:06
  to
• 4:06
  a
• 4:07
  psych
• 4:07
  NP
• 4:08
  is
• 4:08
  that
• 4:08
  your
• 4:09
  conversations
• 4:09
  with
• 4:09
  your
• 4:10
  patients
• 4:10
  tend
• 4:10
  to
• 4:11
  involve
• 4:11
  a
• 4:12
  lot
• 4:12
  less
• 4:12
  of
• 4:12
  black
• 4:13
  and
• 4:13
  white
• 4:13
  conversations
• 4:14
  and
• 4:14
  more
• 4:15
  gray
• 4:15
  ones.
• 4:15
  Now,
• 4:16
  I'm
• 4:16
  not
• 4:16
  saying
• 4:16
  being
• 4:17
  an
• 4:17
  RN
• 4:17
  is
• 4:17
  black
• 4:18
  and
• 4:18
  white
• 4:18
  at
• 4:18
  all,
• 4:18
  but
• 4:19
  as
• 4:19
  a
• 4:19
  psych
• 4:19
  np,
• 4:20
  I
• 4:20
  find
• 4:20
  that
• 4:21
  it's
• 4:21
  really
• 4:21
  not
• 4:21
  about
• 4:22
  removing
• 4:22
  risks.
• 4:23
  We
• 4:23
  have
• 4:23
  to
• 4:23
  get
• 4:23
  out
• 4:24
  of
• 4:24
  that
• 4:24
  mentality,
• 4:24
  especially
• 4:25
  as
• 4:25
  we
• 4:25
  graduate.
• 4:27
  We
• 4:27
  get
• 4:27
  a
• 4:27
  little
• 4:27
  paranoid.
• 4:28
  We
• 4:28
  don't
• 4:28
  want
• 4:28
  to
• 4:28
  do
• 4:29
  harm.
• 4:29
  We
• 4:29
  have
• 4:29
  this
• 4:29
  newfound
• 4:30
  responsibility.
• 4:30
  We
• 4:31
  have
• 4:31
  a
• 4:31
  prescription
• 4:31
  pad,
• 4:32
  we
• 4:32
  have
• 4:32
  diagnostics,
• 4:33
  and
• 4:33
  we're
• 4:33
  trying
• 4:34
  to
• 4:34
  do
• 4:34
  the
• 4:34
  right
• 4:34
  thing.
• 4:35
  The
• 4:35
  instinct
• 4:36
  for
• 4:36
  a
• 4:36
  lot
• 4:36
  of
• 4:36
  us
• 4:36
  is,
• 4:37
  hey,
• 4:37
  we
• 4:37
  don't
• 4:38
  want
• 4:38
  to
• 4:38
  make
• 4:38
  a
• 4:38
  mistake
• 4:38
  here.
• 4:38
  Oh,
• 4:39
  my
• 4:39
  God,
• 4:39
  what
• 4:39
  if
• 4:39
  I
• 4:39
  make
• 4:39
  a
• 4:40
  mistake?
• 4:40
  Well,
• 4:41
  there
• 4:41
  are
• 4:41
  definitely
• 4:41
  mistakes
• 4:42
  you
• 4:42
  can
• 4:42
  make,
• 4:43
  right?
• 4:44
  But
• 4:44
  your
• 4:44
  program,
• 4:45
  your
• 4:45
  own,
• 4:45
  studying
• 4:46
  the
• 4:46
  boards,
• 4:46
  are
• 4:47
  kind
• 4:47
  of
• 4:47
  guardrails
• 4:48
  there
• 4:48
  to
• 4:48
  help
• 4:49
  ensure
• 4:49
  that
• 4:50
  they're
• 4:50
  producing
• 4:50
  new
• 4:51
  grads
• 4:51
  that
• 4:52
  understand
• 4:53
  those
• 4:53
  mistakes
• 4:54
  very
• 4:55
  obviously,
• 4:56
  right?
• 4:56
  Titrating
• 4:57
  slowly
• 4:57
  with
• 4:58
  Lamictal,
• 4:59
  not
• 4:59
  prescribing
• 4:59
  Paxil
• 5:00
  to
• 5:00
  a
• 5:00
  pregnant
• 5:01
  woman.
• 5:01
  Right?
• 5:02
  Those
• 5:02
  are
• 5:03
  some
• 5:03
  of
• 5:03
  the
• 5:03
  more
• 5:03
  in
• 5:04
  your
• 5:04
  face
• 5:04
  mistakes
• 5:05
  you
• 5:05
  can
• 5:05
  make.
• 5:06
  There
• 5:06
  are
• 5:06
  a
• 5:06
  million
• 5:07
  others,
• 5:07
  of
• 5:07
  course,
• 5:07
  not
• 5:08
  to
• 5:08
  scare
• 5:08
  you,
• 5:08
  but
• 5:09
  my
• 5:09
  greater
• 5:10
  point
• 5:10
  is
• 5:10
  that
• 5:11
  hopefully
• 5:11
  through
• 5:12
  your
• 5:12
  schooling,
• 5:12
  those
• 5:12
  become
• 5:13
  more
• 5:13
  and
• 5:13
  more
• 5:13
  obvious
• 5:14
  and
• 5:14
  clear.
• 5:14
  And
• 5:15
  drilled
• 5:15
  into
• 5:15
  your
• 5:16
  mind.
• 5:16
  When
• 5:17
  we're
• 5:17
  talking
• 5:17
  about
• 5:18
  a
• 5:18
  Lanzapine
• 5:19
  and
• 5:19
  somebody
• 5:19
  comes
• 5:20
  to
• 5:20
  you,
• 5:20
  whether
• 5:20
  they're
• 5:21
  in
• 5:21
  the
• 5:21
  inpatient
• 5:21
  space
• 5:22
  or
• 5:22
  the
• 5:22
  outpatient
• 5:22
  space,
• 5:23
  they
• 5:23
  have
• 5:23
  severe
• 5:24
  psychosis,
• 5:24
  nothing
• 5:25
  else
• 5:25
  has
• 5:25
  worked,
• 5:26
  and
• 5:26
  they
• 5:27
  need
• 5:27
  immediate
• 5:27
  stabilization
• 5:29
  Olanzapine.
• 5:30
  There's
• 5:30
  a
• 5:30
  time
• 5:31
  and
• 5:31
  place
• 5:31
  for
• 5:31
  it.
• 5:31
  It's
• 5:32
  very
• 5:32
  potent,
• 5:32
  it's
• 5:33
  very
• 5:33
  effective.
• 5:33
  I
• 5:33
  find
• 5:33
  that
• 5:34
  it's
• 5:34
  extremely
• 5:34
  good
• 5:35
  at
• 5:35
  controlling
• 5:36
  psychosis,
• 5:37
  at
• 5:37
  sedating
• 5:37
  a
• 5:38
  patient,
• 5:38
  at
• 5:39
  getting
• 5:39
  them
• 5:39
  to
• 5:40
  sleep
• 5:40
  and
• 5:40
  stabilize
• 5:41
  their
• 5:41
  mood
• 5:41
  in
• 5:42
  the
• 5:42
  right
• 5:42
  context.
• 5:43
  And
• 5:43
  just
• 5:43
  like
• 5:44
  everything
• 5:44
  else,
• 5:44
  there
• 5:44
  are
• 5:44
  drawbacks.
• 5:45
  These
• 5:45
  metabolic
• 5:46
  side
• 5:46
  effects
• 5:46
  are
• 5:46
  significant.
• 5:48
  And
• 5:48
  so
• 5:49
  you
• 5:49
  have
• 5:49
  to
• 5:49
  have
• 5:49
  an
• 5:49
  open
• 5:50
  conversation
• 5:51
  and
• 5:51
  informed
• 5:52
  consent.
• 5:52
  And
• 5:53
  because
• 5:53
  it's.
• 5:53
  There's
• 5:54
  very
• 5:55
  few
• 5:55
  meds,
• 5:55
  if
• 5:55
  any,
• 5:56
  that
• 5:56
  aren't
• 5:56
  going
• 5:56
  to
• 5:56
  involve
• 5:56
  some
• 5:57
  kind
• 5:57
  of
• 5:57
  tangible
• 5:58
  drawback
• 5:59
  in
• 5:59
  addition
• 5:59
  to
• 5:59
  a
• 6:00
  benefit,
• 6:00
  we
• 6:00
  have
• 6:01
  to
• 6:01
  normalize
• 6:01
  those
• 6:01
  conversations,
• 6:02
  be
• 6:03
  as
• 6:03
  transparent
• 6:03
  as
• 6:04
  possible
• 6:04
  so
• 6:04
  patients
• 6:05
  can
• 6:05
  make
• 6:06
  informed,
• 6:06
  empowered
• 6:07
  decisions
• 6:07
  with
• 6:08
  what
• 6:08
  we
• 6:08
  have.
• 6:09
  Now,
• 6:09
  in
• 6:09
  Johnny's
• 6:10
  case,
• 6:10
  the
• 6:11
  concern
• 6:11
  here,
• 6:12
  and
• 6:12
  you
• 6:12
  probably
• 6:12
  heard
• 6:13
  the
• 6:13
  word,
• 6:13
  one
• 6:13
  of
• 6:13
  the
• 6:14
  first
• 6:14
  words
• 6:14
  I
• 6:14
  said,
• 6:15
  is
• 6:15
  that
• 6:15
  he
• 6:15
  is
• 6:16
  stable
• 6:16
  on
• 6:16
  olanzapine.
