These are bits of information and research regarding pharmaceutical medications that are relevant. This post includes the following sections:
MEDICATION TERMS
PRN means "take as needed"
GENERAL DRUG INFO:
Medications that Older Adults Should Avoid or use with Caution
from the site Medications & Older Adults
What Should You Do If Your Medication Isn’t Covered by Insurance? 4 Tips and Tactics
How does your body process medicine? - Céline Valéry (TED ed talk)
The Placebo Phenomenon: An ingenious researcher finds the real ingredients of “fake” medicine.
Why Stimulant Medication Helps ADHD
Medications and other compounds that contain sulfur
How Doctors Accidentally Discovered Psychiatric Drugs
Why grapefruit isn’t a great fruit when you’re taking some medications
"The problem is that grapefruits are rich in furanocoumarins, organic
compounds that block an enzyme produced by the liver and intestines to
break down certain medications in the body. Without this enzymatic
activity, levels of these medications can grow to harmful, even toxic,
levels."
There is a very long list of medications
that are affected this way. One whole grapefruit (or 200ml juice) is
enough to increase drug concentration in the blood and therefore
increase side effects of the drug. Pomellos, seville oranges, and limes
also contain furanocoumarins. If they are consumed 4 hours before meds
are taken they have the strongest effect, 10 hours after meds the
effect is 50%, and 24 hours after the effect is down to 25%.
Clinical equivalence of generic and brand-name drugs used in cardiovascular disease: a systematic review and meta-analysis
GENERAL DRUG TOXICITY and SIDE EFFECTS:
What Americans Don’t Know About Their Medications (The Atlantic)
This article has information about under-reported side effects that many prescription drugs have.
What Americans Don’t Know About Their Medications (The Atlantic)
This article has information about under-reported side effects that many prescription drugs have.
LiverTox - Clinical and research information on drug-induced liver injury (page on NIH website).
Drugs for the Treatment of Parkinson's Disease
The Worst Side Effect You've Never Heard Of: common drugs can trigger rare and sometimes deadly Stevens-Johnson Syndrome
"Zenkner, now 20, was a victim of one of the most frightening drug side effects you've likely never heard of: Stevens-Johnson Syndrome (SJS), a rare but devastating condition where the top layer of skin and mucous membranes, such as those covering the eyes and lips, blisters and peels off in waves. It can even affect the internal organs like the lungs. Some patients go blind. Some wind up with severe scarring. Some patients die."
(this information is from a video made by Dr Sam Bailey)
Drugs for the Treatment of Parkinson's Disease
The Worst Side Effect You've Never Heard Of: common drugs can trigger rare and sometimes deadly Stevens-Johnson Syndrome
"Zenkner, now 20, was a victim of one of the most frightening drug side effects you've likely never heard of: Stevens-Johnson Syndrome (SJS), a rare but devastating condition where the top layer of skin and mucous membranes, such as those covering the eyes and lips, blisters and peels off in waves. It can even affect the internal organs like the lungs. Some patients go blind. Some wind up with severe scarring. Some patients die."
Ototoxic medicines
Ototoxicity refers to toxic injury to the ears. Many drugs are
ototoxic, and tinnitus is often the first symptom to appear when damage
to the ears is occurring. These drugs include certain antibiotics including gentamycin, amikacin, neomycin, kanamycin, netilmicin, streptomycin, tobramycin, azithromycin, clarithromycin, erythromycin, and vancomycin. Antimalarial drugs including chloroquine, mefloquine, and quinine. Some chemotherapy medications such as carboplatin, cisplatin, and cyclophosphamide. Some diuretics including bumetanide, ethacrynic acid, furosemide, and torasemide. And lastly non-steroidal analgesics including acetaminophen (paracetamol), aspirin (high doses), ibuprofen, indomethacin, and salicylates.(this information is from a video made by Dr Sam Bailey)
Medications that increase the risk of blood clots
Oral contraceptives (birth control pills), especially if they contain estrogen, increase the risk of DVTs (deep vein thrombosis) and pulmonary embolism (blood clot in the lungs).
Hormone Replacement Therapy (HRT), especially if they contain estrogen, lead to increased risk of blood clots.
