Tag Archives: prednisone

Twitter Helps Identify Side Effects of Steroids

When it comes to taking steroid medication, people seem to be more concerned with minor side effects than major ones.

Researchers from the University of Manchester examined more than 20,000 Twitter posts on prednisone or prednisolone, both commonly prescribed steroid. Those posts indicated people are more worried about the minor side effects associated with the drug, according to a study published in the journal Nature Partner Journals (NPJ) – Digital Medicine.

Researchers used advanced computer software that helped them collect 159,297 tweets mentioning the 2 steroids over the course of 3 years. Of those tweets, approximately 20,000 mentioned possible side effects. The study results found that 8.6% mentioned insomnia, 8.2% mentioned weight gain, 7.8% mentioned nonspecific reactions, such as “I hate the way prednisolone makes me feel,” 7.5% mentioned increased appetite and 4.4% mentioned feeling uneasy.

Although insomnia and weight gain were 2 symptoms popularly mentioned, studies have typically focused on the more serious side effects associated with prednisone, such as hyperglycemia and osteoporosis.

The researchers think that social media platforms such as Twitter can serve as a gateway to learning about possible side effects that people may find problematic.

What to Do If You Have Allergic Reactions to Antibiotics?

What started out as a few pinprick-sized dots on my forearms on Christmas Day turned into a huge allergic reaction that would go on — in various forms — until the 4th of July.

The culprit was the antibiotic dicloxacillin, a member of the penicillin family.

Though antibiotics can be lifesaving, I was taking this one mostly out of convenience. I am prone to mastitis, which occurs when a lactating woman’s milk duct clogs and becomes infected. The symptoms include fever and body aches.

Lactating women — as I was at the time — are typically busy moms with at least one very young child. My youngest was 11 months old. My other two sons were 3 and 8. I had no time to deal with my own illnesses, so if there was a quick fix, I took it.

I now know that was a big mistake.

This was not my first time taking dicloxacillin. I had developed mastitis 6 times over the previous 3 years, and dicloxacillin had quickly cured it with no ill effects.

My seventh round of this antibiotic was the unlucky one. By the time the rash popped up, I had already finished taking the 10-day antibiotic series. I was having a delayed reaction.

Allergies May Be Immediate or Delayed

Drug allergies are still somewhat of a mystery, says Dr. Min Jung Lee, an assistant professor of pediatrics and internal medicine at the University of Texas Southwestern. However, there are indications that frequent antibiotic use does make patients more susceptible to developing allergies.

“The most common symptoms of the immediate reactions occur a half an hour to an hour after taking the medication,” she says. “Symptoms include swelling, vomiting, coughing and anaphylaxis.”

Then there is the delayed reaction, which can happen after the entire series of antibiotic has been consumed. While still dangerous and often lengthy, delayed reactions move more slowly and any life-threatening symptoms usually can be treated with antihistamines and steroids.

Those pinprick spots on my forearms gave way to huge hives all over my body. The last week of December 2010, I went to the emergency room 3 times. Once in an ambulance, I developed large hives, fainted, had swollen lips, mouth sores, gum swelling, fullness in my throat, body aches and more.

Unlike food and seasonal allergies, drug reactions are difficult to understand and predict, says Dr. Corinna Bowser, an allergist at Narberth Allergy and Asthma clinic in Narberth, Penn.

“The difficulty we are facing is that we just don’t know what gets broken down into our bodies,” she says. “It’s unpredictable. What’s the mechanism? Does it happen right away, will it happen later?”

I continued to develop smaller rashes, experienced joint pain, mouth sores and swelling in my fingers, as well as other strange symptoms, like parosmia, a disorder where your brain can’t identify common odors.

Adding to the confusion, many drug allergy symptoms can be confused for symptoms caused by the bacteria that the drug has been prescribed to treat. Bacterial infections can cause rashes.

In my case, it was clear that my reaction, which was becoming serious, was caused by a drug allergy. I was prescribed a massive dose of the corticosteroid prednisone, which tapered over the next 20 days. The steroid did get the rash under control, but my symptoms would continue for weeks.

I continued to develop smaller rashes, experienced joint pain, mouth sores and swelling in my fingers, as well as other strange symptoms, like parosmia, a disorder where your brain can’t identify common odors.

To make matters worse, while going through this process I developed mastitis an eighth and final time. This time I took clindamycin, a drug that comes from a completely different antibiotic family.

I reacted again. And as a result, I finally had to stop breastfeeding.

