Tag Archives: cyclosporine

‘It’s a Gamble:’ St. John’s Wort, Depression and Drug Interactions

In my 20s, I wasn’t much for traditional medicine. For one thing, navigating our labyrinthine health care system seemed like a lot of unnecessary work. For another, I was broke. Plus, I used henna to dye my hair. I wanted something natural.

That meant that when I felt down in the winter and was quick to worry and anxiety, I didn’t go to the doctor. I went to the drug store and got myself a bottle of St. John’s wort (Hypericum perforatum).

By the time I started taking St. John’s wort around 2003, the plant had been used to rid the environment of evil spirits in ancient Greece and medicinally to menstrual cramps, heal wounds, and treat kidney conditions in later centuries. Today, it’s primarily used to treat depression.

What those early practitioners didn’t know and what I didn’t, either, was that St. John’s wort can interact with prescription medicines in ways that can be serious. With everything from hormonal contraception to organ-transplant drugs interacting with the supplement, the more you know about the interactions, the better off you are.

Powerful or Placebo

In 1998, St. John’s wort was the second most popular supplement in the US, according to the nonprofit supplement industry group the American Botanical Council.

That’s when I first heard about it. But what I didn’t know was that, 4 years earlier, passage of the Dietary Supplement Health and Education Act created the category of dietary supplements and prevented the FDA from requiring supplement companies to prove their products were safe, certify levels of active ingredient or produce evidence that they work.

So, I was working with spotty knowledge. I wasn’t the only one.

Research on St. John’s wort was positive early on, but over the years, the findings have been more muddy, said D. Craig Hopp, PhD, deputy director of the Division of Extramural Research, National Center for Complementary and Integrative Health (NCCIH), part of the National Institutes of Health (NIH) . St. John’s wort seems to be associated with a “strong” reduction in depressive symptoms, including lack of interest in once-pleasurable activities, sleep or eating changes, hostility, irritability, and feelings of guilt, worthlessness or helplessness.

“But you get the same response from the placebo,” he said. “It’s not real clear whether it has [any] benefit.”

A 2002 NCCIH-funded study found that neither St. John’s wort nor the antidepressant tested was any more powerful than placebo for major depression. Another study found the same for mild depression.

On the other hand, a 2008 Cochrane review of 29 studies on the herb found that St. John’s wort is as effective as antidepressants in ameliorating mild to moderate depressive symptoms. But there was a catch: In countries where supplements are regulated and prescribed, the results were more positive. Studies conducted in the US had less positive results.

In any case, Hopp added, “St. John’s wort by itself is safe. But when taken in combination with something else, it dramatically influences how well those medicines work.”

Multiple Interactions

That’s because when you’re taking a whole-herb supplement, you aren’t just getting whatever the active ingredient of the herb is — you’re getting everything else that comes with it, too.

It’s unclear what St. John’s wort’s active ingredient is, though researchers have studied 2 components, hyperforin and hypericin. What researchers do know is that St. John’s wort also delivers significant doses of enzymes that help the body break down medications.

Any drug that is broken down by these particular enzymes breaks down a lot faster than it would otherwise. Drugs include the heart medication digoxin, the opioid oxycodone, some HIV medications, cancer drugs like irinotecan, cyclosporine for organ transplants, and the anticoagulant warfarin. That means that the medication exits the body more rapidly.

In the case of HIV medications, that could mean that the virus mutates and develops resistance to the drug so it never works as well again. In the case of heart medicines, it can increase the risk of a cardiac event.

And in the case of organ transplants, it can be fatal.

“Studies have shown that St. John’s wort would clear immunosuppressive medicines 10 times faster,” Hopp said, “That could cause organ rejection and organ failure.”

Plus, because St. John’s wort is unregulated, you don’t know exactly how much active ingredient you’re getting. That limits doctors’ ability to adjust dosages to accommodate St. John’s wort use, said Austin De La Cruz, PharmD, BCPP, a clinical pharmacist who treats mental health disorders. In addition, he teaches psychiatric treatment and over-the-counter medications at the University of Houston College of Pharmacy.

“It is definitely a gamble,” he said. “If you’re taking St. John’s wort with digoxin and switch to a different St. John’s wort brand that has lower amounts of active ingredient, that can lead to significant toxicity with digoxin.”

