Tag Archives: antidepressants

Antidepressants May Boost Risk of Death in COPD Patients

Older patients with COPD (chronic obstructive pulmonary disease) should take precautions when using certain antidepressants because they may increase the risk of death.

Researchers analyzed 28,360 new users of serotonergic antidepressants – such as SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin norepinephrine reuptake inhibitors) – that had COPD and were aged 66 and older, then matched them to 28,360 non-users. SSRIs and SNRIs are among the most commonly prescribed antidepressants.

The results, published in the European Respiratory Journal, indicated that new users of these antidepressants have a 20% increased risk of death related to respiratory issues, as well as death overall compared to non-users of the medication.

Also, antidepressant use among those with COPD – a progressive lung disease characterized by breathlessness – was associated with a 15% increased risk of hospitalization and emergency room visits due to related symptoms. The results demonstrate a strong association, but not a definite cause and effect, the researchers caution.

According to lead author Nicholas Vozoris, MD, a respirologist at St. Michael’s Hospital in Toronto, the findings were not surprising because “there are biological reasons why antidepressants could lead to respiratory issues.

“These drugs can cause sleepiness, vomiting and can negatively impact immune system cells. This increases the likelihood of infections, breathing issues, and other respiratory adverse events, especially in patients with COPD.”

Researchers noted that the findings shouldn’t alarm COPD patients who are currently using antidepressants, but rather increase awareness among users and prescribers.

Can Cannabis Control Depression?

Untreated and inadequately controlled depression is a big problem. In 2016, 16.2 million American adults experienced at least one major depressive episode, according to the National Institute of Mental Health. Approximately 37% did not receive any kind of professional treatment –- no counseling, no antidepressants, no mental health evaluation. That’s nearly 6 million people living, working and parenting under a cloud of depression.

Additionally, somewhere between 10 and 30% of those who receive treatment for depression do not improve or only improve partially. Many eventually quit their antidepressant medication and therapy due to frustration.

Could cannabis help these patients? At least one doctor thinks so. Jordan Tishler, MD, a Harvard-trained internal medicine physician who currently serves as the president of the Association of Cannabis Specialists and treats patients via his private practice, Inhale MD, recommends cannabis as a substitute for or adjunct to prescription antidepressants.

“Cannabis can be a good substitute [for medication], but only under certain circumstances,” Dr. Tishler says.

Marijuana & Mood: What We Know – and What We Don’t

To date, scientific research regarding the effects of Cannabis sativa (marijuana) on mood have been mixed. Some studies suggest that marijuana usage has a negative impact on mood; that cannabis use over time can cause or worsen depression. Other studies suggest that cannabis can alleviate depression.

The problem with the research is that it’s incomplete. Under US federal law, marijuana is still a Schedule I drug and therefore subject to strict rules. Researchers can’t, for instance, give subjects cannabis. “The best they can do,” Dr. Tishler says, “is have them bring their own cannabis or talk about their cannabis use.”

Such studies don’t allow researchers to control or compare strains of cannabis, and make it difficult to accurately assess dosage. That’s a problem because “that’s exactly where the devil lies in this particular discussion,” Dr. Tishler says.

The only source of marijuana approved for medical studies is under control of the National Institute for Drug Abuse (NIDA) at the University of Mississippi. And it requires researchers to complete a mountain of paperwork just to have NIDA consider such a request.

One researcher who requested marijuana from NIDA — and was approved — is Sue Sisley, MD, the president and principal investigator at Phoenix’s Scottsdale Research Institute, arguably the nation’s foremost private research institute investigating medicinal uses of marijuana.

Sisley echoed Tishler’s concerns. Speaking at a panel on marijuana at the American Psychiatric Association Annual Meeting in New York City earlier this month, she mentioned one problem with NIDA’s marijuana once it arrived at her offices. The marijuana had not only the leaves, but stems and other parts that are considered non-therapeutic. In other words, much of the marijuana sent to her via FedEx was useless.

But that wasn’t the worst of it. Sisley added that she suspected the marijuana was bagged years ago and not stored under proper conditions in Mississippi, because mold was present.

A 2007 study published in the Journal of Neuroscience examined the impact of cannabis on rats, concluding that tetrahydrocannabinol, or THC, cannabis’ psychoactive chemical, has antidepressant effects at low doses. High doses of THC, however, can worsen depression, at least in rats.

Data on cannabis’ effect on human mood is sparse. “We don’t have clean data in patients with depression. We have data from people who suffer from multiple sclerosis or other diseases, such as epilepsy,” says Gabriella Gobbi, MD, PhD, CSPQ, a psychiatrist in the Mood Disorders

Program at the McGill University Health Centre in Montreal. In other words, some researchers who were assessing the effectiveness of marijuana to treat multiple sclerosis, epilepsy and other diseases asked subjects about the drug’s impact on their mood, but no one has formally studied cannabis as a treatment for depression.

“We need to do randomized clinical trials in people with depression,” Dr. Gobbi says. Such trials would compare cannabis versus a placebo, and assess the treatment’s effect on depressive symptoms.

Available human and animal studies suggest that adolescents and adults respond differently to cannabis. “In animal experiments, it’s very clear: Cannabis given during adolescence every day increases the risk of developing depression in adulthood,” Dr. Gobbi says. “If you start cannabis later in life, this risk to develop depression is less important.”