Anti-depressants many different classes including SSRIs (selective serotonin reuptake inhibitors) and tricyclic antidepressants are associated with increased rates of blood clots. It's not known why, but platelets contain a significant amount of serotonin so this is one hypothesis as to why the association exists. Another hypothesis is that the risk may be associated with the weight gain and decreased exercise that many people experience as side effects of these meds.
Anti-psychotic medications such as clozapine have been shown to increase the risk of clots.
Any medication that leads to decreased mobility, which is relevant to many different medications. These include benzodiazepines, muscle relaxants, and sedatives. Movement is important for blood flow, so anything that interferes with it decreases blood flow. DVTs tend to form in the legs so anything that leads to less walking will have this effect.
Chemotherapy agents some, such as tamoxifen and thalidamide are associated with increased risks of blood clots.
Symptoms of blood clots- edema (swelling) in the leg can be a sign, especially if there is more swelling in one leg than the other. The symptoms of a pulmonary embolism include shortness of breath, chest pain, palpitations, and dizziness.
NOTES BY DRUG CLASSES:
Allergy medications (see my post about them here)
Antidepressants
Antidepressant Drugs Effects on Blood Pressure
"Individuals suffering from depressive disorders display a greater incidence of hypertension compared with the general population, despite reports of the association between depression and hypotension. This phenomenon may depend, at least in part, on the use of antidepressant drugs, which may influence blood pressure through different effects on adrenergic and serotoninergic pathways, as well as on histaminergic, dopaminergic, and cholinergic systems. This review summarizes extant literature on the effect of antidepressant drugs on blood pressure." This is a very thorough review.
Serotonin Syndrome (aka "Serotonin Storm" or "Serotonin Toxicity") can occur when a medication (or combination of meds) is given that causes a person's serotonin level to become too high. This can be a chronic or acute state, and the symptoms vary from mild to fatal, depending on the cause or source of the excessive serotonin as well as the individual's genetic makeup (loss of function mutations in the enzymes that break down excessive serotonin, such as COMT and MAO, can make people more prone to develop Serotonin Toxicity). Symptoms can range from mild (such as feeling too hot, diarrhea, nausea) to fatal (from seizures, cardiac events, or coma).
Brain Zaps and Antidepressants - Why Do they Happen?
Why do you gain weight with antidepressants and mood stabilizers?
While the actual cause of weight gain from antidepressant medications is not fully understood (including SSRIs and some anti-psychotics), in this video two proposed mechanisms are presented that seem likely. The first is that SSRIs block certain histamine receptors on brain cells (H1) that allow the brain to register "satiety", which is the feeling of being full that indicates that it's time to stop eating. This results in people overeating and gaining weight that way. The other mechanism involves some anti-psychotic medications that are used for mood stabilization. These meds block the 5HT2c receptor (one of the receptors for serotonin) that is involved in regulating the cell's production of heat from burning fuel, called thermogenesis. This results in the cell burning less energy and instead storing more of it as fat.
Psychiatric Drugs and Violence: A Review of FDA Data Finds A Link
"Moore and his collaborators concluded: "These data provide new
evidence that acts of violence towards others are a genuine and serious
adverse drug event that is associated with a relatively small group of
drugs. Varenicline, which increases the availability of dopamine, and
serotonin reuptake inhibitors were the most strongly and consistently
implicated drugs."Antidepressants
Antidepressant Drugs Effects on Blood Pressure
"Individuals suffering from depressive disorders display a greater incidence of hypertension compared with the general population, despite reports of the association between depression and hypotension. This phenomenon may depend, at least in part, on the use of antidepressant drugs, which may influence blood pressure through different effects on adrenergic and serotoninergic pathways, as well as on histaminergic, dopaminergic, and cholinergic systems. This review summarizes extant literature on the effect of antidepressant drugs on blood pressure." This is a very thorough review.
Serotonin Syndrome (aka "Serotonin Storm" or "Serotonin Toxicity") can occur when a medication (or combination of meds) is given that causes a person's serotonin level to become too high. This can be a chronic or acute state, and the symptoms vary from mild to fatal, depending on the cause or source of the excessive serotonin as well as the individual's genetic makeup (loss of function mutations in the enzymes that break down excessive serotonin, such as COMT and MAO, can make people more prone to develop Serotonin Toxicity). Symptoms can range from mild (such as feeling too hot, diarrhea, nausea) to fatal (from seizures, cardiac events, or coma).