Birth Control and St. John’s Wort

Notably, since the majority of people reporting depressive symptoms are women, St. John’s wort seems to break down the contraceptive hormone ethinyl estradiol, a component of most estrogen-containing birth control, about twice as fast as when it is taken alone.

“There were also a number of unintended pregnancies because women taking oral birth control were not getting effective doses,” Hopp said of studies on the topic. “This isn’t fatal [the way organ failure is] but it is still a serious adverse event.”

Treating Accurately

For De La Cruz, all of this makes it hard for him to recommend St. John’s wort. He also pointed to a ban on sale of St. John’s wort in France and Ireland, and careful regulation in other countries as evidence of concern.

If people are interested in non-pharmacological approaches to depression, he recommends therapy. Cognitive behavioral therapy has been found to be more effective than antidepressants alone, he said, and carries no risk of side effects.

Then he’ll make sure patients are trying everything that drugs can’t address — like exercise, food and sleep habits — and light therapy lamps if the depression is seasonal.

“It’s important to identify if the depression can be managed by self-care,” De La Cruz said. For instance, a patient may only come in when they feel depressed, but they may also have bouts of mania. Using only St. John’s wort or an antidepressant could exacerbate manic episodes in bipolar disorder.

Besides, he said, 800,000 people die by suicide related to depression every year.

“Depression is a serious illness,” he said. “I have a hard time recommending St. John’s wort.”

NCCIH’s Hopp was less absolute. If you don’t take any of the medications that interact with St. John’s wort, its risk is essentially zero. But because it interacts with so many medications, people should tell their doctors they are taking it.

“It’s not that you can’t take St. John’s wort,” he said. “But it warrants a high level of extra care.”

Grapefruit Juice Can Have Dangerous Interactions With Some Meds

Eating a grapefruit or having a glass of grapefruit juice in the morning can be a healthy way to start your day – the fruit is high in vitamin C and potassium. But the FDA is reminding consumers that grapefruit can interact with many drugs and how they work in the body, especially if you have high blood pressure or an irregular heartbeat.

When grapefruit interacts with certain medications, the problem is that the juice causes too much of the drug to enter the bloodstream. That can lead to more side effects. For example, drinking grapefruit juice while taking statins such as Zocor (simvastatin) and Lipitor (atorvastatin), drugs used to lower cholesterol, can lead to too much of the drug remaining in your system, increasing your risk for liver and muscle damage that can lead to kidney failure.

Here are some types of drugs that may interact with grapefruit juice:

  • Some drugs that treat high blood pressure, such as Procardia and Adalat CC (both nifedipine)
  • Some organ-transplant rejection drugs, such as Sandimmune and Neoral (both cyclosporine)
  • Some anti-anxiety drugs, such as buspirone
  • Some corticosteroids that treat Crohn’s disease or ulcerative colitis, such as Entocort EC and Uceris (both budesonide)
  • Some drugs that treat abnormal heart rhythms, such as Pacerone and Nexterone (both amiodarone)
  • Some antihistamines, such as Allegra (fexofenadine)

For a further list of drugs that interact with grapefruit, click here.

Grapefruit juice actually causes less Allegra to enter the bloodstream, which may hamper the effectiveness of the drug.

If you eat grapefruit or drink grapefruit juice and have concerns about it interacting with any of the drugs you are taking, talk it over with your doctor. You can also read the medication guide or patient information sheet that comes with your prescription drugs to see if there is a grapefruit juice warning. For OTC (over-the-counter) drugs, check out the Drug Facts label on the bottle.

If you have to avoid grapefruit and grapefruit juice, pay attention to the labels of other fruit juices as they may contain grapefruit juice. Seville oranges, pomelos and tangelos can have the same effect on drugs as grapefruit, so best to avoid them if you know your drug can interact with grapefruit.

Crying Over Dry Eyes

Did your ophthalmologist suggest that you try Restasis (cyclosporine) or another prescription drug if you have dry eyes? You might want to reconsider your choice of doctor and, if you said yes to the drug, reconsider if you really need it or if your doctor was just adding to his bottom line.