The Risks & Benefits of Using Cannabis to Treat Depression

Although cannabis is known for inducing euphoria, “it’s a relatively weak antidepressant,” Dr. Tishler says. Therefore, it’s not likely to be an effective stand-alone treatment for many people with depression. Cannabis can also trigger mania or psychotic episodes in people with bipolar depression or a family history of psychosis or bipolar depression.

Other risks of cannabis use include “the acute risk of impaired judgment and driving,” says Kevin Hill, MD, MHS, director of the Division of Addiction Psychiatry at Beth Israel Deaconess Medical Center and author of Marijuana: The Unbiased Truth About the World’s Most Popular Weed. Risks from chronic use, he says, include “worsening depression or even addiction.”

Dr. Tishler tries to control risks by carefully selecting patients for treatment. “If a patient comes in and says, ‘Doc, I’m on a starter dose of Zoloft (sertraline), 25 milligrams, and it’s working but I want to get off it because of side effects,’ then I think cannabis is reasonable substitution,” he says. “But if somebody is on a high dose – 100 milligrams or more –- then I don’t think it’s reasonable or responsible to try to do a substitution.” Instead, he might suggest cannabis as an adjunct to prescription antidepressant medication.

“Adding cannabis on top of a selective serotonin reuptake inhibitor (SSRI) can let some of the joy of life come back,” Dr. Tishler says. “The other thing we should mention is that SSRIs, generally speaking, are terrible for one’s libido. Cannabis is good for libido.”

Medical professionals agree that it is not a good idea to self-treat depression with cannabis. Dr. Tishler says that patients who are considering using cannabis should consult with a physician. “Even physicians who don’t know very much about cannabis, assuming they are open-minded to it, still know more about human biology and healthcare” than the clerk at the nearest weed shop, he says.

Dr. Hill says it’s critical for patients to discuss their mood openly with their physicians. “Decisions about how to treat depression should be made as part of a conversation between a patient and a doctor who knows them well,” Dr. Hill says. “Patients should collaborate with their physician to make sure that evidence-based treatments have been given a chance to work before turning toward treatments like cannabis that have no evidence behind them.”

Can Using Dumbbells Help Alleviate Depression?

Resistance exercise training (RET) may significantly curb depressive symptoms, according to a study published in JAMA Psychiatry.

Though previous reviews have shown that exercise provides physical health benefits, the new study attempted to determine whether exercise — specifically resistance training — could combat or prevent mental health problems.

Researchers looked at 33 clinical trials that included 1,877 participants between 25 and 60 years old. Some of them were battling major or minor depression as well as generalized anxiety disorder. Over 16 weeks, the participants engaged in RET for 2 to 7 days per week.

Study results indicated that continuous resistance training — such as using free weights and weight machines — significantly reduced depressive symptoms in participants, regardless of their age, sex, and health status. The results indicated that RET can be considered an alternative and/or adjuvant therapy for depressive symptoms.

Quick Hits: Pregnant Moms and Antidepressants, Deaths Linked to Parkinson’s Drug & More

Mothers-to-be who take common SSRI antidepressants, such as Lexapro (escitalopram) and Prozac (fluoxetine), may unknowingly alter the brain development of their unborn child. Researchers from Columbia University Medical Center examined brain scans of nearly 100 newborns. Some of those babies were born to mothers who took SSRIs (selective serotonin reuptake inhibitors) while pregnant. The scans revealed that babies who were exposed to certain antidepressants while in the womb had alterations in both the gray and white matter of their brains. Researchers indicated that these alterations could ultimately increase the child’s risk of depression and anxiety. Alarmingly, the changes identified were “much greater than the brain changes or abnormalities associated with psychiatric disorders” that the researchers usually detect in children or adults. The study did not demonstrate cause and effect and did not test long-term consequences of the brain changes linked to antidepressant use during pregnancy. Posted April 9, 2018. Via JAMA Pediatrics.

The Parkinson’s disease drug Nuplazid may be responsible for hundreds of deaths. Nuplazid (pimavanserin), manufactured by Acadia Pharmaceuticals in San Diego, was created to regulate Parkinson’s disease psychosis. A CNN article reports that more than 700 patients have died after they started taking Nuplazid. A report from the non-profit Institute for Safe Medication Practices indicated that 244 patients who took the drug died between the drug’s launch in 2016 and March 2017. The FDA approved Nuplazid in 2016, and the agency classified the drug as a “breakthrough therapy” and granted a “priority review,” which sped up the review process. Posted April 9, 2018. Via CNN.

Increasing cigarette prices would curb extreme poverty and poor health around the world. According to an analysis, low-income people would benefit from the price increase the most. After examining 500 million male smokers in 13 countries, researchers discovered that a 50% price increase in cigarettes would lead to 67 million men abandoning cigarettes. Also, the price increase would allow 15.5 million men to dodge catastrophic health spending in the 7 out of 13 countries without universal health coverage. “A higher price would encourage cessation, lead to better health, and save money much more strongly for the poor than the rich,” said lead researcher Prabhat Jha, MD, DPhil, director of the Centre for Global Health Research of St. Michael’s Hospital. Posted April 11, 2018. Via BMJ.

