Archive for the ‘Medication: Side Effects’ Category

I am bipolar two and when I started taking Lamictal it worked great. But it may have caused vasculitis of my skin. I had acne bumps all over my legs and also encountered a "break out" on my face.

Serious adverse rashes can occur with Lamictil but it is rare.  Most reactions are mild – they go away when the Lamictal is stopped and many people tolerate Lamictal okay when it is restarted.  If a week or more goes by before skin clears you have to start back at 25mg or even lower.

Severe reactions are rare but can include anything above the neck such as swollen lymph nodes,  lesions in the mucous membranes in the mouth, or under the eyelids.  Then it is not considered safe to try taking it again.

I can’t tell how severe your reaction was but on the face is worrisome and "vasculitis" doesn’t sound good.  You should probably discuss this reaction with a dermatologist before trying Lamictal again.    

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Say Goodbye To The Pill Ladies

I am now completely against birth control pills. I’m also against hormone replacement with oral estradiol. Estradiol (in every birth control pill) taken by mouth goes through the liver and causes problems with thyroid, testosterone, and the most effective form of estrogen.

In anyone with a history of depression and/or stress reactivity, this can be a major contributing factor to their functioning and quality of life.

For premenopausal women the NuvaRing seems to be the best option. This is because the hormone blood levels are about 1/3 of what they are with the weakest birth control pill.

Controversy continues regarding hormone replacement in postmenopausal women. However, for most women, the benefits outweigh the risks – especially for brain function (mood & memory). Using the right types of hormones and the right dose is essential. The best options are Premarin or Cenestin tablets and/or estradiol by patch or gel.

Remember, estrogen x thyroid x brain transmitters = mood in women.

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Vitamins & Supplements: Are they really worth it?

  We have heard it since we were kids, but do we really need to take our vitamins? 

The answer is yes. 
Most Americans don’t get the nutrition they need simply from the foods they eat, and supplements insure that our body meets its nutrient “quota” enabling our body to function optimally at the cellular level.  However, the vitamin and supplement industry is not regulated by the FDA, so there is no guarantee that products bought from grocery and health food stores are effective or contain the stated ingredients.    
Cooper Complete Vitamins are backed by Science.
That is one reason we decided to make them available to our patients. Reputable physician Kenneth Cooper created the Cooper Institute, a non-profit organization that manufactures, researches and publishes studies on Cooper Complete vitamins. He ensures regular testing to measure efficacy, potency and absorption of Cooper supplements.  Not only does Dr. Jones promote these vitamins, but he takes them himself and he furnishes them to his staff at no charge to promote wellness among staff members.  To encourage patients to take these supplements over other store bought brands, Dr. Jones decided to make these supplements available to his patients at a discounted price, so we offer the Cooper Complete© line of products for less than you can get them at most grocery stores and even less than the price from ordering them directly from his website. 
If you are interested in ordering supplements or would like more information about the supplements, please feel free to contact our office or e-mail us your request to info@askdrjones.com.  


Studies published in the American College of Nutrition and
the American Journal of Medicine found Cooper Complete multi-vitamin lowered: 
· Oxidation rates of LDL Cholesterol by 14%

· Homocysteine levels by 17%

· C-reactive Protein Levels by 32%

High levels of these values are all associated with increased cardiovascular disease risk.


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What's wrong with Luvox?

Question:  Why are you so down on Luvox?  It has worked well for me in the past.  Also, I use 1200 of Lithium and my creatinine is 1.2.  I have used it 10 years.  At what creatinine level should Lithium be stopped?  I would try Abilify but am diabetic. – John

Answer:  I wouldn’t say I’m “down” on Luvox.  I do have a few patients who seem to do well on it.  The reason I try other serotonin reuptake inhibitors is that Luvox has the most drug-drug interactions in that group of meds (Prozac, Zoloft, Paxil, Celexa, Lexapro, low dose Effexor XR 37.5-75).  For example, Luvox blocks the metabolism of caffeine – which may be the reason it causes more insomnia.  It can cause more daytime sedation. It also blocks the metabolism of all the meds (and hormones) in the 3A4 category (the biggest group), so that can make things very complicated.