Brain Zaps and Antidepressants - Why Do they Happen?
Why do you gain weight with antidepressants and mood stabilizers?
While the actual cause of weight gain from antidepressant medications is not fully understood (including SSRIs and some anti-psychotics), in this video two proposed mechanisms are presented that seem likely. The first is that SSRIs block certain histamine receptors on brain cells (H1) that allow the brain to register "satiety", which is the feeling of being full that indicates that it's time to stop eating. This results in people overeating and gaining weight that way. The other mechanism involves some anti-psychotic medications that are used for mood stabilization. These meds block the 5HT2c receptor (one of the receptors for serotonin) that is involved in regulating the cell's production of heat from burning fuel, called thermogenesis. This results in the cell burning less energy and instead storing more of it as fat.
Psychiatric Drugs and Violence: A Review of FDA Data Finds A Link
SSRIs (Selective Serotonin Reuptake Inhibitors):
Serotonin syndrome presenting as hypotonic coma and apnea: potentially fatal complications of selective serotonin receptor inhibitor therapy.
Serotonin syndrome presenting as hypotonic coma and apnea: potentially fatal complications of selective serotonin receptor inhibitor therapy.
The Role of the Serotonergic System in REM Sleep Behavior Disorder
"Acute REM sleep behavior disorder (RBD) can be induced by the use of antidepressants, especially serotonin reuptake inhibitors (SSRI), suggesting a role of the serotonergic system in the pathogenesis of RBD. Overall, serotonin promotes the wake state and inhibits REM sleep."
"Acute REM sleep behavior disorder (RBD) can be induced by the use of antidepressants, especially serotonin reuptake inhibitors (SSRI), suggesting a role of the serotonergic system in the pathogenesis of RBD. Overall, serotonin promotes the wake state and inhibits REM sleep."
"In addition to reducing interest in sex, SSRI medications can make it
difficult to become aroused, sustain arousal, and reach orgasm. Some
people taking SSRIs aren't able to have an orgasm at all. These symptoms
tend to become more common with age."
Post-SSRI Sexual Dysfunction: A Literature Review
"Common PSSD symptoms include genital anesthesia, pleasure-less or weak orgasm, decreased sex drive, erectile dysfunction, and premature ejaculation. Different theories have been proposed to explain the pathophysiology of PSSD: epigenetic gene expression theory, cytochrome actions, dopamine-serotonin interactions, proopiomelanocortin and melanocortin effects, serotonin neurotoxicity, downregulation of 5-hydroxytryptamine receptor 1A, and hormonal changes in the central and peripheral nervous systems. The diagnosis of PSSD is achieved by excluding all other etiologies of sexual dysfunction. Treating PSSD is challenging, and many strategies have been suggested and tried, including serotonergic antagonists and dopaminergic agonists. There is still no definitive treatment for PSSD. Low-power laser irradiation and phototherapy have shown some promising results. "
"Common PSSD symptoms include genital anesthesia, pleasure-less or weak orgasm, decreased sex drive, erectile dysfunction, and premature ejaculation. Different theories have been proposed to explain the pathophysiology of PSSD: epigenetic gene expression theory, cytochrome actions, dopamine-serotonin interactions, proopiomelanocortin and melanocortin effects, serotonin neurotoxicity, downregulation of 5-hydroxytryptamine receptor 1A, and hormonal changes in the central and peripheral nervous systems. The diagnosis of PSSD is achieved by excluding all other etiologies of sexual dysfunction. Treating PSSD is challenging, and many strategies have been suggested and tried, including serotonergic antagonists and dopaminergic agonists. There is still no definitive treatment for PSSD. Low-power laser irradiation and phototherapy have shown some promising results. "
Statins
Lupus erythematosus and other autoimmune diseases related to statin therapy: a systematic review
"Long-term exposure to statins may be associated with drug-induced lupus erythematosus and other autoimmune disorders. Fatal cases have been reported despite early drug discontinuation and aggressive systemic immunosuppressive therapy."