Combining Migraine Meds With Antidepressants Safe

Taking certain migraine medications in combination with antidepressants does not increase the risk of serotonin syndrome, according to a new study published in JAMA Neurology. In 2006, the FDA issued an advisory about triptan migraine drugs being associated with serotonin syndrome when combined with selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs), which are both a common class of antidepressants. However, researchers are suggesting that the advisory should be reconsidered based on new findings.

Over the course of 14 years, researchers analyzed over 47,000 people who were prescribed triptan migraine drugs. Out of that demographic, 21% to 29% of people took antimigraine meds and antidepressants at the same time.

The results indicated that serotonin syndrome was rare in patients who took antimigraine drugs in combination with SSRIs and SNRIs. Serotonin syndrome was suspected in 17 patients. Only 2 patients were classified as having definite serotonin syndrome, while 5 patients were classified as having possible serotonin syndrome. Based on the new findings, the researchers believe that the 2006 FDA advisory is invalid.

Is Kratom Really As Dangerous As the FDA Makes It Out to Be?

America is in the midst of one of the worst epidemics in its history over opioids, which may be one of the reasons the FDA recently issued a warning that kratom, a plant-based supplement often used for pain, is potentially addictive since it has opioid-like qualities.

Kratom has also been used by some people to treat withdrawal from opioids. However, the agency stated that there is “no reliable evidence” to support this and “significant safety issues exist.” The FDA also said it has received reports of 44 deaths related to kratom use. However, as a recent Reason.com blog pointed out, in many of these cases, other substances were found along with kratom in the systems of the deceased, making it difficult to prove kratom was the cause of death.

In one of those deaths, a 22-year-old man had a cocktail of drugs in his system that included the antidepressant Prozac (fluoxetine), antipsychotics Seroquel (quetiapine) and Zyprexa (olanzapine), Lyrica (pregabalin), which is used for nerve pain, and several benzodiazepines (tranquilizers) – in addition to kratom. Also, as Jacob Sullum argued in another Reason.com blog, more people have died from prescription and over-the-counter pain relievers than kratom.

So is kratom really as dangerous as the FDA makes it out to be?

It’s hard to say. But it may be harder to get your hands on kratom. The FDA has already blocked importation of the substance. And in 2016, the Drug Enforcement Agency (DEA) ruled to classify kratom as a Schedule 1 drug, putting it in the same class as marijuana, LSD and heroin as substances with no currently accepted medical use and a high potential for abuse. The DEA backpedaled a bit later in the year following outcry from the public. However, the FDA’s warning could make it more likely for kratom’s Schedule 1 designation to go through.

To me, it seems the FDA is making a bit of a rash decision. Although the FDA says it conducted its own medical analysis of kratom, there is a lot of existing research supporting kratom as effective for conditions such as PTSD and depression. Did they consider this before issuing a warning?

Much like the FDA’s and DEA’s position on marijuana, it seems that decisions are being made based on incomplete examinations of the positives and negatives of herbal substances. The FDA and DEA owe it to patients who use kratom and find benefit from it to conduct a more thorough investigation before deeming it unsafe for public consumption.

Quick Hits: Ibuprofen and Male Fertility, Prostate Cancer Treatment Distress & More

Men may have a greater risk of fertility issues if they take high doses of the pain reliever ibuprofen over the longer term. A Danish study analyzed 31 healthy men who were 18 to 35 years old over the course of 6 weeks. Researchers found that ibuprofen lowered the production of testosterone and led to other health issues such as muscle decay, erectile dysfunction and fatigue. Posted January 8, 2018. Via Proceedings of the National Academy of Sciences.

The side effects that stem from prostate cancer treatment can elevate emotional distress for at least 2 years after the treatment is administered. A study included 1,148 men with prostate cancer who received either surgery or radiotherapy. Results indicated that men who experienced side effects such as urinary, sexual and bowel dysfunction induced by prostate cancer therapy typically reported more emotional distress. Posted December 26, 2017. Via The Journal of Urology

The antidepressant Zoloft (sertraline) may not improve symptoms among patients with chronic kidney disease (CKD). A study assessed 201 patients with non-dialysis-dependent CKD and at least moderate depressive symptoms. Over a 12-week time period, researchers discovered that the use of sertraline did not significantly improve symptoms, but instead caused nausea, vomiting and diarrhea more frequently. Posted November 21, 2017. Via JAMA.

5 Meds That Mess With Digestion (Plus 1 Life-Saving Test)

When your stomach gives you trouble, you might naturally think back to your last couple of meals to try to pinpoint the cause. But it could be something else you’ve swallowed that’s giving you gastrointestinal grief –- like your medication.

Numerous drugs can mess with your digestive system in a variety of ways, from irritating your esophagus or stomach lining to causing stomach bleeding and ulcers.

“With over $4 billion in prescriptions dispensed last year, the odds of such adverse drug reactions are high,” notes Ken Sternfeld, RPh, of RXVIP Enterprises, LTD, a company that provides pharmacy services on site at doctors’ offices, and a spokesperson for the American Pharmacists Association.

Here are 5 common offenders and how to reduce your risk of the issues they can cause. Plus, learn about a simple test that could help you sidestep some of the more serious effects.