Multiple Drug Allergy Syndrome

This time though, I noticed the mild rash after just 1 day. I stopped taking the drug, but the symptoms continued. Rashes popped up on my stomach and feet. I had a fever, mouth sores, back pain and swelling around the eyes.

Later, I discovered natural therapies to treat mastitis through my neuropathologist. Heat and cold compresses, lecithin, garlic, and I actually put cabbage leaves in my bra, which for some reason dries up the milk production. The problem is that there is no magic bullet and it takes longer. So instead of feeling sick for a day, nursing moms will feel sick for a week.

All my reactions and symptoms finally came to a sudden end in mid-July, 7 months after they started. But the fear lingered. I was afraid I’d be allergic to other antibiotics and was terrified to try another.

Seeking answers, I began doing research. I found a name for my condition: Multiple Drug Allergy Syndrome.

I finally made an appointment at the Mayo Clinic in Rochester, Minn., where I met with one of the few doctors who specialize in multiple drug allergies.

He was considerably less concerned than I was, and that gave me hope. He put together a plan so that the next time I needed antibiotics I had some reasonable options.

Photograph Visible Allergy Symptoms

Any visible allergy symptoms should be documented with a photograph, says Dr. Maria Castells, physician at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School.

The antibiotics most likely to cause reactions are penicillins, cephalosporins and sulfonamides, Dr. Castells says.

A Kaiser Permanente study in 2009 found that 7.9% of the population is allergic to penicillin, 4.3% to sulfanimides, and 1.2% to macrolides. Females are more likely to be affected, Dr. Lee says.

The good news is that a lot of research is being done on this topic, she says, “especially on genetic determinants and tests to predict allergies.”

Adding more hope for sufferers, antibiotic allergies are often transient, meaning one can be allergic at one time in their lives and then grow out of it 10 years later, Dr. Lee says.

Also, multiple drug allergies does not mean ALL drug allergies.

“Patients can be allergic to multiple medications, but that is rare,” says Dr. Castells. “Most of the time two or three medications are responsible. There is always an antibiotic that a patient can take.”

Two types of tests are available to determine if you might be allergic to penicillin or cephalosporins: A skin test and graded challenge. The skin test involves inserting a small amount of penicillin under the skin. If a red, itchy bump forms, then the patient is allergic. If not, it doesn’t necessarily mean they are not allergic. The patient could still have a non-immediate, delayed reaction. The graded challenge takes place in a doctor’s office with a low dose of penicillin. The dose is increased. If no reaction, the doctor feels it’s safe to prescribe the antibiotic.

As for me, I’m happy to report that I have since been able to take the antibiotics Levaquin (levofloxacin) and Zyvox (linezolid) with no reaction. However, I do avoid antibiotics whenever possible. If there’s another way to treat a condition, I choose that route.

Serious Side Effects Associated with Short-Term Corticosteroid Use

People who took corticosteroids even for a relatively short period of time were more likely to break a bone, have a blood clot or develop sepsis compared to those who didn’t take the medication, according to results of a new study.

Researchers examined data from 1.5 million non-elderly American adults. Over the 3-year study period, about 20% of them filled a short-term prescription for an oral corticosteroid, such as prednisone. Rates of serious adverse events were highest in the first 30 days after receiving a prescription, the researchers reported in the BMJ. Even more concerning, the risk of such events was still high 3 months later.

“We see a clear signal of higher rates of these 3 serious events within 30 days of filling a prescription,” lead study author Akbar Waljee, MD, of the University of Michigan School of Medicine, said in a statement. “We need to understand that steroids do have a real risk and that we may use them more than we really need to.”

Results also indicated that around half of the people that received an oral steroid got the drug for 6 diagnoses related to back pain, allergies or respiratory tract infections.

Waljee also advised that doctors prescribe and patients use the lowest amount of corticosteroid possible. “If there are alternatives to steroids, we should be using those when possible,” he added.

Feeling Anxious? Depressed? Check Your Meds

If you find yourself feeling on edge for no apparent reason while taking a cold medicine or diuretic, you most likely wouldn’t connect the two. However, anxiety happens to be just one of many mood-altering symptoms that can be brought on by certain meds.

“Many medications, whether prescribed or found over the counter, can cause psychiatric symptoms,” says Shiyun Kim, PharmD, BCACP, BCPP, CDE, a clinical pharmacist and clinical assistant professor at the University of Illinois Hospital & Health Sciences System, and a spokesperson for the American Pharmacists Association.