Benzodiazepines:
How Does Xanax Work?
Lupus erythematosus and other autoimmune diseases related to statin therapy: a systematic review
"Long-term exposure to statins may be associated with drug-induced lupus erythematosus and other autoimmune disorders. Fatal cases have been reported despite early drug discontinuation and aggressive systemic immunosuppressive therapy."
Benzodiazepines:
How Does Xanax Work?
Fluoroquinolone antibiotics:
FDA warns about increased risk of ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients
FDA warns about increased risk of ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients
"Health care professionals should avoid prescribing fluoroquinolone antibiotics to patients who have an aortic aneurysm or are at risk for an aortic aneurysm, such as patients with peripheral atherosclerotic vascular diseases, hypertension, certain genetic conditions such as Marfan syndrome and Ehlers-Danlos syndrome, and elderly patients. Prescribe fluoroquinolones to these patients only when no other treatment options are available. Advise all patients to seek immediate medical treatment for any symptoms associated with aortic aneurysm. Stop fluoroquinolone treatment immediately if a patient reports side effects suggestive of aortic aneurysm or dissection.
We communicated safety information associated with fluoroquinolones in July 2018 (significant decreases in blood sugar and certain mental health side effects), July 2016 (disabling side effects of the tendons, muscles, joints, nerves, and central nervous system), May 2016 (restricting use for certain uncomplicated infections), August 2013 (peripheral neuropathy), and July 2008 (tendinitis and tendon rupture)."
(a CNN report about these recommendations.)
What Americans Don’t Know About Their Medications
"The drugs have been tied to tendon rupture, aortic rupture, hypoglycemia, C. difficile infections, mental-health issues, heart-valve problems, and nerve damage, but in fewer than 1 percent of people who take them. In a 2015 meeting, FDA officials presented data showing that fluoroquinolones were more likely to be associated with disabling side effects than other types of antibiotics. For a very small number of the floxed, the medications seemingly prompt a temporary psychotic episode, during which they, say, step in front of a semitrailer or jump out of a window. In all, as of 2015, more than 60,000 people had reported “serious adverse events” associated with five fluoroquinolone antibiotics since the 1980s, when they were developed."
What Americans Don’t Know About Their Medications
"The drugs have been tied to tendon rupture, aortic rupture, hypoglycemia, C. difficile infections, mental-health issues, heart-valve problems, and nerve damage, but in fewer than 1 percent of people who take them. In a 2015 meeting, FDA officials presented data showing that fluoroquinolones were more likely to be associated with disabling side effects than other types of antibiotics. For a very small number of the floxed, the medications seemingly prompt a temporary psychotic episode, during which they, say, step in front of a semitrailer or jump out of a window. In all, as of 2015, more than 60,000 people had reported “serious adverse events” associated with five fluoroquinolone antibiotics since the 1980s, when they were developed."
Popular antibiotics linked to growing number of suicide deaths
This brief tv news report presents several cases of people commiting suicide after taking Cipro or Levaquin.
This brief tv news report presents several cases of people commiting suicide after taking Cipro or Levaquin.
MAOIs:
The effects of moclobemide alone in overdose are minor, even with
massive ingestion. However, moclobemide overdose in combination with a
serotonergic agent (even in normal therapeutic doses) can cause severe
serotonin toxicity. A hypertensive crisis can result from ingestion of tyramine-rich foods in conjunction with monoamine oxidase inhibitors (MAOIs).
NSAIDs:
This
video from The Institute for Human Anatomy uses actual preserved human
tissues to explain how ibuprofen is metabolized in the body and how it
can cause certain side effects, mostly associated with long-term use.
In particular, the mechanisms that can cause stomach pain and damage and
kidney damage are shown.
Researchers Examine Why Tylenol Affects Empathy (from NPR)
Researchers Examine Why Tylenol Affects Empathy (from NPR)
Naltrexone (low dose) Naltrexone was originally used to treat heroin addiction (and sometimes alcohol addiction), particularly to reduce the symptoms of withdrawl. Later, a doctor found that when given in very low doses (1 to 6mg or so) it could prevent an HIV infection from progressing to AIDS. It began to be used in low doses to treat other things including Crohn's Disease, Fibromyalgia, MS, some skin disorders, and lately even in treating some cancers.