Am I being scurrilous? No. Allergan, the maker of Restasis, just agreed to settle kickback allegations by paying $13 million to the federal government and 19 states. The lawsuit alleged that the primary purpose for the “Allergan Access” program, promoted to ophthalmologists, was “to induce doctors to write prescriptions for Allergan’s eye care products, many of which had less expensive treatment alternatives.”

In addition, the program provided doctors with financial analysis, human resource tools, continuing education resources and other highly expensive perks.

This makes me angry. Doctors run a business and they have the right to grow their business and maximize their profits, but not by violating the principles under which they are licensed and sworn to. Doctors hold the trust of their patients, and the welfare of their patients is their first responsibility — before their paycheck. If a doctor is willing to recommend people use products that are not necessarily the best option for the patient, he or she is no longer acting as a doctor but has turned into a salesperson motivated by profit.

This isn’t to say that no one needs Restasis or similar products. There are those with severe dry eye for whom the drug is effective. However, the marketing push was to encourage doctors to prescribe Restasis in order to increase their profit, not because it was the best choice for that patient.

If a doctor is willing to recommend people use products that are not necessarily the best option for the patient, he or she is no longer acting as a doctor but has turned into a salesperson motivated by profit.

The lawsuit was brought by two Philadelphia ophthalmologists, who, according to FiercePharma’s reporting of the lawsuit, “attended an Allergan ‘Dry Eye Dinner’ in 2009, where a senior business advisor for the company told 16 to 20 eye care professionals that aggressively treating dry eye patients would result in significant increases in annual revenues for their practices. Further, the company encouraged doctors to market their practices as a ‘Dry Eye Center of Excellence’ with Allergan’s assistance, the complaint said.”

The idea that Allergan also offered payments for doctor attendance at meetings and dinners, according to the lawsuit, adds further doubts on the ethics of Allergan and the ophthalmologists who participated.

It’s unfair, but because of the actions of a few, we all need to take a closer look at our doctors to see if they are receiving payments from drug companies. A simple step is to go to the Dollars for Docs site by ProPublica, which is exceptionally easy to use. Or try Open Payments, which is run by CMS (Centers for Medicare and Medicaid Services) and is a much more robust site, offering searchable information on doctors, teaching hospitals, and much more, but is a little more complex.

If you see that your doctor is accepting money from a pharmaceutical company, that shouldn’t condemn the doctor, but it should start a simple — but potentially difficult — conversation with your doctor. After that talk, you might be perfectly comfortable continuing your relationship with your doctor. If not, then it’s time to find another provider.

The relationship between doctor and patient requires that the doctor has the patient’s best interests in mind at all times, and is marked by mutual trust between both parties. But as former President Ronald Reagan was famous for saying, “Trust, but verify.”

6 Medications That Can Harm the Kidneys

No matter what kind of medicine you take, whether OTC (over-the-counter) or prescription, it is destined to take a trip through your kidneys. Taking a drug the wrong way or in excessive amounts can damage these vital, bean-shaped organs and lead to serious complications. In the worst-case scenario, it could necessitate a kidney transplant.

“Compared with 30 years ago, patients today…have a higher incidence of diabetes and cardiovascular disease, take multiple medications, and are exposed to more diagnostic and therapeutic procedures with the potential to harm kidney function,” according to Cynthia A. Naughton, PharmD, senior associate dean and associate professor in the department of pharmacy practice at North Dakota State University. All of these factors are associated with an elevated risk of kidney damage.

An estimated 20% of cases of acute kidney failure are due to medications. The technical term for this scenario is “nephrotoxicity,” which is growing more common as the aging population grows, along with rates of various diseases.

The kidneys get rid of waste and extra fluid in the body by filtering the blood to produce urine. They also keep electrolyte levels balanced and make hormones that influence blood pressure, bone strength and the production of red blood cells. When something interferes with the kidneys, they can’t do their job, so these functions can slow down or stop altogether.

Kidney Impairment Can Be Costly

“Although renal impairment is often reversible if the offending drug is discontinued, the condition can be costly and may require multiple interventions, including hospitalization,” Dr. Naughton explained. To help you avoid getting to that point, we learned about medications that commonly cause kidney damage from Rebekah Krupski, PharmD, RPh, pharmacy resident at the Cleveland Clinic and clinical instructor of pharmacy practice at Northeast Ohio Medical University.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Prescription NSAIDs like ketoprofen, and OTC versions such as Advil (ibuprofen) and Aleve (naproxen), narrow the blood vessels leading to the kidneys. Decreased blood flow can cause dead tissue in the kidneys.