1. NSAIDs (Nonsteroidal anti-inflammatory drugs)

NSAIDs such as over-the-counter Advil (ibuprofen), aspirin and Aleve (naproxen), as well as prescription NSAIDs like diclofenac and Celebrex (celecoxib), can cause a range of stomach problems. According to research findings, an estimated 1-2% of people who take these will develop serious GI issues, and the risk of developing a peptic ulcer is 4 to 5 times higher among NSAID users compared to nonusers. Other stomach woes related to these meds include stomach bleeding and less severe symptoms like heartburn, bloating and post-meal nausea.

2. Antibiotics

Although these lifesavers are often absolutely necessary, they can cause one of the most distressing gastro symptoms –- diarrhea. It typically occurs about a week into treatment, but may appear days or weeks afterward. Antibiotics disrupt the balance of gut bacteria, which can also lead to infection by a type called C. difficile that may cause loose bowel movements, abdominal pain, nausea and low-grade fever, and it must be treated with another antibiotic.

Ask your doctor or pharmacist whether you should take probiotics –- in the form of food (like yogurt with live and active cultures) or supplements –- while on antibiotics. Studies show they can help balance gut bacteria and reduce diarrhea associated with antibiotics and C. difficile.

3. Birth Control Pills

Oral contraceptives have been linked with different types of inflammatory bowel disease, which is likely due to effects of estrogen on the immune system, blood clotting, and other functions. A 2013 study of over 230,000 US women found almost 3 times the rate of Crohn’s disease in current users than that of never-users, and a 39% higher rate of Crohn’s among past users. An association was also observed between oral contraceptives and ulcerative colitis, though only in patients with a history of smoking, so be upfront about your history.

4. Antidepressants

Studies have shown higher rates of GERD (gastroesophageal reflux disease) among people taking antidepressants –- particularly the older kinds called tricyclic antidepressants. In research published in 2010, rates of GERD were 71% higher in patients taking tricyclic antidepressants, while no connection was found between GERD and selective serotonin reuptake inhibitors (SSRIs), the newer class of antidepressants that is generally associated with fewer side effects than the older ones. If this is a problem for you, your doc may recommend a change in treatment or an additional OTC or prescription medication to manage the GERD.

5. Opioid analgesics

Due to various effects on the central nervous system and gastrointestinal tract, opioids can really slow things down. Constipation is the most common side effect of these meds, with studies showing that 40-95% of people taking them struggle with this problem. If the constipation becomes chronic, more extreme issues can arise, like bowel obstruction and rupture. Opioid-induced constipation is typically treated with lifestyle modifications and laxatives, or more potent drugs called opioid antagonists if needed. Opioids should only be taken for a few days (except in extreme cases), so constipation should be temporary.

Below are general tips to help you avoid these kinds of side effects.

Follow the directions for use on your prescription or product package –- they might make your eyes glaze over, but those tips can prevent or minimize many drug-related stomach problems.

Take your medications at the specified time. Those that can cause nausea may be best to take before bed so you’ll sleep through it.

It is often suggested that meds be taken with food or water –- if that applies to yours, then do it! However, certain drugs should be taken on an empty stomach because food can interfere with absorption of the medication.

Alcohol should be avoided while taking certain medications –- like NSAIDs, for example –- because it can worsen the irritation of the stomach lining and increase the risk of ulcers and GI bleeding.

The point is to take as instructed, and if there is any uncertainty, be sure to ask the experts. Heed the common advice to talk to your pharmacist about your medications and any concerns that may arise. “Consumers often take drugs without proper management from a pharmacist, in my opinion,” states Sternfeld.

A Surprising Test

He has personal experience with the topic at hand. “My father-in-law, a healthy man, suffered a horrific adverse drug reaction that not only impacted his digestion, but in fact shut down his entire excretion system, leading to toxic levels that almost killed him,” he recalls. He looked into ways that the episode might have been prevented, and was surprised at what he found: “I learned that a simple pharmacogenomic (PGx) cheek swab saliva test –- which was covered by his Medicare insurance –- could have advised the physician to not prescribe that drug to him.”

This is a genetic test that determines whether someone is likely to benefit from a certain medication or experience negative effects, and it can also help a physician determine the best dosage level for a specific patient.

“As a pharmacist, my goal now is to raise awareness that this life-saving test is something everyone should take,” says Sternfeld. Though pharmacogenomic testing is becoming more widely available, it is not yet offered by all healthcare facilities and may not be covered by your particular insurance plan. Check with your doc and insurance company to see if this is a current option for you.

Quick Hits: Americans Open to Non-Drug Pain Treatments, Psychiatric Drugs’ Impact on Cognition & More

More than three-quarters of Americans — 78% — say they are willing to try non-drug alternatives for pain before turning to prescription painkillers. Results from the Gallup-Palmer College of Chiropractic Annual Study of Americans show that 40% of Americans consider prescription painkillers such as opioids a “crisis” or “very serious problem.” And 55% of those who know about the nation’s opioid epidemic place some of blame on the drug industry’s encouraging physicians to prescribe opioids. Another 53% place a lot of blame on doctors overprescribing painkillers to patients. About 23% of those polled said prescription pain meds such as opioids are not very safe, and 8% said opioids are not safe at all. In 2015, more than two-thirds of the opioid deaths reported involved prescription opioids such as oxycodone, hydrocodone, morphine and fentanyl. Posted Sept. 13, 2017. Via Gallup.