PPIs (Proton Pump Inhibitors:
Popular heartburn drugs linked to gradual yet 'silent' kidney damagePopular Acid Reflux Drugs Are Linked To Kidney Disease Risk (piece from NPR)
Acid reflux medications may increase kidney disease risk
Steroids:
Study indicates use of nasal steroids can stunt growth in children
Effects of neuroactive steroids on myelin of peripheral nervous system. "Because Po and PMP22 play an important physiological role for the maintenance of the multilamellar structure of the myelin of the PNS, the present observations might suggest the utilization of neuroactive steroids as new therapeutically approaches for the rebuilding of the peripheral myelin."
Bismuth Subsalicylate (Pepto-Bismol, Kaopectate, other generic names) has several common side effects when taken as directed including tinnitus, and can cause acute poisoning when more is taken or the patient has poor gastric function and it builds up.
Bismuth Subsalicylate Poisoning
Clonidine is in a class of medications called centrally acting
alpha-agonist hypotensive agents, which treat high blood pressure by decreasing your heart rate and
relaxing the blood vessels so that blood can flow more easily through
the body. Clonidine extended-release tablets may treat ADHD by affecting
the part of the brain that controls attention and impulsivity.
Ketamine: is an NMDA receptor antagonist generally used for sedation and anesthesia, but increasingly used to treat depression.
Metformin: can cause a vitamin B12 deficiency.
Miralax:
Teriparatide Treatment for Osteoporosis (Forteo and Tymlos)
Tramadol:
Tramadol is the generic name for a synthetic opioid whose brand names include ConZip, Ryzolt, and Ultram. Because Tramadol can be addictive like other opioid medications, it's long term use is restricted. It's use for treating pain after surgery and other acute pain is relatively common. Tramadol is a prodrug (a precursor to a drug that is converted to it's active drug form in the liver) and not everyone has the enzyme necessary to make this conversion. Tramadol is an SNRI meaning that it blocks the reuptake of serotonin and noradrenaline which are needed in the central nervous system to deal with pain. This action can lead to serotonin syndrome, which is a potentially deadly condition that occurs if the level of serotonin becomes too much, especially if the person takes another medication that also increases serotonin levels. Tramadol is considered to be a weak opioid with a similar potency as codeine. People shouldn't take more than 400mg per day. Overdose of Tramadol is not fully reversed by administration of Naloxone, which is used to treat overdoses of other opioids.
DRUG SHORTAGES:
The FDA keeps a (relatively) updated list of meds that are in shortage here.
The ASHP also keeps a drug shortage list here.
Below is information on the current (October 2018) IV Benadryl shortage:
ASHP update (10/22/2018) regarding the IV Benadryl shortage
For more specific and personal information about the shortage and how it affects patients see these posts from Lisa Klimas of the MastAttack blog and Cheyanne Perry of the Hospital Princess Vlog
Below is information on the current (October 2018) epi pen shortage:
The Mastocytosis Society statements and updates
Extended Expiration Dates for Select Lots of EpiPen®0.3 mg Auto-Injectors and its Authorized Generic (from Mylan who is the distributor of the epi pen)
"On Aug. 21, 2018, the U.S. Food and Drug Administration announced to extend the expiration dates of specific lots of EpiPen 0.3 mg Auto-Injectors and its authorized generic version, after review of stability data. Patients should have confidence in using the products from these particular lots as Pfizer works to stabilize supply, which is anticipated in the fourth quarter of 2018."
"Mylan, the distributor, is expediting shipments upon receipt from Pfizer and continues to encourage patients who are experiencing difficulty accessing product to call its Customer Relations team at 800-796-9526 for assistance in locating other pharmacies. To further assist patients during this period of limited supply, Mylan recently extended its Customer Relations hours to Monday through Friday, 8 a.m. to 7 p.m. ET and Saturday through Sunday, 11 a.m. to 4 p.m. ET."
Ketamine: is an NMDA receptor antagonist generally used for sedation and anesthesia, but increasingly used to treat depression.
Metformin: can cause a vitamin B12 deficiency.
