Antibiotics Simplified

It might take a bit more than a minute, but we have created a powerpoint presentation that walks through most antibiotics and helps you see how one relates to another. This is a free resource for you called Antibiotics Oversimplified. This oversimplified approach is not good enough to make therapeutic decisions from, but what is does do, is organize these drugs according to class and type of antimicrobial activity. Of course, for patient care, you should use a local antibiogram or at very least, a Sanford or Johns Hopkins Antibiotic guide. The purpose of this one minute genius is to help you mentally structure your understanding of antibiotics, bacteria and therapeutic uses.

Warfarin Maintenance Dose Adjustments

Simple guidelines

Note: these are for maintenance doses only at steady state. Do NOT use these guidelines for starting someone on warfarin.

INR Dosage Adjustment
Less Than 1.3 Give them an extra dose and increase by 10% (always ask them if they “might” have missed a dose)
1.3 to 1.8 Increase weekly dose by 7 – 8% (always ask them if they “might” have missed a dose
1.8 – 2.0 Repeat the INR in one week, if still <2.0 than increase by 7%
2.0 t0 3.0 Smile
3.0 to 3.5 Check for patient errors in the dose first, then repeat the INR in 2 or 3 days. IF still elevated, decrease by 7% – 8%
3.5 to 4.5 Decrease by 7% – 8% (check for patient errors in the dose first)
Over 4.5 Hold the dose for one or two days and restart at a 10 – 20% lower weekly dose

Vitamin K

Often it is NOT necessary to give vitamin K. If you want to keep the patient anticoagulated, and you cannot stop yourself from giving vitamin K 🙂 … then give only 2.5 mg of phytonadione orally.

Do not give 10mg of vitamin K unless it is OK for the patient to NOT be anticoagulated for one or two weeks.

Obviously, you will usually give Vitamin K if the patient is bleeding.

Number Needed to Treat

Definition:The Number Needed to treat is the number of patients that you would need to treat to prevent one primary outcome (heart attack, death, stroke, whatever)

  • This applies to patients: with the same problem studied
  • treated for the same duration as the study
  • Calculation:

    • First calculate the Absolute Risk Reduction (ARR)
    • Then take the ARR in decimal form (e.g. .05 for 5%) and divide it INTO 1. (1/ ARR = NNT)
    • Example:
      – 8% stroke rate with A. Fib decreased to 3% with Coumadin
      – Absolute risk reduction of 5%
      – NNT = 1 / ARR or 1/.05 = 20
      Therefore you need to treat 20 A. Fib patients for one year with warfarin to prevent one stroke.

      Number Needed to Harm (NNH): this is the same concept as the Number Needed to Treat except that you use:
            Incidence of Adverse Effect MINUS Incidence in the Placebo Group = Absolute Risk Increase

      The calculation is then the same using Absolute Risk Increase instead of ARR.

      – Incidence of gynecomastia is almost zero with placebo
      – Incidence of gynecomastia is 10% with spironolactone
      – Therefore: Absolute increase in risk is 10% – 0% = 10%
      – 1 / 0.10 = 10 = NNH You need to treat 10 patients with spironolactone to cause one case of gynecomastia.

Absolute vs Relative Risk Reduction

Albert and I developed an acute interest in risk reduction at about 3500 feet.


Example 1A:

  • Consider the benefit of using Coumadin for Stroke prevention in Atrial Fibrillation. Moderate risk patients on placebo have 8% risk of stroke in ONE year
  • Coumadin decreases that to 3% risk of stroke in ONE year
  • Quick !! Instinctively, what is the risk reduction? ….. 5% , right? That’s absolute risk reduction, NOT relative to anything else.

    Relative Risk Reduction is RELATIVE to the baseline 8% so… 0.05/0.08 or 5% reduction /8% baseline = .62 or 62% relative risk reduction

    Example 1B:
    OK, now consider if there was a very high baseline risk of 93%

    • Suppose Coumadin decreased the risk to 88%
    • Quick !! The absolute reduction is? …. You’re right! 5% (the same as the first example)
    • The relative risk though is different. 5 / 93 = 5.3% relative risk reduction

    So which is the most important? Absolute reduction or Relative reduction. Well, they each give you different kinds of information. I prefer the absolute risk reduction, but both are important. See also the Number Needed To Treat

Thyroid Pharmacotherapy

Normal Thyroid Physiology

Thyroid stimulation and feedback

Laboratory Tests for Thyroid

Total T4 Free T4 Total T3 TSH

4.5 – 12.5 mcg/dl

0.8 –  1.5 ng / dl

80 – 220 ng/dl

0.3 – µU /  mL



Thyroid Clinical Pearls

  • Normal levothyroxine dose is 1.6 mcg/kg/ day
  • Some people may benefit symptomatically from addition of 50mcg of T3 to levothyroxine
  • Normal TSH should probably not be above 3.5 Treated
  • Untreated TSH should be between 0.5 to 3.8 mU/L
  • 100 and 300 mcg tabs have yellow dye #5 and have allergic potential

Amidarone induced hypothyroidism: 2 mechanisms :

  • Thyroiditis: use a steroid
  • Iodine induced: use Synthroid

Subclinical hyperthyroidism consequences:

  • Osteoporosis mostly in post-menopausal women
  • A. Fib. 3 fold increase in risk
  • Increase LV mass (diastolic dysfunction)

Alligation Alternate

alligation alternate graphic A common problem encountered in pharmacy is how to combine creams or liquids of different strengths to obtain a new strength. We have prepared a powerpoint demonstrating the Alligation Alternate method, a simple way to solve these problems

You will see that this method takes a relatively complex algebraic formula and makes it simple by employing a crossover grid.

Evils of Pickle Eating-101

Pickles are associated with all the major diseases of the body. Eating them breeds war and Communism. They can be related to most airline tragedies. Auto accidents are caused by pickles. There exists a positive relationship between crime waves and consumption of this fruit of the cucurbit family. For example …

Nearly all sick people have eaten pickles. The effects are obviously cumulative.

  • 99.9% of all people who die from cancer have eaten pickles.
  • 100% of all soldiers have eaten pickles.
  • 96.8% of all Communist sympathizers have eaten pickles
  • 99.7% of the people involved in air and auto accidents ate pickles within 14 days preceding the accident.
  • 93.1% of juvenile delinquents come from homes where pickles are served frequently.

Evidence points to the long term effects of pickle eating.
Of the people born in 1839 who later dined on pickles, there has been a 100% mortality.

  • All pickle eaters born between 1849 and 1859 have wrinkled skin, have lost most of their teeth, have brittle bones and failing eyesight if the ills of pickle eating have not already caused their death.
  • Even more convincing is the report of a noted team of medical specialists: rats force fed with 20 pounds of pickles per day for 30 days developed bulging abdomens. Their appetites for WHOLESOME FOOD were destroyed.

In spite of all the evidence, pickle growers and packers continue to spread their evil. More than 120,000 acres of fertile U.S. soil are devoted to growing pickles. Our per capita consumption is nearly four pounds.
Eat orchid petal soup. Practically no one has as many problems from eating orchid petal soup as they do with eating pickles.

SOURCE: “Evils of Pickle Eating,” by Everett D. Edington, originally printed in Cyanograms.