Taking high doses of antipsychotic drugs over an extended period may be associated with poorer cognition in schizophrenia. However, taking low doses of antipsychotics such as benzodiazepines and antidepressants over a long time doesn’t affect cognition, according to a new study published in the journal European Psychiatry. The research also found that schizophrenia patients who took a long break from using antipsychotic drugs tended to see their cognitive function improve. Posted Sept. 5, 2017. Via EurekAlert/European Psychiatry.

Women who take antiepileptic drugs (AEDs) during pregnancy have a higher risk of having premature babies or babies that have a low birth weight for their age in the womb. Women with epilepsy who took AEDs while pregnant had a 9.3% increased risk of having a premature baby, while women without epilepsy who took an AED had a 10.5% increased risk, according to results published in the Annals of Neurology. Women who did not take a medication and didn’t have epilepsy had only a 6.2% increased risk of a premature baby. Compared to women who didn’t take an AED and didn’t have epilepsy, women with epilepsy who took one of the drugs gave birth to a child with a mean lower birth weight of 3.9 ounces. For women who took an AED and didn’t have epilepsy, the figure was 4.8 ounces. Common AEDs include Lamictal (lamotrigine), Topamax (topiramate), Tegretol (carbamazepine), Keppra (levetiracetam) and Neurontin (gabapentin). Posted Sept. 11, 2017. Via Medical Express/Annals of Neurology.

Can a Pill Prevent Breast Cancer? For Some Women, the Answer May Be Yes

By Jennifer L.W. Fink
Every morning, I swallow a little white pill in the hope that it will keep me from losing my breasts — or my life — to the disease that’s already taken so much from so many women in my family.

The drug is tamoxifen, a selective estrogen receptor modulator that reduces the effects of estrogen in most parts of the body. The disease I’m running from is breast cancer. And the hope is that this pill will alter my destiny. Breast cancer cells need estrogen to grow and tamoxifen works by blocking hormone receptors on those cells so that estrogen doesn’t attach to those receptors.

My maternal grandmother died of breast cancer. So did her mother. My mother and aunt are both alive and well, but not without significant pain and sacrifice. Both had breast cancer and lost both of their breasts. My mother developed ovarian cancer too, 10 years after she beat breast cancer.

That’s when I pushed for genetic testing, and when we learned that the cancer that plagues our family is likely due to inherited BRCA2 mutations. Women who have a BRCA2 mutation (one of the so-called “breast cancer genes”) have a 45% chance of developing breast cancer by age 70, compared to an approximately 8% risk for women in the general population, according to the National Cancer Institute. Women with a BRCA2 mutation also face a significantly higher risk of ovarian cancer — between 11% and 17% by the time they reach 70, compared to 1.3% for women in the general population.


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Weighing Removal of Breasts and Ovaries

I can decrease my risk of both breast and ovarian cancer by having those organs removed. That’s the choice Angelina Jolie famously made a few years ago. A test showed that Jolie had the BRCA1 mutation — which also greatly raises the risk of breast and ovarian cancers — and her mother, grandmother and aunt had all died from cancer.

I watched my mother go through her mastectomy and recovery, and know the process is far from pain-free. Plus, I like my breasts and my ovaries. They’re important components of my sexuality, health and well-being. I don’t want to surrender them if I don’t have to.

Ask Your Doctor About Chemoprevention If:

  • You have a strong family history of breast cancer
  • You have a known genetic mutation that increases your risk of cancer, such as BRCA1, BRCA2 or PALB2
  • You’ve ever had a breast biopsy
  • You’ve ever been diagnosed with atypical ductal hyperplasia (ADH)

But on the other hand, I see the devastation cancer treatment has wreaked on my mother’s body. Some days, it’s hard for her walk because chemotherapy damaged the nerves in her feet. Her lung problems are likely related to the many doses of radiation to her chest. I’d like to avoid all that too, if I can.

A 5-Year Course of Tamoxifen

So I swallow the white pill. I’m 1-1/2 years into a prescribed 5-year course of tamoxifen.

Chemoprevention, or the use of chemical agents to prevent cancer, is one option for women who are at high risk of developing breast cancer. Prophylactic, preventive surgeries — what Angelina Jolie chose — are another. Watching and waiting is yet another.

Chemoprevention is perhaps the option that is least widely discussed. According to a 2015 article in the New England Journal of Medicine, “even though the benefit-risk ratios for chemopreventive agents are favorable for many women… these agents are infrequently prescribed and infrequently used… Studies focusing on high-risk women show that many physicians are reluctant to prescribe these agents… Numerous other studies have documented the reluctance of women — even women who are considered high-risk — to take tamoxifen, mainly because of a fear of side effects.”

Chemoprevention Can Reduce Cancer Risk, But With Side Effects

Studies have shown that chemoprevention with either tamoxifen or raloxifene — the latter is also a selective estrogen receptor modulator — can decrease the risk of cancer by about half in high-risk women. But both drugs carry significant risks. Both drugs can cause menopausal symptoms, including hot flashes, night sweats, vaginal dryness and weight gain. Both also increase the risk of developing blood clots, and tamoxifen increases a woman’s risk of developing uterine cancer.