Antibiotics

Various classes of antibiotics can harm the kidneys in different ways. Aminoglycosides such as tobramycin can cause toxicity in “renal tubular cells,” which are more sensitive to the toxic effects of drugs because their role in kidney filtration exposes them to high levels of toxins. Sulfonamides, a group of antimicrobials, can produce crystals that do not dissolve in urine, thus blocking the flow of urine, and  vancomycin can cause kidney swelling and inflammation.

Antiviral drugs

Antivirals such as acyclovir, which is used for herpes, chickenpox and shingles and Valtrex (valaciclovir), a herpes treatment, may lead to kidney swelling and inflammation and can also produce those pesky crystals that won’t dissolve. Medications can cause inflammation in several parts of the kidney, often resulting from an immune reaction or allergic response.

Antirejection post-transplant medications

Antirejection drugs including cyclosporine and tacrolimus can constrict the blood vessels near the kidneys, leading to reduction in blood flow and kidney function.

HIV medications

Viread (tenofovir) and Reyataz (atazanavir) can also cause toxicity in renal tubular cells, which are the ones that are especially vulnerable because of the large numbers of toxins they come in contact with.

Diuretics

Water pills like hydrochlorothiazide and furosemide, used for high blood pressure and edema, can cause dehydration and can also lead to swelling and inflammation of the kidneys.

Though symptoms of kidney toxicity can vary from person to person, signs might include a decreased amount of urine, swelling in your legs, feet or ankles due to fluid retention, fatigue, nausea, confusion, shortness of breath and pressure or pain in the chest.

The following tips can help prevent the risk of kidney damage.

  • While taking OTC drugs, pay careful attention to labels and take the medication exactly as directed.
  • When possible, avoid taking medicines like NSAIDs over long periods of time. Any long-term use of any medications, even OTC and herbs, should be under the guidance of your healthcare provider.
  • Make sure you are not taking medications more often or at a stronger potency than needed, as this is a common cause of toxicity.
  • Drink adequate fluids to flush out the toxins. Dehydration is a known risk factor for kidney failure, as it can cause the medication to become too concentrated and to stay in the system too long.
  • Avoid taking NSAIDs during pregnancy, though Tylenol (acetaminophen) is ok. Kidney infections are more common during pregnancy and may result in lower birth weight or premature birth (https://patient.info/health/kidney-infection-pyelonephritis).
  • Avoid drinking alcohol, while taking these medications, as it can lead to dehydration, increased blood pressure, and liver disease, placing you at greater risk of kidney dysfunction.

It is particularly crucial to get close, professional guidance if you have existing medical conditions, including high blood pressure, diabetes and, of course, kidney disease. If so, it is also important to follow your doctor’s advice about keeping your symptoms under control. If you are taking meds that might stress your kidney, your healthcare provider can get an idea of your level of kidney functioning through a blood test that reveals your glomerular filtration rate (GFR). This is considered the best available test for this purpose, and it takes individual factors like age, sex, and race into account. It may be determined that your dosage should be adjusted based on how well your kidneys are working.

More than 30% of preventable kidney events related to meds were caused by a lack of proper monitoring, according to one study. And 37% of such events were due to the healthcare provider’s failure to take action when laboratory results or other clinical signs suggested the patient was at risk.

The Need to Monitor Kidney Function With Certain Drugs

Experts have suggested that after the initial assessment of kidney function, physicians should consider regular monitoring “after starting or increasing the dosage of drugs associated with nephrotoxicity, especially those used chronically in patients with multiple risk factors” for impaired kidney function, Dr. Naughton noted. If there is any sign of kidney impairment, the provider should review the medications you are taking in order to identify which one is causing the problem.

“If multiple medications are present and the patient is clinically stable, physicians should start by discontinuing the drug most recently added to the patient’s medication regimen.” Once that has been taken care of, further harm to the kidneys may be minimized by keeping blood pressure stable, staying hydrated, and temporarily avoiding the use of other medications that may cause nephrotoxicity.

These safety tips can ensure you get the care you need while keeping your kidneys safe. That way, they can tend to essential functions like keeping things flowing (pun intended).