Prolonged use of Lithium can lead to some type of kidney impairment, probably inflammatory.  It’s more likely if serum levels are higher (1.0 and above) and may be more likely in individuals that have frequent urination and thirst.  It usually develops after years of use, and so far in my experience, it has not progressed to be a severe problem. But usually the Lithium itself was stopped.

I don’t routinely monitor creatinine levels.  They only start going up if kidney function is reduced by 75% or more.  If that occurs, the serum Lithium will go up without a change in dose or decrease in sodium intake or excess sodium loss (e.g. taking diuretics, vomiting, or diarrhea).

The normal creatinine range is 0.7 to 1.3.  One high value could be some minor issue, so it needs to be repeated.  Other tests are more specific (e.g. 24 urine creatinine or creatinine clearance).  One easy test is to restrict water and see if you can concentrate your urine (becomes dark).  Urine can also be tested with a dipstick available over-the-counter for specific gravity (level of concentration), glucose, protein, inflammatory cells, etc.

The fact that you have Diabetes is a bigger concern as regards your kidneys.  I’m sure your doctor has counseled you about the importance of maintaining good blood sugar levels.  There shouldn’t be any sugar in your urine.

I don’t think you should rule out Abilify because you have Diabetes.  The FDA has required all meds in the atypical group (Abilify, Geodon, Risperdal, Seroquel, Zyprexa, and Symbyax) to list Diabetes as a possible side effect. But actual reported cases with Abilify have been extremely rare.

As with all meds, the decision comes down to benefit vs. risks, and in your case, Abilify might be a good option.

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Treating Fibromyalgia

Question:

I am taking cymbalta, concerta and ambien – this week to substitute daytrana – for fibromyalgia. Key problems are sleep, pain, mental fog, low energy to the level of cfs. Is it standard treatment to use a stimulant drug for this condition? I have relief in all areas when taking the meds – but the energy and motivation are still laggin behind. (this question originally appeared as a comment on the article Determining the Best Stimulants.)

— Linda

Answer:

Strictly speaking, there is no standard treatment for Fibromyalgia. I’m not aware of any treatment having formal FDA approval. Cymbalta does have some positive controlled studies and Eli Lilly may be applying for approval.

Low thyroid is a common problem associated with fibromyalgia (see Thyroid Facts and Myths).

Stimulants are frequently used for chronic fatigue although they are not FDA approved for this. You are on a good combination of meds. If you are taking Cymbalta early in the day, switching to bedtime might help.

There are multiple options that could help motivation and energy levels:

  • Increasing Concerta
  • Increasing Cymbalta
  • Adding Wellbutrin XL

Of course, you would need to discuss options with your doctor. It’s usually best to make only one change at a time.

Good luck!

Dr. Jones

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You Can’t Have It Both Ways

Give me something to fix my problem. Don’t give me anything that could ever cause any side-effects …

Fortunately most people are fair and reasonable. They know anything strong enough to significantly change brain functioning, put you to sleep, stop panic attacks or anxiety, relieve depression, or improve focus and motivation has to be strong enough to sometimes cause side-effects. The infinite variety of genetics that helps make each of us unique can cause a myriad of idiosyncratic reactions to medication.

Case in point. “Perchance To … Eat? A few Ambien users find themselves at the fridge” was an article in Newsweek, March 27, 2006. The story is about a woman who was sleepwalking and bingeing during the night. She found out online that other people taking Ambien were having this problem. A New York attorney has filed a class action suit on behalf of 300 patients who complain of similar problems or of doing things while sleepwalking that are dangerous, like driving a car. Most or all of these people apparently have a history of sleepwalking.

Sleepwalking occurs during deep, stage 4 sleep. Ambien (and other sleep medications Lunesta, Sonata) help restore normal sleep, which includes deep sleep. Twenty-six million prescriptions were written in the U.S. last year for Ambien. Since this case was reported 2-3 weeks ago, prescriptions have been falling off.

In our litigious society, there is a history of overreaction where the benefits of the many are lost because of the misfortune or idiocy of the few (or sometimes the one).

For any given medication, there are literally hundreds of possible side-effects, including those that are rare (defined as less than 1 per 1,000). The massive amount of information makes it difficult to find the important, relevant information.