Shikha Jain, MD, an oncologist at Northwestern Memorial Hospital in Chicago, helps high-risk women weigh the pros and cons of chemoprevention. “In most breast cancer prevention studies, the overall risk of blood clots developing over the years of treatment was less than 1%,” she says. “Now, if you’ve had a serious blood clot in the past, your risk could be higher. In that case, we wouldn’t recommend chemoprevention.”

Similarly, for most women, the risk of developing uterine cancer as a side effect of chemoprevention is very low. “In one study of women who were on tamoxifen for up to 5 years, specifically to lower their risk of breast cancer, less than 1% of those women developed uterine cancer,” Dr. Jain says.

Still, the decision is not an easy one. Here, 2 women share their experiences with chemoprevention.

Laury Watts

Age: 39

Risk Factors: Family history of breast cancer and PALB2 mutation

On Tamoxifen: since May 2017

“Right off the bat, my oncologist threw tamoxifen at me. I was hesitant. I told her, ‘I don’t want it to ruin my bones.’ She was like, ‘Would you rather get cancer, or brittle bones?’ It was like she didn’t have any sympathy for me… I wavered for 2 months before I started taking it.”
Side Effects: Irregular periods, “stiffness in my bones”

The Doctor Says: “I typically recommend vitamin D and calcium supplementation in premenopausal women if there are no contraindications.” – Dr. Jain

Takeaway: “I feel like I shouldn’t have taken it. I felt fine. I didn’t have cancer. But I also understand that I’m lowering the risk as I’m taking it. I’m on it now, so I might as well stick it out.”

Kelly Miller

Age: 51

Risk Factor: Diagnosis of atypical ductal hyperplasia (ADH)

On Tamoxifen: for 2.5 years

“I started on the tamoxifen so I would feel like I was doing something. I didn’t have any other options except the preventive mastectomy.”

Side Effects: Decreased libido, hot flashes, insomnia, night sweats, increased emotional stability

The Doctor Says: “If patients are having severe symptoms that affect their lives on a day-to-day basis, we can use medications to help. Effexor (venlafaxine) is the one I use the most. It’s been shown to be very helpful with hot flashes.” – Dr. Jain

Takeaway: “It’s definitely scary, but isn’t it amazing that science can tell us that we are prone for a certain thing? At least we have the choice of whether or not to take a pill to try and fight it off.”

Overprescribing: Do You Really Need to Take That Med?

Do you take 4 pills a day? If so, you’re like most Americans. Yet what are we taking all these pills for, and are they improving our lives?

The overuse of prescription drugs has become a serious problem in the US. We hear about this most in the context of opioids — narcotic painkillers whose widespread use and abuse has become a national crisis.

The overuse of antibiotics has also become the focus of an intensive campaign to steer doctors and patients to more judicious use.

The soaring use of prescription drugs has been driven by several factors: A plethora of new drugs coming to the market; a culture that has come to expect a “pill for every ill”; aggressive marketing to both doctors and consumers by the pharmaceutical industry; and treating some “pre-”diseases with pills rather than with lifestyle changes.

Between 1997 and 2016, the number of prescriptions filled in the US increased 85% — from 2.4 billion to 4.5 billion — even though the population increased by just 21%. Nearly half (49%) of adults take at least 1 prescription drug, 23% take 3 or more and about 12% take 5 or more, according to the latest data from the CDC (Centers for Disease Control and Prevention). One in 10 adults takes 10 or more drugs, and the average adult takes 4 prescription medications, according to a Consumer Reports survey of 1,947 adults conducted in April.

What can you do to make sure you’re not getting a drug you don’t need and to avoid harm?

Ten “secret shoppers” were sent to 45 drugstores across the US in a recent Consumer Reports investigative study. The shoppers were testing how well pharmacists identified potential problems with drugs.

Of course, it’s your doctor who should be your main consultant on the medicines you take. But bring a big measure of skepticism to your doctor visits: The evidence is now clear that they can be a part of the problem.

Based on the secret shoppers’ findings and more than a decade of Consumer Reports’ grant-funded Best Buy Drugs program, we have compiled a list of drugs that you should use special caution with when prescribed by your healthcare provider.

(For more detailed information, check out Consumer Reports’ September 2017 cover story and the physician-led Choosing Wisely program.

Abilify and Seroquel for Dementia or ADHD

These powerful antipsychotics have potent sedative effects and can be downright dangerous. Studies over the last decade show they have been overprescribed in general and particularly for elderly people with dementia.

The FDA and other healthcare and physician organizations now advise against their use entirely in elderly people. Multiple studies over many years have found an increased risk of death in elderly people prescribed these drugs.

Abilify (aripiprazole) and Seroquel (quetiapine) are also overprescribed to treat children and adults with attention-deficit/hyperactivity disorder (ADHD). The two drugs are not even approved for this condition. Their use to treat ADHD is not advisable unless a person is diagnosed with other psychiatric conditions, such as bipolar disorder. And even then, caution is warranted. Behavioral therapy is a better initial treatment for ADHD.