Need to Know: Psoriasis Drugs

There’s been a push for psoriasis drugs, and now that there are more choices on the shelves — and in TV ads — the options can be a bit overwhelming. Which ones work? Which ones have the fewest side effects? We have some answers.

Common Names

Methotrexate, Cyclosporine, Soriatane (Retinoids), Humira, Enbrel, Remicade (TNF-Alpha Biologics), Taltz, Cosentyx (IL-17A Biologics), Stelara (IL-12/13 Biologics), Otezla

Side Effects and What to Do About Them

Methotrexate is one of the oldest psoriasis drugs, in regular use since the 1960s, and is the least costly. It can be taken orally or you can inject it yourself under the skin. Methotrexate can cause nausea and abdominal discomfort, but folic acid can partially alleviate those problems, says Dr. Amy Paller, director of dermatology at Northwestern Memorial Hospital.

Other common side effects include difficulty sleeping, headache and lightheadedness. Other risks include liver damage, especially if you drink, and a small but increased risk for some cancers, including lymphoma. Expect regular blood tests and liver biopsies to make sure your body is processing the drug safely.

Cyclosporine is another older drug with wide-ranging effects on the entire body. It is taken orally. Cyclosporine suppresses the immune system, and Dr. Paller says this drug brings some of the “most concerning” risks of all the psoriasis drugs. Kidney damage is a potential risk, and the risk increases the longer you take the drug. The FDA recommends that patients not take cyclosporine for more than a year, but there are no specific guidelines for what to do after a
year.

Some doctors will prescribe it for more than a year, or will re-start the prescription after you take a break from the drug. Other side effects can include high blood pressure, excessive hair growth and increased growth of the tissue in your gums. Pregnant and breastfeeding women should not take it. Cyclosporine can also increase the risk of skin cancer, especially if you have previously taken methotrexate or had radiation therapy.

Retinoids’ side effects include drying out skin and mucous membranes. They can also cause high triglyceride levels (a type of fat in the blood) and can affect liver function. Retinoids can also cause very serious birth defects, so women who can have children are asked to use 2 effective forms of birth control while they are on the drug and for 3 years afterward. They also should not drink alcohol, because it can combine with the drug to make it stay in the body even longer.

TNF-Alpha biologics (Enbrel, Humira, Remicade), which are given as an injection or as an intravenous infusion, have fewer side effects than the drugs listed. Unfortunately, biologics are extremely expensive. Common side effects of TNF-Alpha biologics include flu-like symptoms and injection site reactions. These drugs can also cause an increased chance of certain infections, such as respiratory and urinary tract infections. They can also cause reactivation of old infections, including hepatitis B. More rare risks include lupus-like syndrome, nervous system problems and new or worsening heart failure. Biologics have not been well studied in pregnant or breastfeeding women.

Taltz and Cosentyx (IL-17A biologics) target an even more specific part of the immune system than TNF-alpha inhibitors. Side effects include an increased risk of fungal infections on the skin and upper respiratory infections. They can also cause reactivation of hepatitis B or other old infections.

Find out more about why the newest psoriasis drugs may not be the best treatment for you here.

Like IL-17A biologics, IL-12/23 biologics (Stelara) target a specific part of the immune system. Side effects include fatigue, headache and upper respiratory infections. Rare risks include an increased risk for cancer and a condition called reversible posterior leukoencephalopathy syndrome. This temporary condition includes headaches, confusion and seizures.

Otezla seems to target a more specific part of the immune system than the older drugs, but it is not a biologic. It is taken orally, and common side effects include diarrhea, headache and nausea. The drug’s prescribing information also includes warnings about depression and unexplained weight loss.

Effectiveness and Considerations

Retinoids are a form of vitamin A, and can be taken orally. One advantage of acitretin is that it does not suppress the entire immune system, says Dr. Paller.

Dr. Michael Siegel, director of research for the National Psoriasis Foundation, describes TNF-Alpha biologics as a “master regulator of inflammation.” By targeting this protein, which is overactive in psoriasis, the treatment is affecting a specific part of the immune system rather than the entire system. That means TNF-Alpha inhibitors, and other biologics, have fewer side effects and risks than the older classes of drugs.