Common side-effects are usually due to

  • over-shooting the blood level in search of the “right dose”
  • common genetic variants
  • combining different medications
  • or many other possibilities

In making a joint decision to try a medication, a doctor and patient consider potential benefit vs. potential risk. It’s not fair or reasonable to say after a rare side-effect “this medication shouldn’t have been prescribed.”

If we use the principle, “don’t prescribe any medication that can ever cause a potentially serious side-effect,” we might as well close the pharmacies. Anaphylactic reactions to penicillin are a case in point. While we’re at it, let’s also get rid of shell fish, peanuts, and strawberries.

There has to be a reasonable balance. On the one hand, the Hippocratic Oath is, “first do no harm.” On the other hand, surgeons are told if you never remove a normal appendix you are being too careful – dangerously cautious. Waiting until an appendix ruptures while waiting to be certain will jeopardize a life. The best mantra is, “benefit vs. risk.”

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Management of Stomach Pain Associated with Medication

Question: I have bad stomach pain after taking a drug for a bladder condition. I was also on Prozac, Elavil and Lorazepam at the time, for bladder and depression issues. I stopped the Prozac because I wanted to take less drugs, because now I also have to take Prevacid. So, currently I am taking Prevacid, Lorazepam, and Elavil (lowest dose of each) Would cymbalta work for me for the stomach pain? The doctors are calling it nonulcer dyspepsia.

— Ellen

Answer: I’m not clear about whether you are still on a med for a bladder condition, but I’m presuming not. Meds that effect the bladder usually also have some effects on the stomach. I’m guessing that the bladder condition is interstitial cystitis, but there are several other possibilities.

Prozac can result in stomach spasms and pain, either when first starting it or when going off. Tapering Prozac more slowly would help if that was the case. Starting it back would initially help and then tapering at 1-2/week would be less likely to cause problems. Cymbalta has been found to help with pain of various types, but Elavil also helps by similar mechanisms. Increasing the dose of Elavil should be tried before adding Cymbalta, which shouldn’t be mixed with Elavil (i.e., Elavil would best be tapered off before adding Cymbalta).

Make sure you find out what was causing the stomach pain. Sometimes the cause remains unclear in which case you need to monitor any possible related symptoms or changes and be periodically reevaluated.

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Management of Anxiety and Medication Side Effects

Question: If Effexor XR helps decrease the amount of serotonin and norepinephrine uptake in the case of GAD, then why does it feel like I am racing all the time?

— Ryan

Answer: Generalized Anxiety Disorder presumably is due to genetic vulnerability, personality traits, and stress. We know of one specific genetic variation that alters serotonin levels. Giving an anxious person meds that stimulate serotonin receptors or norepinephrine receptors (e.g., metabolite of Trazodone or Yohimbine) increases anxiety.

Giving Effexor, especially at higher doses, may initially worsen anxiety symptoms since it initially increases levels of serotonin and norepinephrine. But over a period of 2-3 weeks or more on Effexor, symptoms improve – presumably related to down regulation of both of these transmitters. 225 mg of Effexor usually works better than 150, and 150 works better than 75. At 225 effects on norepinephrine and serotonin are about equal. At 75 the effects are mostly on serotonin.

Some people with GAD do well on just an SSRI like Lexapro. You may be supersensitive to the norepinephrine effect of Effexor and would do better on Lexapro. Other possibilities include some bipolar gene that results in being overstimulated by an antidepressant.

Taking a benzodiazepine like Niravam might help with “racing.” Klonopin might be better if your thoughts are racing.

Anxiety symptoms can be associated with many conditions. Physiology of norepinephrine and serotonin are complicated, especially for serotonin, because there are more than 10 different types of serotonin receptors, any of which can be too high or low. Each of these transmitters also does different things in different areas of the brain.

In the future we will be able to better predict your medication response by looking at your specific genetic profile and other brain function parameters. For now, if you can’t find a dose of Effexor that helps without causing significant side effects, you need to phase off and try other meds. You may also need a reevaluation to look for other possible causes of your symptoms. The average person with a significant anxiety or mood disorder has a total of 3 different diagnoses. This phenomenon of frequent comorbidity is mostly due to the “blind men and the elephant” problem. We just don’t have the full picture yet of how the mind and brain work.