She explains that a wide range of factors influence the way a drug affects each person, including things like metabolism, underlying illness, and interactions with other drugs. “Any variations that occur, such as with improper doses or individual reactions, can result in undesirable psychiatric symptoms,” though they are relatively uncommon.

If you feel that you may be suffering from these side effects, notify your providers immediately. “Keep in mind that some medications can be stopped abruptly, while others need to be tapered to prevent further adverse effects,” Dr. Kim emphasizes. “Your provider can make the best decision with you.”

Take note of the following medications that can have these kinds of effects, and read on to find out how to minimize the risks.

Oxycontin and Similar Pain Medications

“Most prescription pain medication, such as oxycodone (OxyContin) or hydrocodone, can cause drowsiness, which can make one feel ‘cloudy’ and lack motivation — and these symptoms closely mimic depression,” according to Bree Meinzer, PharmD, CTTS, a pharmacy practice resident at Ohio Northern University. Opioids can also lead to more severe symptoms like paranoia, hallucinations, psychosis and dementia, especially at high doses. Signs that you may have taken too much of an opioid include trouble breathing and unconsciousness. People with opioid dependence and those who suffer from HIV, liver or lung disease or suffer from depression may be more susceptible to these effects, according to the World Health Organization. If you are on a pain medication that makes you drowsy or “cloudy” and you do not like how it makes you feel, you should talk to your doctor about other ways to adequately manage your pain.

Lasix, Microzide and Other Diuretics

Medications that reduce fluid retention and swelling, including furosemide (Lasix) and hydrochlorothiazide (Microzide), increase urination. This can lead to dehydration, especially in the elderly, and can result in hallucinations and dizziness, says Dr. Meinzer. SGLT2 inhibitors such as canagliflozin (Invokana) and empagliflozin (Jardiance), which are drugs used to treat diabetes, can also increase urination and cause dehydration. If you are taking these types of medication, be sure to drink plenty of water to stay sufficiently hydrated. The amount of water to drink should be discussed with your doctor and is dependent on your weight. “These medications should also be taken in the morning or early afternoon to avoid frequent urination at night,” which could disrupt sleep, she advises.

Ask your doctor to take a look at your current medication regimen to rule out potential drug-drug interactions that could cause psychiatric side effects.

Requip and Other Dopamine Agonists. Medications like ropinirole (Requip), often prescribed for restless leg syndrome and Parkinson’s disease, increase the brain chemical dopamine, which helps regulate mood and behavior. Too much dopamine can cause hallucinations, notes Dr. Meinzer, and more extreme potential side effects include confusion, mania, depression and impulse control disorders like compulsive gambling or eating. “There are other options for restless leg syndrome that don’t increase dopamine, though medications like ropinirole typically work best.” There are also different medications for Parkinson’s, though you and your doctor should carefully consider your particular treatment needs. If you experience these kinds of symptoms while taking this type of medication, it may be that your dose is too high.

Ritalin, Adderall and Other Stimulants

Drugs that are commonly used for the treatment of attention-deficit hyperactivity disorder (ADHD) include those sold under the brand names Ritalin and Adderall. Although these stimulant medications “help children and adolescents focus and stay on task, side effects include increased heart rate and insomnia, which can often cause anxiety and restlessness,” says Dr. Meinzer. Stimulants “excite the central nervous system and can disrupt normal communication between cells in the brain,” adds Dr. Kim. “This class of drugs may also cause bizarre behavior, agitation, mania, paranoia and nightmares.” Dr. Meinzer suggests talking to your healthcare provider if you feel extremely restless and anxious while taking this type of medication. Again, it is possible that your dose is simply too high.

Corticosteroids

Medications like prednisone, cortisone and methylprednisolone are often prescribed “to help respiratory symptoms and decrease inflammation with chronic diseases,” Dr Meinzer explains. They are typically only “used for a short term to help alleviate symptoms, but if you are on these medications for a long time, they can cause some unwanted side effects.” Use of these drugs for more than a few months can increase the chances of experiencing mania, anxiety, depression, paranoia and psychosis, which have mostly been reported by patients using high doses or abusing the medication, says Dr Kim. Though experts are unclear about the exact reasons for such side effects with these drugs, research suggests that it may have to do with the way steroids work in the area of the brain that influences memory and emotion. It is also possible that “high levels of steroids result in brain damage and cause cognitive dysfunction.”