• 6:17
  When
• 6:17
  you
• 6:18
  have
• 6:18
  a
• 6:18
  patient
• 6:18
  who's
• 6:18
  doing
• 6:19
  well
• 6:19
  psychiatrically
• 6:20
  and
• 6:20
  then
• 6:21
  you
• 6:21
  have
• 6:21
  this
• 6:21
  metabolic
• 6:22
  drag,
• 6:22
  so
• 6:22
  now
• 6:23
  you're
• 6:23
  thinking,
• 6:23
  well,
• 6:23
  we
• 6:23
  might
• 6:24
  need
• 6:24
  to.
• 6:24
  We
• 6:25
  might
• 6:25
  need
• 6:25
  to
• 6:25
  fix
• 6:25
  this,
• 6:26
  you
• 6:27
  could
• 6:27
  flirt
• 6:28
  with
• 6:28
  the
• 6:28
  idea
• 6:28
  of
• 6:29
  lowering
• 6:29
  the
• 6:29
  Zyprexa
• 6:30
  dose.
• 6:31
  That's
• 6:31
  something
• 6:31
  you
• 6:32
  can
• 6:32
  think
• 6:32
  about.
• 6:33
  Sometimes
• 6:33
  with
• 6:34
  these
• 6:34
  medications,
• 6:35
  the
• 6:35
  weight
• 6:35
  gain
• 6:36
  can
• 6:36
  be
• 6:36
  dose
• 6:36
  dependent.
• 6:37
  There's
• 6:38
  other
• 6:38
  literature,
• 6:38
  though,
• 6:38
  that
• 6:39
  suggests
• 6:39
  that
• 6:39
  after
• 6:40
  a
• 6:40
  certain
• 6:40
  point,
• 6:41
  there
• 6:41
  is
• 6:41
  not
• 6:41
  more
• 6:42
  weight
• 6:42
  gain
• 6:42
  after
• 6:42
  a
• 6:43
  certain
• 6:43
  dose
• 6:43
  with
• 6:43
  particular
• 6:44
  medications.
• 6:44
  I
• 6:45
  won't
• 6:45
  go
• 6:45
  into
• 6:45
  the
• 6:45
  weeds
• 6:45
  too
• 6:46
  much
• 6:46
  on
• 6:46
  that,
• 6:47
  but
• 6:47
  let's
• 6:48
  just
• 6:48
  say
• 6:48
  for
• 6:48
  simplicity's
• 6:49
  sake,
• 6:49
  we
• 6:50
  need
• 6:50
  to
• 6:51
  jump
• 6:51
  ship
• 6:51
  on
• 6:51
  the
• 6:52
  Olanzapine
• 6:52
  here.
• 6:53
  And
• 6:53
  we've
• 6:53
  got
• 6:54
  to
• 6:54
  think
• 6:54
  about
• 6:54
  which
• 6:55
  medications
• 6:55
  might
• 6:56
  be
• 6:56
  more
• 6:56
  suitable.
• 6:56
  So
• 6:57
  I'll
• 6:57
  give
• 6:57
  you
• 6:57
  just
• 6:57
  a
• 6:57
  quick
• 6:58
  pop
• 6:58
  quiz
• 6:59
  question
• 6:59
  we
• 6:59
  can
• 6:59
  come
• 7:00
  back
• 7:00
  to
• 7:00
  later
• 7:00
  in
• 7:00
  our
• 7:01
  discussion
• 7:02
  today.
• 7:02
  It
• 7:02
  goes
• 7:03
  something
• 7:03
  like
• 7:03
  this.
• 7:03
  Which
• 7:04
  one
• 7:04
  of
• 7:04
  these
• 7:04
  medications
• 7:05
  is
• 7:05
  not
• 7:05
  an
• 7:06
  ideal
• 7:06
  switch
• 7:07
  for
• 7:07
  Johnny,
• 7:08
  in
• 7:08
  this
• 7:08
  case,
• 7:08
  going
• 7:08
  from
• 7:09
  Zyprexa
• 7:10
  to
• 7:10
  a
• 7:10
  new
• 7:10
  medication?
• 7:11
  So
• 7:11
  which
• 7:11
  one
• 7:12
  of
• 7:12
  these
• 7:12
  is
• 7:12
  not
• 7:12
  ideal?
• 7:13
  Would
• 7:13
  it
• 7:13
  be
• 7:13
  A,
• 7:14
  Abilify,
• 7:15
  B
• 7:15
  Latuda,
• 7:16
  C
• 7:17
  Gawn,
• 7:17
  or
• 7:18
  D,
• 7:18
  Seroquel?
• 7:19
  I'll
• 7:20
  let
• 7:20
  you
• 7:20
  think
• 7:20
  about
• 7:20
  that
• 7:21
  a
• 7:21
  little
• 7:21
  bit.
• 7:22
  What
• 7:22
  we
• 7:22
  have
• 7:22
  here,
• 7:23
  right,
• 7:23
  is
• 7:23
  the
• 7:23
  triple
• 7:24
  threat.
• 7:25
  So
• 7:25
  Johnny's
• 7:26
  taking
• 7:26
  a
• 7:26
  medication,
• 7:26
  Olanzapine,
• 7:27
  that
• 7:27
  is
• 7:27
  antagonizing
• 7:28
  histamine,
• 7:29
  that
• 7:29
  is
• 7:29
  reducing
• 7:30
  his
• 7:31
  satiety
• 7:31
  signaling.
• 7:32
  It
• 7:32
  means
• 7:32
  essentially
• 7:33
  that
• 7:34
  blocking
• 7:34
  histamine
• 7:35
  is
• 7:35
  interfering
• 7:36
  with
• 7:36
  his
• 7:36
  ability
• 7:37
  to
• 7:37
  understand
• 7:37
  when
• 7:38
  he's
• 7:38
  full
• 7:38
  or
• 7:38
  not.
• 7:39
  It's
• 7:39
  also
• 7:39
  making
• 7:39
  him
• 7:39
  Move
• 7:40
  less
• 7:40
  that
• 7:40
  those
• 7:41
  are
• 7:41
  major
• 7:41
  contributors
• 7:42
  to
• 7:42
  weight
• 7:43
  gain.
• 7:43
  So
• 7:44
  by
• 7:44
  antagonizing
• 7:45
  histamine,
• 7:46
  we're
• 7:46
  interfering
• 7:47
  with
• 7:47
  parts
• 7:48
  of
• 7:48
  the
• 7:48
  hypothalamus
• 7:49
  that
• 7:49
  regulate
• 7:50
  satiety.
• 7:50
  And
• 7:51
  so
• 7:51
  there
• 7:52
  in
• 7:52
  comes
• 7:52
  the
• 7:52
  weight
• 7:52
  gain.
• 7:53
  He's
• 7:53
  more
• 7:53
  sluggish.
• 7:54
  He's
• 7:54
  not
• 7:54
  moving
• 7:54
  as
• 7:55
  as
• 7:55
  much.
• 7:55
  I
• 7:56
  don't
• 7:56
  know
• 7:56
  if
• 7:56
  you've
• 7:56
  ever
• 7:56
  taken
• 7:56
  Benadryl
• 7:57
  before,
• 7:58
  but
• 7:58
  that's
• 7:58
  the
• 7:58
  same
• 7:58
  kind
• 7:59
  of
• 7:59
  histamine.
• 7:59
  We're
• 7:59
  talking
• 8:00
  about
• 8:00
  the
• 8:00
  antagon,
• 8:01
  antagonization
• 8:02
  of
• 8:03
  histamine.
• 8:03
  And
• 8:04
  last
• 8:04
  time
• 8:04
  I
• 8:04
  took
• 8:04
  Nyquil
• 8:05
  or
• 8:05
  Benadryl,
• 8:06
  I
• 8:06
  wasn't
• 8:06
  really
• 8:06
  in
• 8:06
  the
• 8:07
  mood
• 8:07
  to
• 8:07
  go
• 8:07
  out
• 8:08
  for
• 8:08
  a
• 8:08
  walk,
• 8:09
  let
• 8:09
  alone
• 8:09
  sprint
• 8:10
  on
• 8:10
  the
• 8:10
  treadmill.
• 8:11
  Right.
• 8:11
  You're
• 8:11
  slowing
• 8:12
  down
• 8:12
  movement
• 8:12
  significantly
• 8:13
  with
• 8:14
  the
• 8:14
  histamine
• 8:15
  receptor.
• 8:16
  Keep
• 8:16
  that
• 8:16
  in
• 8:17
  mind.
• 8:17
  And
• 8:18
  you're
• 8:18
  getting
• 8:18
  kind
• 8:18
  of
• 8:18
  hungry,
• 8:19
  too.
• 8:19
  Now,
• 8:20
  the
• 8:20
  second
• 8:20
  threat
• 8:21
  with
• 8:21
  zyprexa
• 8:22
  is
• 8:22
  the
• 8:22
  5ht
• 8:23
  2c
• 8:24
  blockade,
• 8:25
  causing
• 8:26
  a
• 8:26
  removal
• 8:27
  of
• 8:27
  the
• 8:27
  satiety
• 8:28
  pathway.
• 8:28
  And
• 8:29
  patients
• 8:29
  will
• 8:30
  particularly
• 8:30
  get
• 8:30
  hungry
• 8:31
  for
• 8:31
  carbs
• 8:31
  and
• 8:31
  sweets.
• 8:32
  They
• 8:32
  don't
• 8:33
  really
• 8:33
  crave
• 8:33
  spinach.
• 8:33
  You
• 8:34
  don't
• 8:34
  see
• 8:34
  people
• 8:34
  binging
• 8:34
  on
• 8:35
  spinach
• 8:35
  here.
• 8:36
  They're
• 8:36
  craving
• 8:36
  those
• 8:37
  kind
• 8:37
  of
• 8:37
  short,
• 8:38
  fast
• 8:38
  dopamine
• 8:39
  highs.