Advil, Aleve, Celebrex and Any Opioid for Back and/or Joint Pain

The non-steroidal anti-inflammatory drugs (NSAIDs) Advil (ibuprofen), Aleve (naproxen) and Celebrex (celecoxib) are commonly prescribed to treat back and joint pain (and headaches, of course). Short-term use — up to 10 days — is fine at the lowest dose that helps.

But long-term use — which is all too common — is ill-advised because all these drugs can cause bleeding in the intestines and stomach, and increase the risk of heart attack and stroke (especially at higher doses).

Opioids should simply never be a first-line treatment for either chronic back pain or garden-variety periodic back pain (“I threw my back out” kind of pain). The risks are too high. The side effects include drowsiness, sedation, nausea, vomiting, constipation, addiction and overdose. Instead, try yoga, swimming, gentle stretches, tai chi, massage, physical therapy, acupuncture or heat.

For intense pain flare-ups (pain in the range of 8 to 10 on a 10-point scale), an opioid can be useful, but it should be prescribed at the lowest dose that’s effective and for the shortest time possible, like a day or 2. And never more than a week to 10 days.

Celexa, Cymbalta, Lexapro and Prozac for Mild Depression

Antidepressants are overprescribed for people who have mild or so-called “situational” depression — that is, depression triggered by a life event such as a death in the family, job loss, divorce or breakup, accident, trauma or diagnosis with a serious health condition.

You don’t need a pill if these life events befall you. Social support, time and psychotherapy or counseling almost always help. Also, be sure to exercise and perhaps try meditation and/or yoga. For the vast majority of people who have situational depression, the symptoms lift within a few weeks to a couple months.

Nexium, Prevacid and Prilosec for Heartburn

These drugs, called proton-pump inhibitors (PPIs), reduce stomach acid. They were designed to treat a condition called gastroesophageal reflux disease (GERD). But they are greatly overprescribed for common, uncomplicated heartburn, which most of the time can be just as effectively treated with over-the-counter (OTC) products such as Maalox, Pepcid AC, Tums or Zantac 75.

The problem with taking PPIs is that they carry serious risks — a few of which were not fully appreciated until a few years ago. These include a reduction in the body’s ability to absorb certain nutrients and medications, along with an increased risk of gastrointestinal and other infections.

Instead, as a first-line treatment, eat smaller meals, don’t lie down soon after eating, lose excess weight, and avoid acidic or greasy meals that trigger heartburn.

If heartburn occurs twice weekly or more for 4 weeks or longer despite the above diet and lifestyle changes, then you might have damaged your esophagus. Check with your doctor, and if GERD is diagnosed, it would be appropriate to take a PPI for a few months while your esophagus heals.

Ambien, Belsomra and Lunesta for Insomnia

These strong sleeping pills are way overprescribed for people who have insomnia triggered by a life event, as well as for people who have chronic insomnia.

If you find yourself in the first group, try an OTC sleep aid containing an antihistamine, but not for longer than a few days. People with chronic insomnia are not helped in the long term by taking these medicines, recent evidence shows. Instead, try cognitive behavioral therapy (CBT), where a provider teaches you good sleep habits and suggests ways to change your behavior and nighttime habits.

Prescription medicines have significant side effects and risks, including dizziness, next-day drowsiness, impaired driving, dependence, and worsened sleeplessness when you try to stop.

AndroGel, Axiron, Androderm and Aveed for Low Testosterone

Low testosterone (“low T”) is a controversial diagnosis. If you get such a diagnosis and your doctor advises you to take any of these medicines, get a second opinion.

A small percentage of men (usually in their 50s, 60s and 70s) have “low T,” but the manufacturers of these products have sought to create a condition that is not firmly established in medical literature — one marked by low energy and low sex drive due to “low testosterone.”

Don’t buy into it. The drugs can cause blood clots in the legs, sleep apnea, an enlarged prostate and possibly an increased risk of heart attack or stroke.

Instead, talk to your doctor about treating common underlying conditions that can decrease testosterone level, such as diabetes, obesity and aging. Also discuss non-drug ways to boost energy and vitality by exercising, getting enough sleep and couples therapy with your partner.

Actonel, Boniva and Fosamax to Treat Osteopenia (Low Bone Density)

These drugs, called bisphosphonates, are widely prescribed to treat a condition dubbed “pre-osteoporosis.” But there’s scientific controversy about the prevalence and impact of mildly or marginally low bone density, and whether it warrants treatment with these strong medicines.

All have side effects and carry risks, which include diarrhea, nausea, vomiting, heartburn, esophageal irritation and bone, joint or muscle pain. Long-term use has also been linked to an increased risk of fractures of the femur (thigh bone).

Before considering one of these medicines, walk more, quit smoking and try eating more foods high in calcium and vitamin D. If bone density tests show you have full-blown osteoporosis, you should consider one of these medicines. But use caution with long-term use.

Detrol and Oxytrol for “Overactive Bladder”

The sudden or frequent need to pee is frustrating and inconvenient. These medicines, called anticholinergics, are often prescribed even to people who have mild symptoms.

The drugs can cause constipation, blurred vision, dizziness and confusion. So before trying one, cut back on caffeine, soft drinks and alcohol, and watch your liquid intake overall. Also, try bladder training (slowly increasing the time between bathroom visits) and Kegel exercises — repeatedly tightening and relaxing the muscles that stop urine flow. These techniques have been proven effective.