Zarontin and Other Anticonvulsants

Medications such as ethosuximide (Zarontin), which are used to control seizures in people with epilepsy, can cause symptoms resembling depression. These drugs have also been found to increase suicidal thoughts and behavior. “If you start to experience these symptoms on an anticonvulsant, you should talk to your doctor about other regimens,” Dr. Meinzer recommends. “There are other medications in the same class that are less likely to cause this side effect,” though your doctor may want you to stay on the medication because it may be the one that is most effective for you. “Anticonvulsants are usually tricky to dose and may need lab monitoring to make sure they are in the proper range.”

Dr. Kim offers the following general tips to help prevent or deal with these side effects:

  • When you are prescribed a drug, ask your provider about potential side effects that are commonly noted and reported.
  • Ask your provider to take a look at your current medication regimen to rule out potential drug-drug interactions that could cause psychiatric side effects.
  • Withdrawal of some drugs can cause symptoms such as anxiety, agitation or depression. Therefore, call your doctor before stopping medications on your own.
  • When purchasing an over-the-counter (OTC) medication, take the time to read the instructions on the package. If anything is unclear, ask the pharmacist for guidance.

Long-Term Effects of Corticosteroids

Corticosteroids are used to treat many different medical conditions, from rheumatoid arthritis to allergies to lupus and more. The prescribed medicines include: Celestone (betamethasone), Cortone (cortisone acetate), Decadron/Hexadrol (dexamethasone), Acticort/Aristocort/Cortef (hydrocortisone), Medrol (methylprednisolone), Prelone (prednisolone) and Deltasone/Sterapred (prednisone).

Some concerns patients have over long-term side effects of corticosteroids include:

  • uclers / gastrointestinal bleeding
  • osteoperosis
  • increase risk of heart disease
  • decrease in bone density
  • increased risk of infections
  • thin skin, bruise easily, slower healing of wounds

These are just some of the concerns, please visit the resources section of this page for more information.

See also:

Because of the wide variety of medical conditions that corticosteroids treat, it is very important that any conversations with your medical provider include understanding the long-term effects.  Remember that long-term effects of drugs are relevant to prescription dose and length of treatment, and MedShadow encourages discussions that give you enough information to make an educated decision about your healthcare.  Effects, both positive and negative, have long lasting repercussions on our quality of life.

Studies

Studies on corticosteroids tend to lean toward the extreme use, rather than the average use.  For example, some studies look at corticosteroids for extreme and rarer cases of eczema.  This makes it harder to research what long-term studies are out there on steroid use.  To complicate things further, corticosteroids can be oral, topical, injected, or inhaled, and this dramatically changes the benefits and risks, and in turn the short-term and long-term effects.  Speak with your doctor and pharmacist on what, if any, long-term studies out there are relevant to your own medical treatment.

Here are some studies, but we encourage you to look at our Organizations and Other Resources section below to complement your own search for more information.

Study of Asthma and Steroid Study (STAN)

This study found that long-term use (24 weeks) of nasal steroid was not better at improving asthma control in adults or children. There are also studies here on the short- and long-term use of topical steroids for eczema.

Inhaled Corticosteroids for Cystic Fibrosis

A recent Cochrane review found that clinical trials cannot prove that inhaled corticosteroids reduce inflammation in the lungs of cystic fibrosis patients. However, one trial revealed that inhaled corticosteroids can inhibit a child’s growth when used in high doses.

Corticosteroids for Rheumatoid Arthritis

Another Cochrane review found that while there is convincing evidence that corticosteroids can reduce the rate of erosion progression in rheumatoid arthritis, unfortunately, there is also concern that the long-term effects of corticosteroids, such as increased cardiovascular risk and osteoporosis, may outweigh their benefits.

Corticosteroids and Staph Infection Risk

A study found that when used over the long term, systemic glucocorticoids, a type of corticosteroids, may make patients more susceptible to life-threatening staph blood infections.

There are also studies here on the short and long-term use of topical steroids for eczema.

Articles We Like

Prednisone and Other Corticosteroids: Balance the Risks and Benefits

A good guide from the Mayo Clinic outlining the risks and benefits of taking many types of corticosteroids.

Corticosteroids

A nice overview of corticosteroids from the Cleveland Clinic

Steroid Side Effects: How to Reduce Corticosteroid Side Effects

A physician from New York’s Hospital for Special Surgery describes drug-related side effects for different kinds of corticosteroids and provides self-care tips to minimize the chances of experiencing them.