• 8:40
  Also,
• 8:40
  when
• 8:40
  you
• 8:41
  block
• 8:41
  5ht
• 8:41
  2c,
• 8:42
  as
• 8:42
  we've
• 8:42
  discussed
• 8:43
  in
• 8:43
  other
• 8:43
  episodes,
• 8:44
  dopamine
• 8:44
  fires
• 8:45
  more
• 8:45
  easily
• 8:46
  in
• 8:46
  the
• 8:46
  reward
• 8:46
  pathways
• 8:47
  of
• 8:47
  the
• 8:47
  brain,
• 8:47
  and
• 8:47
  food
• 8:48
  can
• 8:48
  actually
• 8:48
  feel
• 8:48
  more
• 8:49
  rewarding.
• 8:49
  So
• 8:50
  you
• 8:50
  have
• 8:50
  this
• 8:50
  increase
• 8:51
  not
• 8:51
  just
• 8:51
  in
• 8:51
  hunger,
• 8:52
  but
• 8:52
  in
• 8:52
  the
• 8:53
  dopamine
• 8:54
  hits
• 8:54
  especially
• 8:55
  become
• 8:55
  more
• 8:55
  rewarding
• 8:56
  sugar
• 8:57
  and
• 8:57
  carbs.
• 8:58
  So
• 8:58
  that's
• 8:58
  the
• 8:58
  second
• 8:58
  threat,
• 8:59
  the,
• 9:00
  the
• 9:00
  double
• 9:00
  threat,
• 9:01
  the
• 9:01
  histamine
• 9:01
  antagonism
• 9:02
  and
• 9:02
  antagonizing
• 9:03
  5ht
• 9:04
  2c.
• 9:05
  And
• 9:05
  the
• 9:05
  third
• 9:05
  triple
• 9:06
  threat
• 9:06
  is
• 9:07
  muscarinic
• 9:07
  receptor
• 9:08
  blockade.
• 9:08
  We
• 9:08
  talked
• 9:09
  about
• 9:09
  M3.
• 9:10
  Now,
• 9:10
  M3
• 9:11
  is
• 9:11
  a
• 9:11
  little
• 9:11
  bit
• 9:11
  more
• 9:12
  complicated.
• 9:12
  We
• 9:12
  won't
• 9:13
  go
• 9:13
  too
• 9:13
  far
• 9:13
  into
• 9:13
  the
• 9:14
  weeds,
• 9:14
  but
• 9:14
  we
• 9:14
  want
• 9:14
  to
• 9:14
  go
• 9:15
  far
• 9:15
  enough
• 9:15
  to
• 9:16
  give
• 9:16
  you
• 9:16
  a
• 9:16
  conceptual
• 9:17
  appreciation
• 9:18
  of
• 9:18
  what
• 9:18
  M3
• 9:19
  is
• 9:19
  different
• 9:19
  than
• 9:19
  the
• 9:19
  5ht2c
• 9:20
  or
• 9:20
  H1
• 9:21
  M3.
• 9:23
  That
• 9:23
  receptor
• 9:23
  plays
• 9:24
  a
• 9:24
  role
• 9:24
  in
• 9:24
  insulin
• 9:25
  release
• 9:25
  and
• 9:25
  metabolism.
• 9:26
  It's
• 9:26
  antagonism.
• 9:27
  So
• 9:27
  antagonizing
• 9:28
  M3
• 9:29
  can
• 9:29
  impair
• 9:29
  glucose
• 9:30
  handling
• 9:30
  and
• 9:31
  promote
• 9:31
  fat
• 9:31
  storage
• 9:32
  and
• 9:32
  weight
• 9:32
  gain.
• 9:33
  So
• 9:34
  this
• 9:34
  is
• 9:34
  a
• 9:34
  tricky
• 9:35
  one
• 9:35
  because
• 9:35
  metabolically,
• 9:36
  your
• 9:36
  numbers
• 9:37
  can
• 9:37
  get
• 9:37
  a
• 9:37
  lot
• 9:37
  worse
• 9:38
  before
• 9:38
  the
• 9:39
  scale
• 9:39
  moves
• 9:39
  here.
• 9:40
  So
• 9:40
  triglycerides
• 9:41
  and
• 9:42
  glucose,
• 9:43
  A1C.
• 9:43
  Right.
• 9:44
  Those
• 9:44
  numbers
• 9:45
  can
• 9:45
  get
• 9:45
  a
• 9:45
  lot
• 9:45
  worse
• 9:46
  before
• 9:47
  we're
• 9:47
  seeing
• 9:47
  a
• 9:47
  lot
• 9:48
  of
• 9:48
  weight
• 9:48
  gain,
• 9:48
  although
• 9:48
  we
• 9:48
  can
• 9:49
  also
• 9:49
  see
• 9:49
  weight
• 9:49
  gain
• 9:50
  here
• 9:50
  too.
• 9:51
  And
• 9:51
  M3
• 9:52
  blockade
• 9:52
  is
• 9:53
  very
• 9:53
  interesting.
• 9:54
  Normally,
• 9:54
  acetylcholine
• 9:55
  will
• 9:56
  bind
• 9:56
  to
• 9:56
  the
• 9:56
  M3
• 9:56
  receptors
• 9:57
  on
• 9:57
  pancreatic
• 9:58
  beta
• 9:58
  cells.
• 9:58
  And
• 9:59
  that
• 9:59
  triggers
• 9:59
  insulin
• 10:00
  release
• 10:00
  when
• 10:01
  blood
• 10:01
  sugar
• 10:02
  rises.
• 10:02
  Well,
• 10:03
  medications
• 10:03
  like
• 10:04
  clozapine
• 10:04
  and
• 10:04
  olanzapine
• 10:05
  in
• 10:05
  this
• 10:06
  case
• 10:06
  and
• 10:06
  some
• 10:06
  other
• 10:07
  second
• 10:07
  generation
• 10:08
  antipsychotics,
• 10:08
  they
• 10:09
  actually
• 10:09
  block
• 10:10
  M3
• 10:11
  receptors.
• 10:11
  Again,
• 10:11
  antagonize
• 10:12
  them.
• 10:13
  And
• 10:13
  that
• 10:13
  blockade
• 10:14
  will
• 10:14
  reduce
• 10:14
  insulin
• 10:15
  release.
• 10:15
  So
• 10:15
  glucose
• 10:16
  just
• 10:16
  stays
• 10:16
  in
• 10:16
  the
• 10:17
  blood
• 10:17
  longer
• 10:18
  and
• 10:18
  insulin
• 10:19
  resistance
• 10:20
  develops.
• 10:21
  And
• 10:21
  insulin
• 10:22
  resistance
• 10:22
  essentially
• 10:23
  tells
• 10:23
  the
• 10:23
  body
• 10:23
  we're
• 10:23
  starving.
• 10:24
  It
• 10:24
  triggers
• 10:25
  hunger
• 10:25
  and,
• 10:25
  and
• 10:25
  boom,
• 10:26
  fat
• 10:26
  storage,
• 10:27
  even
• 10:27
  without
• 10:28
  increased
• 10:28
  calories
• 10:29
  at
• 10:29
  first.
• 10:29
  So
• 10:29
  over
• 10:30
  time,
• 10:30
  your
• 10:30
  metabolic
• 10:31
  markers
• 10:31
  worsen
• 10:32
  and
• 10:32
  you
• 10:33
  ultimately
• 10:33
  have
• 10:33
  weight
• 10:34
  gain.
• 10:34
  So
• 10:35
  that
• 10:36
  sugar
• 10:36
  that
• 10:36
  doesn't
• 10:36
  get
• 10:36
  cleared
• 10:37
  effectively
• 10:38
  will
• 10:38
  end
• 10:38
  up
• 10:38
  converted
• 10:39
  to
• 10:39
  fat.
• 10:40
  And
• 10:40
  that's
• 10:40
  why
• 10:40
  M3
• 10:41
  blockade
• 10:41
  produces
• 10:42
  metabolic
• 10:42
  weight
• 10:43
  gain.
• 10:43
  M
• 10:43
  as
• 10:44
  in
• 10:44
  metabolic.
• 10:44
  I
• 10:44
  want
• 10:44
  you
• 10:45
  to
• 10:45
  think
• 10:45
  mnemonically
• 10:46
  M3M
• 10:47
  metabolic,
• 10:48
  right?
• 10:49
  Because
• 10:49
  it's
• 10:49
  dealing
• 10:50
  with
• 10:50
  insulin
• 10:51
  on
• 10:51
  a
• 10:51
  receptor
• 10:52
  level,
• 10:52
  nitty
• 10:53
  gritty,
• 10:53
  messing
• 10:54
  with
• 10:54
  insulin
• 10:55
  storage
• 10:55
  and
• 10:55
  thereby
• 10:55
  your
• 10:56
  metabolic
• 10:57
  signals.
• 10:57
  Very
• 10:58
  important
• 10:58
  and
• 10:58
  a
• 10:59
  bit
• 10:59
  of
• 10:59
  a
• 10:59
  distinction,
• 10:59
  right,
• 11:00
  because
• 11:00
  the
• 11:00
  other
• 11:01
  two
• 11:01
  have
• 11:01
  to
• 11:01
  deal
• 11:01
  with
• 11:02
  satiety
• 11:03
  in
• 11:03
  the
• 11:03
  hypothalamus.
• 11:59
  C
• 11:59
  A5HT2C
• 12:01
  dealing
• 12:01
  with
• 12:02
  the
• 12:02
  craving
• 12:03
  of
• 12:03
  carbohydrates
• 12:04
  and
• 12:04
  sugars,
• 12:05
  and
• 12:05
  H1
• 12:05
  dealing
• 12:06
  with
• 11:12
  movement,
• 12:07
  dealing
• 12:08
  with
• 12:09
  also
• 12:09
  satiety
• 12:10
  and
• 12:10
  weight
• 12:10
  gain
• 12:10
  and
• 12:11
  hunger.