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SSRI's, SNRI's & Weight Gain

Question: I have been on Effexor XR 150 mg for 5-6 months now, but am disappointed with the weight gain – esp. around the belly. I was wondering if I can ask my doctor about Wellbutrin XL to help counteract that. What are your thoughts on that?

— Mona

Answer: All SSRI’s and SNRI’s can cause weight gain. Sometimes, increasing the dose of Effexor to 225 mg will make it easier to control weight, since it mainly increases Norepinephrine effect at the higher dose. Adding Wellbutrin is more likely to help (either 150 or 300 mg). Wellbutrin XL is probably better but not in generic. Taking Wellbutrin in a.m. and Effexor around supper time decreases overlap.

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Side Effects Related to Combined Antidepressants

Question: I have been on Prozac for several years. Recently I suffered a rather sudden and dramatic increase in depression — not crying or irritable, just totally flat line; I found it impossible to function.
My doctor increased the dosage which did not appreciably help. She then switched me to Cymbalta (30 mg. for 1 week and then up to 60 mg.). One thing to note is that I did not stop taking or decrease the Prozac first, I just switched one day to Cymbalta. During the first week I had no problems with the drug, but no real change in my depression either.
Four days after starting the 60 mg. (and when I first started to think there was an improvement in how I felt) I suffered a strange occurrence as I was dozing in & out of sleep first thing in the morning. Impossible to truly describe, but it felt like someone set off a very bright flash bulb inside my brain. This was not an external visual thing, totally “in my mind.” It was so fast and startling that I bolted straight up and cried out. I thought that a blood vessel had ruptured or I had suffered a small stroke (actually, I thought my brain had exploded but obviously since I was thinking, that hadn’t happened!) It happened two more times, just as I was falling asleep again. That night (or around 5 a.m. the next morning) I suffered 4 more of these events, and again early the next morning.
They seem to be increasing in the “violence effect” in that it seems like my whole brain lights up and I lunge awake. I do not recall any pain — just a brief state of panic. I am fully aware afterwards and I am able to think and speak coherently. I discovered this morning that while just falling asleep again, I was somehow able to sense one coming and stopped it by waking myself up first. Sorry for the long description — it’s too weird to describe.
My question is: could this be an effect of taking Cymbalta while the Prozac was still in my system (I read where you stated Prozac stays in the body for a rather long time)? As unlike any type of seizure I’ve ever heard of, could it possibly be a seizure symptom from only the Cymbalta? My own doctor has never heard of such an “event” and told me to quit taking the Cymbalta (immediately) to see if this went away. I was concerned about stopping cold turkey but am more concerned about waking to this worsening symptom one more time. Can you shed any light?

— S.S.
Answer: Since Prozac gradually leaves your system (over 6 weeks) and Cymbalta builds up more quickly (3 days), it is possible that your symptoms are due to an interaction of your two medications (due to excess serotonin levels).
I agree with your doctor that it’s not a typical presentation of symptoms and I’m not sure what it was. I am confident that it wasn’t due to withdrawal or discontinuation effects from Prozac. Rebound can cause significant symptoms, especially with Paxil or Effexor, and probably more common in kids and teens due to their faster metabolism. I also agree with getting off the Cymbalta although a slight taper might have been better.

The fact that you have been on Prozac for years means that you are not super sensitive to serotonin although it’s possible that your serotonin level was higher on the combination of Cymbalta and gradually reducing Prozac. Serotonin can produce vascular related side effects such as the auras before a migraine. Sometimes these “pre migraine” symptoms don’t progress to an actual headache.

Cymbalta modulates serotonin and norepinephrine. It may be that you don’t tolerate the norepinephrine. You might have had hypnogogic and hypnopompic hallucinations that occur going into and coming out of sleep. They are actually considered normal phenomena although the frequency and severity of your episodes was certainly not normal.

There’s no way to be sure what the exact cause was – either in terms of what the meds were doing or what was happening in your head. In my opinion, the safest thing to do would be to use meds that work through different mechanisms like Lamictal. If episodes persist you should see a neurologist for evaluation and testing or have a sleep study.
Good Luck!
Dr. Jones


This article originally appeared in the Q&A section 05/31/2005. Revised 01/22/2006.

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