Miralax:
Scrutiny for Laxatives as a Childhood Remedy from The New York Times
more on this from The New York Times:
Drug for Adults Is Popular as Children’s Remedy
Spotlight Finally on Miralax (Response to above article from NYT)
"Back in December of 2011, the FDA placed MiraLAX — a polyethylene
glycol-containing blockbuster drug marketed by Merck & Co — on its
Adverse Event Reporting System (AERS) in connection to “neuropsychiatric
events.”
Besides MiraLAX, this warning also applies to Movicol, Dulcolax, Colyte, Colovage, Co-Lav, Clensz-Lyte, ClearLax, GoLYTELY, GaviLyte C, GlycoLax, Go-Evac, GlycoPrep, E-Z-Em Fortrans, Halflytely, Lax-a-Day, LaxLyte, MoviPrep, Macrogol, NuLytely, OCL, Peg-Lyte, Prep Lyte, Softlax, TriLyte, and all other brands with Polyethylene Glycol 3350 (PEG for short) as their active ingredient. The “3350” qualifier refers to the molecular weight of this particular variant of PEG."
Besides MiraLAX, this warning also applies to Movicol, Dulcolax, Colyte, Colovage, Co-Lav, Clensz-Lyte, ClearLax, GoLYTELY, GaviLyte C, GlycoLax, Go-Evac, GlycoPrep, E-Z-Em Fortrans, Halflytely, Lax-a-Day, LaxLyte, MoviPrep, Macrogol, NuLytely, OCL, Peg-Lyte, Prep Lyte, Softlax, TriLyte, and all other brands with Polyethylene Glycol 3350 (PEG for short) as their active ingredient. The “3350” qualifier refers to the molecular weight of this particular variant of PEG."
Singulair (Monteleukast):
More on this:
Tramadol:
Tramadol is the generic name for a synthetic opioid whose brand names include ConZip, Ryzolt, and Ultram. Because Tramadol can be addictive like other opioid medications, it's long term use is restricted. It's use for treating pain after surgery and other acute pain is relatively common. Tramadol is a prodrug (a precursor to a drug that is converted to it's active drug form in the liver) and not everyone has the enzyme necessary to make this conversion. Tramadol is an SNRI meaning that it blocks the reuptake of serotonin and noradrenaline which are needed in the central nervous system to deal with pain. This action can lead to serotonin syndrome, which is a potentially deadly condition that occurs if the level of serotonin becomes too much, especially if the person takes another medication that also increases serotonin levels. Tramadol is considered to be a weak opioid with a similar potency as codeine. People shouldn't take more than 400mg per day. Overdose of Tramadol is not fully reversed by administration of Naloxone, which is used to treat overdoses of other opioids.
DRUG SHORTAGES:
The FDA keeps a (relatively) updated list of meds that are in shortage here.
The ASHP also keeps a drug shortage list here.
Below is information on the current (October 2018) IV Benadryl shortage:
ASHP update (10/22/2018) regarding the IV Benadryl shortage
For more specific and personal information about the shortage and how it affects patients see these posts from Lisa Klimas of the MastAttack blog and Cheyanne Perry of the Hospital Princess Vlog
Below is information on the current (October 2018) epi pen shortage:
The Mastocytosis Society statements and updates
Extended Expiration Dates for Select Lots of EpiPen®0.3 mg Auto-Injectors and its Authorized Generic (from Mylan who is the distributor of the epi pen)
"On Aug. 21, 2018, the U.S. Food and Drug Administration announced to extend the expiration dates of specific lots of EpiPen 0.3 mg Auto-Injectors and its authorized generic version, after review of stability data. Patients should have confidence in using the products from these particular lots as Pfizer works to stabilize supply, which is anticipated in the fourth quarter of 2018."
"Mylan, the distributor, is expediting shipments upon receipt from Pfizer and continues to encourage patients who are experiencing difficulty accessing product to call its Customer Relations team at 800-796-9526 for assistance in locating other pharmacies. To further assist patients during this period of limited supply, Mylan recently extended its Customer Relations hours to Monday through Friday, 8 a.m. to 7 p.m. ET and Saturday through Sunday, 11 a.m. to 4 p.m. ET."