• 12:11
  H
• 12:12
  for
• 12:12
  hunger.
• 12:13
  You're
• 12:13
  hungry,
• 12:13
  you're
• 12:13
  not
• 12:13
  moving
• 12:14
  as
• 12:14
  much.
• 12:14
  That's
• 12:15
  histamine,
• 12:15
  right?
• 12:16
  You're
• 12:16
  gaining
• 12:16
  weight.
• 12:16
  It's.
• 12:17
  It's
• 12:17
  messing
• 12:18
  with
• 12:18
  satiety
• 12:19
  signaling
• 12:19
  5ht
• 12:20
  2c.
• 12:21
  So
• 12:21
  why
• 12:21
  is
• 12:22
  this
• 12:22
  all
• 12:22
  important?
• 12:22
  It's
• 12:22
  important
• 12:23
  because
• 12:24
  all
• 12:24
  of
• 12:24
  the
• 12:24
  medications
• 12:25
  you
• 12:25
  can
• 12:25
  choose,
• 12:25
  my
• 12:26
  friends,
• 12:26
  you
• 12:27
  want
• 12:27
  to
• 12:27
  do
• 12:27
  a
• 12:28
  nerdy,
• 12:29
  curious,
• 12:29
  deep
• 12:29
  dive
• 12:30
  sometimes
• 12:31
  into
• 12:31
  whether
• 12:32
  or
• 12:32
  not
• 12:32
  they
• 12:33
  act
• 12:33
  on
• 12:33
  these
• 12:34
  specific
• 12:34
  receptors.
• 12:35
  Do
• 12:35
  they
• 12:35
  act?
• 12:36
  Do
• 12:36
  they
• 12:36
  antagonize
• 12:37
  H1?
• 12:38
  And
• 12:38
  if
• 12:38
  so,
• 12:38
  what's
• 12:39
  the
• 12:39
  affinity?
• 12:40
  Right?
• 12:40
  We
• 12:40
  talked
• 12:40
  about
• 12:40
  affinity
• 12:41
  like
• 12:41
  a
• 12:41
  magnet,
• 12:42
  the
• 12:42
  affinity
• 12:43
  for
• 12:43
  the
• 12:43
  receptor.
• 12:44
  And
• 12:44
  the
• 12:44
  stronger
• 12:44
  the
• 12:45
  affinity,
• 12:45
  the
• 12:45
  more
• 12:46
  of
• 12:46
  an
• 12:46
  effect
• 12:46
  it
• 12:46
  can
• 12:46
  have
• 12:47
  on
• 12:47
  that
• 12:47
  receptor.
• 12:48
  So
• 12:48
  it's
• 12:48
  really
• 12:48
  good
• 12:48
  to
• 12:48
  like
• 12:49
  rank
• 12:49
  the
• 12:49
  affinities
• 12:50
  of
• 12:50
  particular
• 12:50
  medications
• 12:51
  on
• 12:51
  these
• 12:51
  receptors
• 12:52
  to
• 12:52
  see
• 12:52
  which
• 12:52
  ones
• 12:53
  in
• 12:53
  particular
• 12:54
  are
• 12:54
  more
• 12:54
  problematic
• 12:55
  than
• 12:56
  others.
• 12:56
  In
• 12:56
  this
• 12:56
  case,
• 12:57
  you
• 12:57
  know,
• 12:57
  5ht2c.
• 12:58
  Well,
• 12:58
  Zyprexa
• 12:59
  has
• 13:00
  a
• 13:00
  very
• 13:00
  strong
• 13:01
  affinity
• 13:01
  for
• 13:01
  all
• 13:01
  three
• 13:02
  of
• 13:02
  these
• 13:02
  receptors,
• 13:03
  but
• 13:03
  you
• 13:03
  might
• 13:03
  find
• 13:03
  a
• 13:04
  second
• 13:04
  generation
• 13:04
  antipsychotic
• 13:05
  that
• 13:06
  is
• 13:06
  not
• 13:06
  antagonizing
• 13:07
  these
• 13:07
  as
• 13:08
  strongly,
• 13:08
  if
• 13:08
  at
• 13:08
  all.
• 13:09
  And
• 13:09
  that,
• 13:09
  my
• 13:10
  friends,
• 13:10
  will
• 13:11
  be
• 13:11
  the
• 13:11
  answer
• 13:12
  that
• 13:12
  you
• 13:12
  can
• 13:12
  go
• 13:12
  to
• 13:13
  when
• 13:13
  you're
• 13:14
  trying
• 13:14
  to
• 13:14
  find
• 13:14
  a
• 13:14
  suitable
• 13:15
  alternative
• 13:16
  for
• 13:17
  these
• 13:17
  receptors.
• 13:18
  And
• 13:18
  so
• 13:19
  I
• 13:19
  think
• 13:19
  that's
• 13:20
  a
• 13:20
  gold
• 13:20
  mine.
• 13:21
  Now,
• 13:21
  getting
• 13:21
  back
• 13:22
  to
• 13:22
  our
• 13:23
  question,
• 13:24
  we
• 13:24
  are
• 13:24
  asking
• 13:25
  ourselves,
• 13:25
  which
• 13:25
  of
• 13:25
  these
• 13:26
  agents
• 13:26
  is
• 13:26
  not
• 13:27
  an
• 13:27
  ideal
• 13:27
  switch
• 13:28
  for
• 13:28
  the
• 13:28
  patient
• 13:29
  on
• 13:29
  Zyprexa?
• 13:30
  Abilify,
• 13:31
  Latuda,
• 13:32
  Geodon,
• 13:32
  or
• 13:33
  Seroquel.
• 13:34
  The
• 13:34
  answer,
• 13:35
  my
• 13:35
  friends,
• 13:36
  if
• 13:36
  you've
• 13:36
  been
• 13:36
  studying
• 13:37
  hard,
• 13:38
  pat
• 13:38
  yourself
• 13:38
  on
• 13:38
  the
• 13:38
  back
• 13:39
  if
• 13:39
  you
• 13:39
  said
• 13:39
  Seroquel.
• 13:40
  Yes,
• 13:40
  Seroquel
• 13:41
  would
• 13:41
  not
• 13:41
  be
• 13:42
  the
• 13:42
  best
• 13:42
  switch
• 13:43
  for
• 13:43
  this
• 13:43
  patient
• 13:44
  because
• 13:44
  Seroquel
• 13:45
  also
• 13:45
  has
• 13:45
  a
• 13:45
  very
• 13:46
  high
• 13:46
  antagonism
• 13:47
  of
• 13:47
  histamine,
• 13:48
  moderate
• 13:49
  to
• 13:49
  high
• 13:50
  antagonism
• 13:50
  of
• 13:50
  the
• 13:50
  5HT2C
• 13:51
  receptor,
• 13:52
  and
• 13:53
  also
• 13:54
  a
• 13:54
  moderate
• 13:55
  antagonism
• 13:56
  or
• 13:56
  affinity
• 13:56
  for
• 13:56
  the
• 13:57
  M3
• 13:58
  receptor.
• 13:59
  So
• 13:59
  you're
• 13:59
  kind
• 13:59
  of
• 13:59
  switching
• 14:00
  from
• 14:00
  a
• 14:00
  Big
• 14:00
  Mac
• 14:00
  to
• 14:01
  a
• 14:01
  Whopper
• 14:01
  here.
• 14:01
  It's
• 14:01
  not
• 14:02
  a
• 14:02
  giant
• 14:03
  leap.
• 14:03
  It's
• 14:04
  not
• 14:04
  a
• 14:04
  great
• 14:04
  help
• 14:04
  to
• 14:05
  your
• 14:05
  patient
• 14:05
  going
• 14:05
  from
• 14:06
  one
• 14:06
  major
• 14:06
  weight
• 14:06
  gainer
• 14:07
  to
• 14:07
  one
• 14:07
  that's
• 14:07
  probably
• 14:08
  also
• 14:08
  going
• 14:08
  to
• 14:08
  cause
• 14:09
  weight
• 14:09
  gain
• 14:09
  through
• 14:09
  these
• 14:10
  same
• 14:10
  pathways.
• 14:11
  So
• 14:11
  when
• 14:11
  you're
• 14:12
  trying
• 14:12
  to
• 14:12
  figure
• 14:12
  out
• 14:13
  what
• 14:13
  is
• 14:13
  the
• 14:13
  next
• 14:13
  best
• 14:14
  thing,
• 14:14
  ask
• 14:14
  yourself,
• 14:15
  what
• 14:15
  is
• 14:15
  a
• 14:15
  second
• 14:16
  generation
• 14:16
  antipsychotic
• 14:17
  out
• 14:17
  there
• 14:17
  that
• 14:18
  does
• 14:18
  not
• 14:18
  antagonize
• 14:19
  histamine
• 14:20
  at
• 14:20
  all
• 14:20
  or
• 14:20
  very
• 14:21
  little?
• 14:21
  What
• 14:22
  is
• 14:22
  an
• 14:22
  antipsychotic
• 14:23
  that
• 14:23
  does
• 14:23
  not
• 14:24
  antagonize
• 14:24
  5ht
• 14:25
  2c
• 14:25
  or
• 14:26
  lightly
• 14:26
  antagonizes
• 14:27
  it,
• 14:27
  rather
• 14:27
  than
• 14:28
  totally
• 14:28
  antagonizes
• 14:29
  it
• 14:29
  with
• 14:29
  a
• 14:29
  high
• 14:30
  strong
• 14:30
  affinity,
• 14:31
  which
• 14:31
  is
• 14:31
  a
• 14:31
  second
• 14:32
  generation
• 14:32
  antipsychotic
• 14:33
  that
• 14:33
  doesn't
• 14:33
  antagonize
• 14:34
  M3
• 14:36
  and
• 14:36
  mess
• 14:36
  around
• 14:36
  with
• 14:37
  metabolic
• 14:37
  pathways?