Nasal and Oral Corticosteroids for Allergies

A nice review of corticosteroids used to treat allergies, including side effects and adverse events to be aware of

Inhaled Corticosteroids Not Linked to Pneumonia

A meta-analysis of 31 studies that included 11,615 children with asthma found that use of inhaled corticosteroids did not lead to an increase in pneumonia or other respiratory diseases.

Common Medicines Should Mimic Timing of Body’s Natural Systems to Prevent Side-Effects

“Debilitating side effects associated with prescription medication for some of today’s most common conditions could be eradicated if they mimicked the body’s natural hormone secretion cycles, a new report has said.” – Science Codex

Steroid Shots for Tennis Elbow Miss the Mark: Study

and With Elbows, Cortisone Shots May Hurt More Than Help

A corticosteroid shot and physical therapy have no long term benefits in the treatment of “tennis elbow”, a new study (Australia) confirms.

Asthma and Arthritis Medications are Drug Muggers

A pharmacist explores the ways that different drugs “mug” the body of important nutrients.

Researchers Discover Genetic Bias for Eczema, New Avenue to Therapies

A University of Oregon study discovered an “underlying genetic cause of atopic dermatitis”, opening up avenues to alternative treatments that may bypass the use of topical steroids.

Organizations and Other Resources

Why are steroids used in medicine?

Access Science by McGraw Hill answers this question from a scientific perspective, but succinctly lays out the breadth of uses of different steroids in medicines.

Asthma Health Center

WebMD has a great page with information on use of inhaled corticosteroids for the long-term control of asthma.

5 Drug Classes That May Cause Depression

Depression can be a complex disorder with many causes, but depressive feelings can also result as a side effect of medication. For most medications, the risk is small, but if you have experienced depression in the past, you may be more likely to develop depression again when you take one of these drugs.

It can be difficult to tell whether depression is due to a drug, says Linda Lang, MD, chair of the Department of Psychiatry at Christiana Care Health System in Delaware, especially if a person also has an illness that itself can lead to depression. “We have to be mindful of the potential that somebody who has breast cancer is put on tamoxifen and they’re depressed,” she says.

“You might say ‘Well of course they’re depressed, they have breast cancer’ but it might be the tamoxifen.” For the same reason, researchers have a hard time concluding whether the drug causes depression because a lot of patients with a cancer diagnosis might develop depression anyway.

Depression isn’t just sadness. Symptoms to watch out for include feelings of hopelessness, change in appetite, thoughts of death, difficulty sleeping, or irritability. You probably won’t feel these effects right away, but they may set in after a few weeks.

Cardiovascular Drugs

Beta-blockers reduce your blood pressure by blocking the effect of the hormone epinephrine, also known as adrenaline. Researchers have suspected a connection between this class of drugs and depression for nearly 50 years, without strong evidence to answer the question either way. The risk for depression, if it exists, is probably small.

Statins, the cholesterol-lowering drugs, are also possibly linked with depression. Statins can interfere with the way the body uses serotonin, and serotonin is important to the brain’s functioning. As with beta-blockers, studies looking for the connection have had mixed results, with some even finding that statins may have an antidepressant effect.

Hormonal Agents

Drugs that interfere with the way hormones operate in the body can affect mood. Corticosteroids, for example, can lower serotonin levels and might be able to cause depression. This class of drugs includes cortisone and prednisone.

Tamoxifen, a breast cancer treatment, also has possible connections with depression. Tamoxifen interferes with estrogen, with different effects in different parts of the body. It’s possible, though not fully proven, that this can lead to depression.

Birth control pills have also been linked with depression, but again the relationship is hard to untangle. A recent study of Danish women found that those on contraceptives were slightly more likely to fill a prescription for an antidepressant. But women who go to the doctor for birth control may have simply been more likely to have an opportunity to get their depression diagnosed.

Antiepileptic Drugs

Antiepileptics are drugs used to treat seizure disorders, and may also be used for other purposes. Topamax (topiramate) can be used to prevent migraines, for example. These drugs both act on neurotransmitters and their receptors in the brain.

Both of these drugs have been linked with depression, even though topiramate can also be used to treat certain kinds of depression. Topiramate was one of the drugs associated with an increased risk of committing suicide in one Danish study. People taking that drug were twice as likely to commit suicide as people who were not taking it. That means the numbers are still small — very few people commit suicide — but the risk is still concerning.

Other anticonvulsants share this risk, and may be worse than topiramate. Since 2008, the FDA has required all anti-epileptic drugs to carry a warning about an increased risk of suicidal thoughts and actions. The agency notes that the increased risk applies to eleven different drugs, that work in different ways and are prescribed for different reasons, so they consider the warning to apply to all antiepileptic drugs.