Taltz was just approved in March 2016. Clinical trials for that biologic were conducted mostly in white patients, so the impact of side effects in non-white populations is not well known.

Similarly, Cosentyx trials were also conducted in a mostly white population.

Otezla is a newer drug, approved in 2014, so long-term effects may not be well understood yet. It has not been studied in pregnant and breastfeeding women.

Alternatives to Psoriasis Drugs

New treatments are in the works, says Dr. Siegel, which may reduce side effects even further. For example, instead of a biologic that acts on both interleukins 12 and 23 (the “IL-12/23” inhibitors), it may be possible to target IL-23 by itself and in the process avoid some of the drug’s side effects. Research is also looking at whether there may be a way to tell which patients will respond best to which drugs, and who is most at risk for side effects.

How They Work (Method of Action)

Since methotrexate interferes with cells’ ability to divide and grow, it can cause birth defects if a pregnant woman takes it, or if her partner takes it when they are trying to conceive. And because methotrexate dampens the immune system, people taking it are at risk for infections, which can be serious.

The National Psoriasis Foundation also has a treatment comparison chart which describes all of the approved psorisasis drugs’ methods of action as well as common side effects and possible risks.

Crohn’s Disease: Treatment Side Effects

Corticosteroids

Examples
prednisone, budesonide
Possible Side Effects
Acne (50%), Facial swelling (35%), Osteoporosis (33%), Eye pressure (22%), Infections (13%), High blood pressure (13%), Ankle swelling (11%), Easy bruising, Memory difficulties, Confusion/agitation, Cataracts, Diabetes, Severe hip damage, Poor adrenal gland functioning
Serious Side Effects (Call Doctor)
Difficulty breathing, skin rash, fever, itching, swelling of face and neck, severe headache, vision changes, bruising, acne

Antibiotics

Example
metronidazole
Possible Side Effects

Vomiting, diarrhea, nausea, loss of appetite, dry mouth, dark urine, numbness or tingling in hands or feet

Cipro can increase the risk of tendonitis or connective tissue injury and can worsen muscle weakness

Serious Side Effects (Call Doctor)
Rash, itching, stuffy nose, fever, joint pain

Aminosalicylates

Example
mesalamine
Possible Side Effects
Muscle or joint pain, aching or stiffness; back pain, nausea, vomiting, heartburn, gas, constipation, dry mouth, itching, dizziness, sweating, acne, slight hair loss, decreased appetite
Serious Side Effects (Call Doctor)
Chest pain, shortness of breath, black or tarry stools, bloody or darkened vomit, swelling anywhere on the body
Example
sulfasalazine
Possible Side Effects
Diarrhea, headache, loss of appetite, upset stomach, vomiting, stomach pain
Skin rash, itching, hives, swelling, sore throat, fever, joint or muscle aches, pale or yellow skin, difficulty swallowing, fatigue, unusual bleeding or bruising, weakness

Immunomodulator methotrexate

Example
Methotrexate
Possible Side Effects
Nausea (43%)
Headache (17%)
Fatigue (less than 10%)Can cause liver damage, lung damage, damage to the mouth, stomach or intestinal lining, serious skin reactions, weakened immune system or a decrease in blood cells in bone marrow; can slightly increase the risk of cancer
Serious Side Effects (Call Doctor)
Sore throat, chills, fever, or other signs of infection; unusual bruising or bleeding; excessive tiredness; pale skin; or shortness of breath; fever, rash, blisters, or peeling skin; blurred vision or vision loss, seizures, confusion, weakness or difficulty moving, loss of consciousness;
Tell your doctor if you’re taking NSAIDs or if you’ve had kidney disease or excess fluid around the stomach or lungs

Thiopurine immunomodulators

Example
Azathioprine
Possible Side Effects
Nausea, vomiting, diarrhea
Allergic reactions
Nausea
Liver abnormalities/hepatitis
Pancreatitis
Serious infections
Can decrease blood cells in bone marrow and slightly increase risk of cancer
Serious Side Effects (Call Doctor)
Rash, fever, weakness, muscle pain
 
 
Example
6-MP
Possible Side Effects
Nausea, vomiting, skin darkening, hair loss, rash
 