• 14:38
  Well,
• 14:38
  all
• 14:38
  of
• 14:39
  them
• 14:39
  are
• 14:39
  better.
• 14:39
  The
• 14:39
  Abilify,
• 14:40
  the
• 14:40
  Latuda,
• 14:41
  the
• 14:41
  Geodon.
• 14:41
  These
• 14:41
  are
• 14:41
  much
• 14:42
  lighter.
• 14:43
  These
• 14:43
  are
• 14:43
  much
• 14:43
  more
• 14:43
  tolerable
• 14:44
  for
• 14:44
  a
• 14:44
  patient
• 14:44
  who's
• 14:45
  dealing
• 14:45
  with
• 14:45
  weight
• 14:46
  gain.
• 14:47
  Can
• 14:47
  weight
• 14:47
  gain
• 14:47
  still
• 14:48
  happen
• 14:48
  on
• 14:48
  these
• 14:48
  medications?
• 14:49
  Absolutely.
• 14:50
  Some
• 14:50
  people
• 14:50
  are
• 14:50
  more
• 14:50
  metabolically
• 14:51
  prone.
• 14:52
  This
• 14:52
  is,
• 14:52
  again,
• 14:52
  not
• 14:53
  as
• 14:53
  simple
• 14:53
  as
• 14:53
  the
• 14:54
  textbooks
• 14:54
  always
• 14:54
  make
• 14:54
  it
• 14:55
  out
• 14:55
  to
• 14:55
  be,
• 14:55
  where
• 14:56
  you
• 14:56
  switch
• 14:56
  from
• 14:57
  Zyprexa
• 14:57
  and
• 14:57
  you
• 14:58
  go
• 14:58
  to
• 14:58
  Abilify
• 14:58
  and
• 14:58
  bam,
• 14:59
  the
• 14:59
  patient
• 15:00
  loses
• 15:00
  all
• 15:00
  the
• 15:00
  weight,
• 15:00
  feels
• 15:01
  better,
• 15:01
  and
• 15:01
  never
• 15:02
  gains
• 15:02
  weight
• 15:02
  on
• 15:02
  Abilify.
• 15:03
  It's
• 15:03
  rarely
• 15:03
  that
• 15:03
  simple,
• 15:04
  my
• 15:04
  friends.
• 15:04
  But
• 15:05
  if
• 15:05
  you
• 15:05
  had
• 15:05
  to
• 15:05
  choose
• 15:06
  between
• 15:06
  Abilify
• 15:07
  and
• 15:07
  a
• 15:07
  lanapine
• 15:08
  and
• 15:08
  you
• 15:09
  were
• 15:09
  going
• 15:09
  out
• 15:10
  of
• 15:10
  your
• 15:10
  way
• 15:10
  to
• 15:10
  make
• 15:11
  sure
• 15:11
  that
• 15:11
  the
• 15:11
  patient
• 15:12
  was
• 15:12
  not
• 15:12
  going
• 15:12
  to
• 15:13
  gain
• 15:13
  a
• 15:13
  lot
• 15:13
  of
• 15:13
  weight
• 15:13
  from
• 15:14
  the
• 15:14
  start,
• 15:14
  Abilify
• 15:15
  would
• 15:15
  be
• 15:15
  a
• 15:15
  better
• 15:16
  option
• 15:16
  in
• 15:17
  that
• 15:17
  case.
• 15:18
  Now,
• 15:18
  my
• 15:18
  friends,
• 15:19
  here's
• 15:19
  the
• 15:19
  nuance
• 15:20
  again.
• 15:20
  We
• 15:21
  talked
• 15:21
  about
• 15:21
  the
• 15:21
  potency
• 15:22
  of
• 15:22
  Olanzapine.
• 15:23
  You
• 15:23
  may
• 15:23
  find,
• 15:24
  though,
• 15:24
  that
• 15:24
  when
• 15:24
  you're
• 15:25
  switching
• 15:25
  to
• 15:25
  these
• 15:26
  other
• 15:26
  agents,
• 15:27
  they
• 15:27
  may
• 15:27
  not
• 15:27
  be
• 15:27
  as
• 15:27
  effective
• 15:28
  in
• 15:28
  treating
• 15:28
  Johnny's
• 15:29
  psychosis
• 15:30
  and
• 15:30
  in
• 15:30
  his
• 15:31
  schizophrenia,
• 15:31
  or
• 15:32
  stabilizing
• 15:32
  his
• 15:32
  mood.
• 15:33
  And
• 15:33
  that's
• 15:33
  why
• 15:33
  it's
• 15:34
  not
• 15:34
  as
• 15:34
  simple
• 15:34
  as
• 15:34
  this,
• 15:35
  right?
• 15:35
  You
• 15:35
  might
• 15:36
  stave
• 15:36
  off
• 15:37
  additional
• 15:37
  weight
• 15:38
  gain.
• 15:38
  Hopefully
• 15:39
  you
• 15:39
  can
• 15:39
  get
• 15:39
  some
• 15:39
  weight
• 15:40
  loss.
• 15:40
  That's
• 15:40
  not,
• 15:41
  in
• 15:41
  my
• 15:41
  experience,
• 15:42
  at
• 15:42
  least
• 15:42
  as,
• 15:43
  as
• 15:44
  realistic.
• 15:44
  I
• 15:45
  don't
• 15:45
  see
• 15:45
  patients
• 15:45
  just
• 15:46
  melting
• 15:46
  the
• 15:46
  weight
• 15:46
  off
• 15:47
  right
• 15:47
  away
• 15:47
  when
• 15:47
  you
• 15:47
  switch.
• 15:48
  Some
• 15:48
  do,
• 15:49
  some
• 15:49
  don't.
• 15:50
  But
• 15:51
  again,
• 15:51
  there's
• 15:51
  trade
• 15:52
  offs
• 15:52
  here
• 15:52
  because
• 15:52
  you
• 15:53
  don't
• 15:53
  want
• 15:53
  to
• 15:54
  clap
• 15:54
  your
• 15:54
  hands
• 15:54
  and
• 15:54
  cheer
• 15:55
  for
• 15:55
  the
• 15:55
  fact
• 15:55
  that
• 15:55
  he's
• 15:55
  not
• 15:56
  gaining
• 15:56
  weight.
• 15:56
  And
• 15:56
  then
• 15:56
  all
• 15:56
  of
• 15:57
  a
• 15:57
  sudden
• 15:57
  he's
• 15:57
  psychotic,
• 15:58
  he's
• 15:58
  back
• 15:58
  in
• 15:58
  the
• 15:58
  hospital
• 15:59
  and
• 15:59
  we're
• 15:59
  at
• 15:59
  square
• 16:00
  one.
• 16:00
  Because
• 16:00
  Abilify,
• 16:01
  yay,
• 16:01
  didn't
• 16:02
  cause
• 16:02
  weight
• 16:02
  gain.
• 16:02
  But
• 16:03
  in,
• 16:03
  in
• 16:03
  comes
• 16:04
  the
• 16:04
  delusions,
• 16:05
  the
• 16:05
  psychosis,
• 16:06
  and
• 16:06
  the
• 16:06
  5150.
• 16:07
  Right.
• 16:08
  So
• 16:08
  trade
• 16:09
  offs.
• 16:09
  And
• 16:09
  I
• 16:10
  would
• 16:10
  also
• 16:10
  make
• 16:10
  sure
• 16:10
  I
• 16:11
  ask
• 16:11
  Johnny,
• 16:12
  how
• 16:12
  bad
• 16:13
  was
• 16:13
  your
• 16:13
  psychosis
• 16:14
  before?
• 16:14
  How
• 16:14
  many
• 16:14
  hospitalizations
• 16:15
  have
• 16:15
  you
• 16:15
  had?
• 16:16
  Have
• 16:16
  you
• 16:16
  tried
• 16:16
  to
• 16:16
  commit
• 16:16
  suicide
• 16:17
  before?
• 16:17
  You
• 16:18
  know,
• 16:18
  how
• 16:18
  severe
• 16:19
  is
• 16:19
  this
• 16:19
  schizophrenia?
• 16:21
  And
• 16:21
  have
• 16:21
  a
• 16:21
  really
• 16:22
  good
• 16:22
  idea
• 16:22
  of
• 16:23
  all
• 16:23
  the
• 16:23
  other
• 16:23
  medications
• 16:24
  he's
• 16:24
  tried.
• 16:24
  Make
• 16:24
  sure
• 16:25
  he
• 16:25
  hasn't
• 16:25
  tried
• 16:25
  Abilify
• 16:26
  before
• 16:26
  and
• 16:26
  it
• 16:26
  wasn't
• 16:27
  successful
• 16:28
  for
• 16:28
  him.
• 16:28
  Why
• 16:28
  would
• 16:29
  you
• 16:29
  waste
• 16:29
  his
• 16:29
  time?
• 16:29
  Right,
• 16:30
  so
• 16:30
  you
• 16:30
  want
• 16:30
  to
• 16:31
  get
• 16:31
  a
• 16:31
  good
• 16:31
  idea
• 16:32
  of
• 16:32
  what
• 16:32
  the
• 16:32
  stakes
• 16:33
  are,
• 16:33
  because
• 16:34
  if
• 16:34
  you
• 16:34
  find
• 16:34
  out
• 16:35
  that
• 16:35
  he's
• 16:36
  tried,
• 16:36
  let's
• 16:36
  say,
• 16:37
  Gidon
• 16:37
  or
• 16:37
  Latuda,
• 16:38
  and
• 16:38
  he
• 16:38
  gained
• 16:38
  weight
• 16:39
  on
• 16:39
  those,
• 16:39
  and
• 16:39
  they
• 16:40
  weren't
• 16:40
  that
• 16:40
  effective,
• 16:41
  even
• 16:41
  though
• 16:41
  they're,
• 16:41
  they
• 16:42
  tend
• 16:42
  to
• 16:42
  be
• 16:42
  more
• 16:42
  weight
• 16:43
  neutral.