If several weeks or months of non-drug strategies don’t provide enough relief, consider an anticholinergic.

Actos and Glucophage for “Pre-diabetes”

Pre-diabetes is a widely accepted condition (unlike “low T”), but there’s no consensus on how aggressively to treat it, or if people with it should take drugs. People with pre-diabetes have blood glucose (sugar) levels at the high end of normal.

Because these diabetes medicines have side effects and carry risks — including dizziness, fatigue, muscle pain and, in rare cases, the dangerous buildup of lactic acid and a vitamin B12 deficiency — talk to your doctor about non-drug options first, such as exercise, a diet rich in unprocessed and non-starchy foods, and weight loss.

If you develop type 2 diabetes, however, you should consider a diabetes drug.

Drugs to treat Pre-hypertension

Like pre-diabetes, pre-hypertension is an accepted condition that warrants monitoring. It’s defined as blood pressure at the high end of normal. But, also like pre-diabetes, there’s no consensus on when to treat it with drugs.

Many classes of medicines are used. They include ACE inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers and diuretics. All are effective at lowering blood pressure but have side effects. Diuretics can cause frequent urination, low potassium levels and erectile dysfunction. ACE inhibitors and ARBs can cause high potassium levels and reduced kidney function. Calcium channel blockers can cause dizziness, an abnormal heartbeat, flushing, headache, swollen gums and, less often, breathing problems.

Unless a patient has other conditions that make the case for starting a drug, non-drug options are a better initial treatment to bring blood pressure into the normal range. Most important among them: Quit smoking, cut back on sodium and alcohol, lose excess weight, and exercise.

Belviq, Contrave, Qsymia and Xenical for Obesity

These weight loss drgs have mixed effectiveness. They work for some people and not at all for others. For patients who are significantly overweight or have diabetes or heart disease, and have been unable to lose weight through exercise and diet, one of these medicines may be worth trying.

But the drugs should not be a first-line treatment for anyone who is just 10 to 20 pounds overweight and hasn’t yet really tried lifestyle and diet changes. All have side effects that are common and can be quite discomforting. Constipation, diarrhea, nausea and vomiting are common.

The drugs also carry rare but dangerous risks, including leaky heart valves with Belviq and liver damage with Xenical.

Americans are all too often pushed — or rushed — into taking drugs too soon. Sure, lifestyle changes can be hard. But they don’t have side effects and the risks are well defined and easily avoidable. And the payoff from adopting a much healthier diet or sticking to an exercise regimen often goes well beyond addressing the medical condition at hand and improves your overall physical and mental health.

Quick Hits: Antidepressant Use Soars, FDA Looks at Presenting Fewer Risks in Drug Ads and Marijuana Linked to Hypertension

Between 1999 and 2014, antidepressant use by Americans increased by 65%. By 2014, 1 in 8 Americans (12.7%) 12 and over reported using an antidepressant recently. In 1999, only 7.7% did, according to a new report published by the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS). Results also showed that women are twice as likely to take an antidepressant than men. Between 2011 and 2014, 24.4% of women had taken an antidepressant in the last month compared to 12.6% of men. Whites were more likely to use antidepressants than any other racial or ethnic group, with 16.5% of them admitting to doing so in the last month. That compares to 5.6% of blacks, 5% of Hispanics and 3.3% of Asians. Researchers also found that most people are using antidepressants over a long period of time. For example, 25% of people surveyed reported taking an antidepressant for 10 years or more, and 68% were taking one for 2 years or more. The findings are based on responses from a national health survey of more than 14,000 people conducted between 2011 and 2014, which were compared to responses from the same survey done in 1999. Posted August 16, 2017. Via NCHS.

The long list of risks mentioned in TV prescription drug ads may be whittled down to only covering the most severe risks and side effects. The FDA says research it has conducted found that “a more targeted presentation of risks” presented in direct-to-consumer (DTC) ads can lead consumers to remember more of the most relevant risks and side effects rather than overwhelming them with every single one. The agency noted that it wants to ensure consumers who are viewing these ads are walking away “properly informed” of the key benefits and risks associated with an advertised medication. The FDA is exploring the possibility that DTC ads will include only the most severe (life-threatening) side effects, along with a note that there are other risks not included in the advertisement. The FDA is also asking for comments from the public. “To inform our policies on how risks should be disclosed, we’re asking consumers, providers and other members of the public to help us better understand what risk information is most useful in TV and other broadcast ads,” FDA Commissioner Scott Gottlieb said in a statement. Posted August 18, 2017. Via FDA.

Regular marijuana use may more than triple the risk of dying from hypertension (high blood pressure). In addition, the risk increases with each year of smoking cannabis. Researchers from Georgia State University analyzed data from 1,213 people aged 20 and older who had been involved in an ongoing National Health and Nutrition Examination Survey. The information collected on marijuana use among the group was merged with mortality data from the U.S. National Center for Health Statistics in 2011. Researchers found that marijuana users had a 3.4 times higher risk of death from hypertension than non-users. Posted August 8, 2017. Via European Journal of Preventive Cardiology.