Serious Side Effects (Call Doctor)
Pale skin, weakness, shortness of breath, sort throat, fever, chills, signs of infection, swelling in legs or ankles or feet, unusual bruising or bleeding, yellowing in the skin or eyes, appetite loss, diarrhea, abdominal swelling or pain

Other immunomodulators

Example
cyclosporine
Possible Side Effects
Headache, diarrhea, heartburn, gas, increased hair growth on face or arms or back, extra tissue growth in gums, acne, muscle or joint pain, cramps, pain or pressure in the face, ear problems, depression, male breast enlargement, insomnia, burning or tingling in the hands, feet, arms or legs
Serious Side Effects (Call Doctor)
Uncontrollable shaking, unusual bleeding or bruising, pale skin, yellowing in the eyes or skin, seizures, loss of consciousness, behavior or mood changes, difficulty controlling body movements, vision changes, confusion, rash, purple blotchy skin, swelling in the hands, arms, feet, ankles or legs
Example
tacrolimus
Possible Side Effects
Headache, diarrhea, constipation, nausea, vomiting, heartburn, stomach pain, appetite loss, insomnia, dizziness, weakness, back or joint pain, tingling or numbness in the hands or fingers, rash, itching
Serious Side Effects (Call Doctor)
Uncontrollable shaking, decreased or painful urination, weight gain, unusual bruising or bleeding, seizures, loss of consciousness, or swelling of arms, legs, feet, hands or ankles

Biologics:
TNF-inhibitors

Example
Infliximab
Possible Side Effects
Infusion or injection site reactions; stomach pain, nausea, heartburn, headache, runny nose, back pain, oral white patches, flushing, and vaginal itching, burning or pain
Serious Side Effects (Call Doctor)
Serious infections; Drug-related lupus-like reactions; any rash, chest pain, weight gain, shortness of breath, blurred vision or vision changes, arm or leg weakness, muscle or joint pain, numbness or tingling in body, seizures, yellowing in skin or eyes, darker urine, appetite loss, upper abdominal pain, unusual bruising or bleeding, bloody stools, pale skin, red/scaly patches or pus-filled bumps on skin, and swelling of feet, ankles, stomach or lower legs
Example
adalimumab
Possible Side Effects
Nausea, headache, back pain, injection site reactions
 
Serious Side Effects (Call Doctor)
Numbness or tingling, vision problems, leg weakness, chest pain, shortness of breath, rash, new joint pain, hives, itching, difficulty breathing or swallowing, unusual bleeding or bruising, pale skin, dizziness, red/scaly patches or pus-filled bumps on the skin, fever/sore throat/chills/infection, swelling of the face, feet, ankles or lower legs
Example
certolizumab
Possible Side Effects
Headache, back pain, injection site reactions
 
Serious Side Effects (Call Doctor)
Facial swelling, hoarseness, shortness of breath, difficulty swallowing or breathing, chest pain, sudden weight gain, hives, hot flashes, dizziness or fainting, rash, unusual bruising or bleeding, pale or blistering skin, extreme fatigue, numbness or tingling, vision problems, arm or leg weakness, joint pain, appetite loss, red/scaly patches or pus-filled bumps on the skin

Biologics: Anti-integrins

Example
natalizumab
Possible Side Effects
Headache, fatigue, joint pain or swelling, arm or leg pain or swelling, muscle cramps, stomach pain, diarrhea, heartburn, constipation, gas, weight loss or gain, depression, night sweats, painful or missed periods, frequent or painful urination, tooth pain, cold sores, white vaginal discharge, and swelling/redness/burning/itching of vagina
Serious Side Effects (Call Doctor)
Sore throat, rash, cough or fever, infection, rash, hives, itching, difficulty breathing, chest pain, dizziness, chills, flushing, yellowing in the skin or eeys, nausea, vomiting, unusual dark urine
Example
vedolizumab
Possible Side Effects
Headache, nausea, joint/back pain, pain in arms or legs, injection site reactions
Serious Side Effects (Call Doctor)
Red or painful skin or sores on body, urination pain, confusion or memory problems, loss of balance, changes in walking or speech, blurred vision or vision loss, extreme fatigue, appetite loss, upper abdominal pain, unusual bleeding or bruising, dark urine, yellowing in skin or eyes, decreased strength or weakness on one side of the body, fever/cough/runny nose/sore throat/chills/aches or other infection