• 16:43
  So
• 16:43
  we
• 16:44
  need
• 16:44
  to
• 16:44
  go
• 16:44
  to
• 16:44
  a
• 16:44
  different
• 16:45
  part
• 16:45
  of
• 16:45
  this
• 16:45
  algorithm.
• 16:46
  Has
• 16:46
  he
• 16:46
  already
• 16:46
  trialed
• 16:47
  to
• 16:48
  second
• 16:48
  generation
• 16:48
  antipsychotics?
• 16:50
  And
• 16:50
  maybe
• 16:50
  it's
• 16:50
  time
• 16:51
  for
• 16:51
  Clozapine.
• 16:52
  Of
• 16:52
  course,
• 16:52
  that's
• 16:53
  a
• 16:53
  huge
• 16:53
  weight
• 16:54
  gainer
• 16:54
  too.
• 16:55
  But
• 16:55
  again,
• 16:56
  I
• 16:56
  hope
• 16:57
  you
• 16:57
  appreciate
• 16:57
  how
• 16:58
  layered
• 16:58
  and
• 16:58
  complex
• 16:59
  and
• 16:59
  fun
• 16:59
  this
• 16:59
  is,
• 17:00
  because
• 17:01
  this
• 17:01
  is
• 17:01
  a
• 17:02
  guy
• 17:02
  who
• 17:02
  came
• 17:02
  to
• 17:02
  you
• 17:02
  with
• 17:02
  stable,
• 17:03
  he's
• 17:03
  stable,
• 17:04
  but
• 17:04
  the
• 17:04
  weight
• 17:04
  gain
• 17:04
  is
• 17:05
  a
• 17:05
  deal
• 17:05
  breaker.
• 17:06
  And
• 17:06
  so
• 17:06
  knowing
• 17:07
  who's
• 17:07
  who
• 17:08
  in
• 17:08
  the
• 17:08
  zoo
• 17:08
  with
• 17:08
  your
• 17:09
  receptors
• 17:09
  and
• 17:10
  your
• 17:10
  second
• 17:10
  generation
• 17:11
  antipsychotics
• 17:12
  is
• 17:12
  really
• 17:12
  important.
• 17:13
  Nerd
• 17:14
  out
• 17:14
  on
• 17:14
  the
• 17:14
  receptor
• 17:15
  profiles,
• 17:15
  the
• 17:16
  affinities.
• 17:16
  Know
• 17:17
  what
• 17:17
  the
• 17:18
  difference
• 17:18
  is
• 17:18
  between
• 17:19
  a
• 17:19
  Risperidol
• 17:20
  and
• 17:20
  an
• 17:20
  Abilify.
• 17:21
  How
• 17:22
  does
• 17:22
  Abilify
• 17:22
  act
• 17:23
  differently
• 17:23
  than
• 17:23
  Risperidol?
• 17:24
  And
• 17:24
  what
• 17:24
  brain
• 17:25
  circuits?
• 17:25
  What
• 17:25
  happens
• 17:26
  when
• 17:26
  we
• 17:27
  partially
• 17:27
  agonize
• 17:28
  that
• 17:28
  brain
• 17:29
  circuit
• 17:29
  versus
• 17:30
  antagonize
• 17:31
  this
• 17:31
  other
• 17:32
  brain
• 17:32
  circuit?
• 17:32
  So
• 17:33
  having
• 17:33
  an
• 17:33
  appreciation
• 17:34
  for
• 17:34
  these
• 17:34
  receptors
• 17:35
  is
• 17:35
  very
• 17:36
  important.
• 17:36
  And
• 17:36
  again,
• 17:37
  I
• 17:37
  think
• 17:37
  it's
• 17:37
  very
• 17:37
  fun
• 17:38
  because
• 17:38
  it
• 17:38
  allows
• 17:39
  you
• 17:39
  to
• 17:40
  understand
• 17:40
  what
• 17:40
  you're
• 17:40
  doing
• 17:41
  on
• 17:41
  a
• 17:41
  more
• 17:41
  granular
• 17:42
  level
• 17:42
  and
• 17:43
  get
• 17:43
  it
• 17:43
  done
• 17:43
  for
• 17:43
  your
• 17:44
  patient.
• 17:44
  There
• 17:45
  might
• 17:45
  be
• 17:45
  a
• 17:45
  new
• 17:45
  medication
• 17:46
  that
• 17:46
  comes
• 17:46
  out
• 17:47
  in
• 17:47
  five
• 17:48
  years
• 17:48
  that
• 17:48
  acts
• 17:49
  on
• 17:49
  a
• 17:49
  completely
• 17:50
  different
• 17:50
  receptor.
• 17:50
  And
• 17:51
  it
• 17:51
  might
• 17:51
  be
• 17:51
  very
• 17:51
  important
• 17:52
  for
• 17:52
  you
• 17:52
  to
• 17:53
  appreciate
• 17:53
  the
• 17:53
  fact
• 17:54
  that,
• 17:54
  oh,
• 17:54
  wow,
• 17:55
  great,
• 17:55
  this
• 17:55
  new
• 17:56
  antipsychotic
• 17:57
  doesn't
• 17:57
  antagonize
• 17:58
  histamine
• 17:58
  it
• 17:59
  doesn't
• 17:59
  antagonize
• 18:00
  the
• 18:00
  muscarinic
• 18:00
  receptor
• 18:01
  or
• 18:01
  5ht2c.
• 18:02
  Wonderful.
• 18:03
  Or
• 18:04
  maybe
• 18:04
  it
• 18:04
  acts
• 18:04
  as
• 18:05
  a
• 18:05
  partial
• 18:05
  agonist
• 18:06
  on
• 18:06
  2C,
• 18:07
  so
• 18:07
  it
• 18:07
  doesn't
• 18:07
  totally
• 18:08
  antagonize
• 18:08
  it.
• 18:08
  Therefore
• 18:09
  the
• 18:09
  weight
• 18:09
  gain's
• 18:09
  not
• 18:10
  as
• 18:10
  bad.
• 18:10
  Well,
• 18:10
  hey,
• 18:10
  that's
• 18:10
  great.
• 18:11
  That's
• 18:11
  so
• 18:12
  much
• 18:12
  better.
• 18:12
  We
• 18:12
  need
• 18:12
  that
• 18:13
  because
• 18:13
  last
• 18:13
  time
• 18:13
  I
• 18:14
  prescribed
• 18:14
  a
• 18:15
  5ht
• 18:15
  2c
• 18:16
  antagonist,
• 18:17
  my
• 18:17
  patient
• 18:18
  really
• 18:18
  ballooned
• 18:19
  up
• 18:19
  and
• 18:19
  his
• 18:20
  cholesterol
• 18:20
  went
• 18:20
  to
• 18:20
  600.
• 18:21
  Right.
• 18:22
  So
• 18:22
  we've
• 18:22
  got
• 18:22
  to
• 18:22
  really
• 18:24
  know
• 18:24
  this
• 18:24
  stuff
• 18:25
  because
• 18:25
  the
• 18:25
  devil's
• 18:26
  in
• 18:26
  the
• 18:26
  details.
• 18:26
  And
• 18:27
  if
• 18:27
  you
• 18:27
  don't
• 18:27
  really
• 18:27
  know
• 18:28
  the
• 18:28
  receptors,
• 18:29
  it's
• 18:29
  hard
• 18:29
  to
• 18:30
  appreciate
• 18:30
  why
• 18:31
  we
• 18:31
  make
• 18:31
  these
• 18:31
  changes
• 18:32
  in
• 18:32
  the
• 18:32
  first
• 18:33
  place.
• 18:33
  Right.
• 18:34
  So
• 18:35
  that's
• 18:35
  super
• 18:35
  important,
• 18:36
  to
• 18:36
  say
• 18:37
  nothing
• 18:37
  of
• 18:38
  the
• 18:38
  good
• 18:38
  things
• 18:39
  that
• 18:39
  5ht
• 18:40
  or,
• 18:40
  excuse
• 18:41
  me,
• 18:41
  that
• 18:41
  an
• 18:41
  H1
• 18:41
  blockade
• 18:42
  would
• 18:42
  do,
• 18:42
  which
• 18:43
  allows
• 18:43
  your
• 18:43
  patient
• 18:43
  to
• 18:43
  get
• 18:44
  a
• 18:44
  little
• 18:44
  more
• 18:44
  sedated.
• 18:45
  There's
• 18:45
  psychosis
• 18:46
  that
• 18:47
  happens
• 18:47
  when
• 18:47
  people
• 18:48
  really
• 18:48
  need
• 18:48
  to
• 18:48
  sleep,
• 18:49
  too.
• 18:49
  And
• 18:49
  so
• 18:49
  that
• 18:50
  histamine
• 18:51
  antagonism
• 18:51
  is
• 18:52
  a
• 18:52
  welcome
• 18:52
  thing,
• 18:53
  but
• 18:53
  again,
• 18:54
  trade
• 18:54
  offs.
• 18:55
  Right?
• 18:55
  You
• 18:55
  get
• 18:55
  hungry
• 18:56
  and
• 18:56
  it
• 18:57
  messes
• 18:57
  with
• 18:57
  your
• 18:57
  satiety
• 18:58
  signaling.
• 18:59
  So
• 18:59
  those
• 18:59
  were
• 18:59
  three
• 19:00
  roads
• 19:01
  to
• 19:01
  weight
• 19:01
  gain,
• 19:02
  all
• 19:02
  different
• 19:02
  receptors.
• 19:04
  And
• 19:04
  there's
• 19:04
  more
• 19:05
  of
• 19:05
  them
• 19:05
  out
• 19:05
  there,
• 19:05
  but
• 19:05
  those
• 19:06
  are,
• 19:06
  I
• 19:06
  think,
• 19:06
  the
• 19:06
  three
• 19:07
  biggest
• 19:07
  offenders
• 19:08
  that
• 19:08
  you
• 19:09
  tend
• 19:09
  to
• 19:09
  come
• 19:09
  across
• 19:10
  in
• 19:10
  psychiatry.
• 19:11
  This
• 19:12
  is
• 19:12
  why
• 19:12
  we
• 19:12
  need
• 19:12
  to
• 19:12
  check
• 19:13
  a
• 19:13
  1C
• 19:14
  and
• 19:15
  lipid
• 19:15
  panel
• 19:15
  levels
• 19:16
  very
• 19:16
  frequently.
• 19:17
  Definitely
• 19:17
  at
• 19:17
  baseline
• 19:18
  and
• 19:19
  thereafter
• 19:19
  regularly.
• 19:20
  We
• 19:20
  don't
• 19:21
  want
• 19:21
  to
• 19:21
  wait
• 19:21
  for
• 19:22
  our
• 19:22
  patients
• 19:22
  to
• 19:22
  get
• 19:23
  30,
• 19:23
  40
• 19:23
  pounds
• 19:23
  heavier.
• 19:24
  And
• 19:24
  we
• 19:24
  didn't
• 19:24
  do
• 19:24
  anything.
• 19:25
  That's
• 19:25
  a.
• 19:25
  That's
• 19:26
  malpractice.
• 19:26
  That's
• 19:26
  bad.
• 19:27
  We
• 19:27
  don't
• 19:27
  want
• 19:27
  that.
• 19:28
  We
• 19:28
  want
• 19:28
  to
• 19:28
  have
• 19:29
  these
• 19:29
  conversations
• 19:30
  and
• 19:30
  figure
• 19:30
  this
• 19:31
  out
• 19:31
  beforehand.
• 19:32
  And
• 19:32
  so
• 19:33
  I
• 19:33
  hope
• 19:33
  you
• 19:33
  have
• 19:33
  an
• 19:33
  appreciation
• 19:34
  for
• 19:34
  these.
• 19:35
  Get
• 19:36
  out
• 19:36
  a
• 19:36
  spreadsheet
• 19:37
  and,
• 19:37
  you
• 19:37
  know,
• 19:37
  pick
• 19:38
  out
• 19:38
  respiratory,
• 19:39
  pick
• 19:39
  out
• 19:39
  Seroquel,
• 19:40
  pick
• 19:40
  out
• 19:40
  Zyprexa,
• 19:41
  and,
• 19:42
  you
• 19:42
  know,
• 19:42
  pick
• 19:42
  out
• 19:42
  Haldol
• 19:43
  if
• 19:43
  you
• 19:43
  want,
• 19:44
  and
• 19:44
  figure
• 19:44
  out
• 19:44
  the
• 19:45
  affinities
• 19:46
  for
• 19:46
  these
• 19:46
  various
• 19:47
  receptors.
• 19:47
  And
• 19:48
  it'll
• 19:48
  be
• 19:48
  very
• 19:48
  interesting
• 19:49
  to
• 19:50
  figure
• 19:50
  out
• 19:50
  the
• 19:50
  details
• 19:51
  and
• 19:51
  the
• 19:51
  nuances
• 19:52
  because
• 19:52
  you
• 19:53
  don't
• 19:53
  want
• 19:53
  to
• 19:53
  be
• 19:53
  that
• 19:53
  new
• 19:54
  grad,
• 19:54
  my
• 19:54
  friends,
• 19:55
  that
• 19:56
  stares
• 19:56
  a
• 19:56
  patient
• 19:56
  in
• 19:56
  the
• 19:56
  eye
• 19:56
  and
• 19:57
  goes,
• 19:57
  you
• 19:57
  know
• 19:57
  what?
• 19:57
  I'm
• 19:57
  sorry,
• 19:58
  Zyprexa
• 19:58
  is
• 19:59
  not
• 19:59
  working
• 19:59
  for
• 19:59
  you.
• 19:59
  Let's
• 20:00
  just
• 20:00
  switch
• 20:00
  to
• 20:00
  Risperidol.
• 20:01
  And
• 20:01
  you're
• 20:02
  just
• 20:02
  following
• 20:02
  some
• 20:02
  algorithm
• 20:03
  that
• 20:03
  you
• 20:03
  think
• 20:03
  switching
• 20:04
  the
• 20:04
  antipsychotic
• 20:05
  is
• 20:05
  what
• 20:05
  you're
• 20:06
  supposed
• 20:06
  to
• 20:06
  do,
• 20:06
  but
• 20:07
  you
• 20:07
  don't
• 20:07
  really
• 20:07
  know
• 20:07
  why
• 20:08
  you're
• 20:08
  doing
• 20:08
  it.
• 20:09
  That's
• 20:09
  disempowering.
• 20:10
  Right.
• 20:10
  There's
• 20:11
  Something
• 20:11
  just
• 20:12
  sad
• 20:12
  about
• 20:12
  that.
• 20:12
  You
• 20:13
  want
• 20:13
  to
• 20:13
  know
• 20:13
  why
• 20:13
  you're
• 20:14
  doing
• 20:14
  it.
• 20:14
  That's
• 20:14
  what
• 20:14
  separates
• 20:15
  you
• 20:15
  from
• 20:16
  the
• 20:16
  layman.
• 20:16
  You
• 20:16
  want
• 20:17
  to
• 20:17
  be
• 20:17
  a
• 20:17
  subject
• 20:17
  matter
• 20:18
  expert.
• 20:18
  You
• 20:18
  want
• 20:18
  to
• 20:18
  have
• 20:18
  an
• 20:19
  understanding
• 20:19
  of
• 20:19
  this.
• 20:20
  Maybe
• 20:20
  not
• 20:21
  down
• 20:21
  to
• 20:21
  the
• 20:21
  molecular
• 20:22
  nitty
• 20:22
  gritty,
• 20:23
  but
• 20:23
  it's
• 20:23
  not
• 20:24
  enough
• 20:24
  to
• 20:24
  be.
• 20:24
  Well,
• 20:24
  we're
• 20:25
  just
• 20:25
  going
• 20:25
  to
• 20:25
  start
• 20:25
  you
• 20:25
  on
• 20:25
  Risperdal,
• 20:26
  okay?
• 20:27
  Why?
• 20:27
  What
• 20:28
  can
• 20:28
  I
• 20:28
  expect
• 20:29
  from
• 20:29
  respiratory
• 20:30
  that's
• 20:30
  different
• 20:30
  than
• 20:31
  Zyprexa?
• 20:32
  And
• 20:33
  now
• 20:33
  that
• 20:33
  you
• 20:33
  understand
• 20:34
  which
• 20:35
  receptors
• 20:35
  are
• 20:35
  implicated
• 20:36
  in
• 20:36
  weight
• 20:36
  gain,
• 20:37
  you
• 20:37
  can
• 20:37
  have
• 20:37
  a
• 20:38
  richer
• 20:38
  conversation
• 20:39
  with
• 20:39
  your
• 20:39
  patient.
• 20:40
  And
• 20:40
  you
• 20:40
  don't
• 20:41
  have
• 20:41
  to
• 20:41
  get
• 20:41
  them
• 20:41
  in
• 20:41
  the
• 20:41
  receptor
• 20:42
  nitty
• 20:42
  gritty
• 20:42
  conversation.
• 20:43
  But
• 20:43
  you
• 20:44
  can
• 20:45
  explain
• 20:45
  to
• 20:45
  them
• 20:46
  that
• 20:47
  these
• 20:47
  medications
• 20:48
  have
• 20:48
  different
• 20:50
  here,
• 20:51
  you
• 20:51
  can
• 20:51
  explain
• 20:52
  to
• 20:52
  them
• 20:52
  that
• 20:53
  you
• 20:54
  know
• 20:54
  these.
• 20:54
  Each
• 20:54
  of
• 20:55
  these
• 20:55
  medications
• 20:56
  unlocks
• 20:56
  different
• 20:57
  doors
• 20:57
  that
• 20:57
  lead
• 20:58
  to
• 20:58
  different
• 20:58
  side
• 20:58
  effects,
• 20:59
  some
• 20:59
  of
• 20:59
  which
• 20:59
  can
• 20:59
  be
• 21:00
  in
• 21:00
  your
• 21:00
  favor,
• 21:00
  some
• 21:00
  of
• 21:01
  which
• 21:01
  won't
• 21:01
  be.
• 21:01
  And
• 21:02
  we
• 21:02
  want
• 21:02
  to
• 21:02
  gravitate
• 21:03
  towards
• 21:03
  a
• 21:03
  medication
• 21:04
  that
• 21:04
  still
• 21:05
  controls
• 21:05
  some
• 21:06
  of
• 21:06
  your
• 21:06
  bizarre
• 21:06
  thoughts
• 21:07
  and
• 21:07
  your
• 21:07
  dark
• 21:08
  or
• 21:08
  distressing
• 21:08
  thoughts,
• 21:09
  but
• 21:09
  manages
• 21:10
  these
• 21:10
  side
• 21:10
  effects
• 21:11
  that
• 21:11
  are
• 21:11
  bothering
• 21:11
  you
• 21:12
  right
• 21:12
  now.
• 21:12
  Bing.
• 21:13
  That's
• 21:13
  what
• 21:13
  you
• 21:13
  want
• 21:14
  anyway.
• 21:14
  We
• 21:15
  appreciate
• 21:15
  each
• 21:15
  and
• 21:15
  every
• 21:16
  one
• 21:16
  of
• 21:16
  you,
• 21:17
  and
• 21:17
  I
• 21:17
  highly
• 21:17
  encourage
• 21:18
  all
• 21:18
  of
• 21:18
  you
• 21:18
  to
• 21:18
  become
• 21:18
  Patreon
• 21:19
  members.
• 21:20
  Go
• 21:20
  in
• 21:20
  the
• 21:20
  show
• 21:21
  notes,
• 21:21
  become
• 21:21
  a
• 21:22
  Patreon
• 21:22
  member.
• 21:22
  You
• 21:22
  can
• 21:22
  become
• 21:23
  a
• 21:23
  free
• 21:23
  member
• 21:23
  and
• 21:23
  message
• 21:24
  me
• 21:24
  episode
• 21:25
  ideas
• 21:25
  you'd
• 21:25
  like
• 21:25
  to
• 21:26
  go
• 21:26
  over
• 21:26
  or
• 21:27
  questions
• 21:27
  you
• 21:27
  have.
• 21:27
  But
• 21:28
  you
• 21:28
  could
• 21:28
  be
• 21:28
  a
• 21:28
  paid
• 21:28
  member.
• 21:29
  5
• 21:29
  bucks
• 21:30
  a
• 21:30
  month
• 21:30
  or
• 21:30
  so,
• 21:31
  and
• 21:31
  you
• 21:31
  will
• 21:31
  have
• 21:32
  slide
• 21:32
  decks
• 21:32
  full
• 21:33
  of
• 21:33
  rich
• 21:33
  clinical
• 21:34
  pearls
• 21:34
  to
• 21:35
  empower
• 21:35
  you
• 21:35
  in
• 21:35
  your
• 21:36
  practice,
• 21:36
  to
• 21:36
  empower
• 21:37
  you
• 21:37
  to
• 21:37
  pass
• 21:37
  your
• 21:38
  boards.
• 21:38
  It's
• 21:38
  well
• 21:38
  worth
• 21:38
  it.
• 21:39
  We
• 21:39
  even
• 21:39
  drop
• 21:40
  episodes
• 21:40
  earlier
• 21:41
  if
• 21:41
  you're
• 21:41
  a
• 21:41
  Patreon
• 21:42
  member,
• 21:42
  so
• 21:42
  you
• 21:42
  see
• 21:42
  episodes
• 21:43
  even
• 21:43
  earlier
• 21:44
  and
• 21:44
  you
• 21:44
  get
• 21:44
  new
• 21:45
  episodes
• 21:45
  that
• 21:45
  are
• 21:45
  not
• 21:46
  even
• 21:46
  accessible
• 21:46
  to
• 21:47
  non
• 21:47
  Patreon
• 21:47
  members,
• 21:48
  where
• 21:48
  you
• 21:48
  can
• 21:49
  do
• 21:49
  deep
• 21:50
  dives
• 21:50
  on
• 21:50
  really
• 21:51
  cool
• 21:51
  things
• 21:51
  that
• 21:51
  help
• 21:52
  you
• 21:52
  pass
• 21:53
  your
• 21:53
  boards.
• 21:54
  Very
• 21:54
  fun.
• 21:54
  I
• 21:55
  highly
• 21:55
  recommend
• 21:55
  all
• 21:56
  the
• 21:56
  knowledge
• 21:56
  that
• 21:56
  comes
• 21:56
  with
• 21:57
  being
• 21:57
  a
• 21:57
  Patreon
• 21:57
  member.
• 21:58
  And
• 21:58
  if
• 21:58
  nothing
• 21:58
  else,
• 21:59
  my
• 21:59
  friends,
• 22:00
  take
• 22:00
  three
• 22:01
  minutes
• 22:01
  out
• 22:01
  of
• 22:01
  your
• 22:01
  day.
• 22:02
  Jump
• 22:02
  on
• 22:02
  Apple
• 22:02
  Podcasts.
• 22:03
  Give
• 22:03
  us
• 22:03
  five
• 22:03
  stars.
• 22:04
  Write
• 22:04
  a
• 22:04
  little
• 22:04
  comment
• 22:05
  that
• 22:05
  helps
• 22:05
  us
• 22:05
  a
• 22:06
  lot
• 22:06
  as
• 22:06
  well.
• 22:07
  We
• 22:07
  really
• 22:07
  wish
• 22:08
  the
• 22:08
  best
• 22:09
  for
• 22:09
  each
• 22:09
  and
• 22:09
  every
• 22:09
  one
• 22:09
  of
• 22:10
  you.
• 22:10
  This
• 22:10
  podcast
• 22:10
  has
• 22:11
  gotten
• 22:11
  really
• 22:11
  big,
• 22:11
  really
• 22:12
  quick,
• 22:12
  and
• 22:13
  we
• 22:13
  appreciate
• 22:13
  the
• 22:13
  love
• 22:14
  and
• 22:14
  support.
• 22:15
  Let's
• 22:15
  make
• 22:15
  our
• 22:15
  Patreon
• 22:16
  membership
• 22:17
  again
• 22:17
  free
• 22:17
  or
• 22:18
  not
• 22:18
  free
• 22:18
  don't
• 22:18
  matter.
• 22:19
  But
• 22:19
  it's
• 22:19
  great
• 22:19
  to
• 22:20
  have
• 22:20
  a
• 22:20
  community
• 22:20
  and
• 22:20
  we
• 22:21
  can
• 22:21
  really
• 22:21
  put
• 22:21
  our
• 22:22
  analogies
• 22:22
  together
• 22:23
  as
• 22:23
  a.
• 22:23
  As
• 22:23
  a
• 22:23
  little
• 22:24
  community
• 22:24
  where
• 22:25
  we
• 22:25
  can
• 22:25
  make
• 22:26
  all
• 22:26
  these
• 22:26
  receptors
• 22:26
  make
• 22:27
  sense.
• 22:27
  I'm
• 22:27
  very
• 22:28
  interested
• 22:28
  in
• 22:28
  hearing
• 22:29
  how
• 22:29
  you
• 22:29
  guys
• 22:29
  conceive
• 22:30
  of
• 22:30
  these
• 22:31
  receptors
• 22:32
  and
• 22:32
  these
• 22:33
  neurotransmitters
• 22:34
  and
• 22:34
  these
• 22:34
  medications,
• 22:35
  Right?
• 22:35
  Let's
• 22:35
  think
• 22:36
  of
• 22:36
  creative
• 22:36
  ways
• 22:37
  to
• 22:37
  make
• 22:37
  this
• 22:38
  stick
• 22:38
  even
• 22:38
  more
• 22:39
  and
• 22:39
  build
• 22:40
  that
• 22:40
  community.
• 22:40
  And
• 22:40
  gather
• 22:41
  pearls.
• 22:41
  Remember,
• 22:42
  every
• 22:42
  time
• 22:42
  we
• 22:42
  get
• 22:42
  a
• 22:43
  pearl,
• 22:43
  every
• 22:43
  time
• 22:43
  we
• 22:44
  come
• 22:44
  across
• 22:45
  some
• 22:46
  newfound
• 22:46
  knowledge,
• 22:46
  even
• 22:47
  if
• 22:47
  it's
• 22:47
  one
• 22:47
  little
• 22:48
  pearl,
• 22:48
  that
• 22:49
  can
• 22:49
  mean
• 22:49
  all
• 22:49
  the
• 22:49
  difference
• 22:50
  in
• 22:50
  a
• 22:50
  patient's
• 22:50
  life.
• 22:51
  And
• 22:51
  that's
• 22:52
  why
• 22:52
  we
• 22:52
  do
• 22:52
  this.
• 22:52
  We
• 22:52
  don't
• 22:53
  just
• 22:53
  do
• 22:53
  this
• 22:53
  to
• 22:53
  pass
• 22:53
  the
• 22:54
  boards.
• 22:54
  We
• 22:54
  don't
• 22:54
  just
• 22:54
  do
• 22:55
  this
• 22:55
  for
• 22:55
  self
• 22:56
  gratification
• 22:57
  or
• 22:57
  to
• 22:57
  graduate
• 22:58
  summa
• 22:58
  cum
• 22:58
  laude
• 22:59
  or
• 22:59
  something.
• 22:59
  No,
• 23:00
  we
• 23:00
  do
• 23:00
  this
• 23:00
  because
• 23:01
  every
• 23:01
  little
• 23:01
  pearl
• 23:01
  we
• 23:02
  learn
• 23:02
  could
• 23:02
  potentially
• 23:03
  change
• 23:03
  somebody's
• 23:03
  life
• 23:04
  for
• 23:04
  the
• 23:04
  better
• 23:04
  or
• 23:05
  make
• 23:05
  their
• 23:05
  day
• 23:05
  a
• 23:05
  little
• 23:06
  easier
• 23:06
  and
• 23:06
  richer.
• 23:07
  That's
• 23:07
  what
• 23:07
  we
• 23:07
  do
• 23:08
  this
• 23:08
  for,
• 23:08
  my
• 23:08
  friends.
• 23:09
  Join
• 23:09
  Patreon.
• 23:11
  We
• 23:11
  will
• 23:11
  catch
• 23:12
  you
• 23:12
  next
• 23:12
  time,
• 23:12
  my
• 23:12
  friends,
• 23:13
  right
• 23:13
  here
• 23:13
  on
• 23:13
  Pearls
• 23:14
  and
• 23:14
  Prep.