Parkinson’s Disease Medications

Parkinson’s disease is often treated with drugs like levodopa that increase the amount of dopamine in the brain. That makes sense, since Parkinson’s results from the death of dopamine-generating cells in the brain. “But as a result of increasing dopamine we can induce depression,” Dr. Lang says.

Dopamine, serotonin, and norepinephrine are neurotransmitters that all have some link to depression, so drugs that change the amounts of these chemicals in the brain may cause depression.

Retin-A (Isotretinoin)

Retin-A (isotretinoin) is a form of retinoic acid used to treat acne. The FDA received a large number of reports of suicides and suicidal thoughts while people were using this drug. As with many of the other drugs linked to depression, it is unclear whether isotretinoin truly causes an increased risk of depression and suicidal thoughts.

For any of these drugs, Dr. Lang says, your doctor should be monitoring your mental health, for example through depression screenings questionnaires. People taking these drugs are often at increased risk for depression, whether due to the drug itself or to the condition it causes.

If a medication seems to be causing any symptoms of depression, talk to your doctor about your options. In many cases, they can change your medication. If you need to stay on that medication, they can help you manage the depression, for example with anti-depressants or other therapy.

6 Dangers Unique to People with Diabetes

If you have diabetes, you probably know all about how food affects your blood sugar, including what, when, how often and how much you eat. Skipping meals, for example, can be a clear recipe for disaster, and overdoing starchy foods can cause glucose to soar. There are several other substances and scenarios that you may not be aware can cause dangerous dips or spikes in your glucose levels. Some experts weigh in so you can learn more about these risks and make sure you don’t end up in any danger.

1. Over-the-counter meds. While most OTC drugs are generally safe for use with diabetes medications, there are a few that can pose risks. Aspirin can lower blood sugar, though it typically takes quite a large quantity to have that effect, and other OTC meds can drive glucose up.

“The most common offenders are the allergy and decongestion products, which include pseudoephedrine or other decongestants that can increase a diabetic patient’s blood sugar level,” according to Kevin M. Pantalone, DO, a staff endocrinologist and director of clinical research at the Cleveland Clinic. Some cough syrups can also boost glucose because they contain sugar. Again, standard doses are unlikely to make a big difference, but “if this is a real concern for a particular patient, a sugar-free cough syrup could be purchased instead.

2. Other prescription drugs. “The medications that patients really need be concerned about raising their blood sugar levels are steroids such as prednisone,” says Pantalone. “It is not unusual for patients to receive an injection of steroid into a joint for pain relief, for example, only to then notice their blood sugar levels spiraling out of control a few days later.”

The injectable and oral varieties tend to have the largest impact, but inhaled and topical steroids can also have glucose-raising effects. Steroids are typically prescribed to treat conditions including asthma, inflammatory bowel disease (Crohn’s disease, ulcerative colitis) and joint/muscle diseases, such as rheumatoid arthritis. To avoid a potential emergency, alert your physician if you have been or will be prescribed steroids. Also, antibiotics, especially the class called fluoroquinolones (e.g., Cipro/ciprofloxacin), can cause significant glucose fluctuations in either direction, leading to hypoglycemia in some people and hyperglycemia in others.

3. Dieting. Diabetes meds reduce blood sugar regardless of how much or little food a patient is eating at a given time, explains Pantalone. During times of decreased appetite or limiting food intake by choice, a person taking such drugs may experience drops in glucose that can cause levels to become dangerously low when combined with the medication. Don’t attempt to tweak your dosage on your own, though.

“Patients should review with their doctors which medications need to be adjusted, if any, prior to making any self-adjustments,” he recommends. “Patients with insulin-dependent diabetes cannot simply skip doses of long-acting basal insulin, as doing so could result in an emergency situation, and maintenance medications usually need to be continued, albeit often times at a lower dose.”

4. Illness. While a cold medicine can raise blood sugar, the “cold itself is likely to increase glucose levels too,” says Matthew Freeby, MD, director of the Gonda Diabetes Center at David Geffen UCLA School of Medicine. People taking diabetes drugs might require a higher dosage when experiencing bodily stress caused by illness.

The disease-fighting hormones your body releases in response to the stress of illness can boost glucose and interfere with your medication. In type 1 diabetes, this can lead to a life-threatening condition called ketoacidosis, and may result in diabetic coma. Though less likely to affect individuals with type 2 diabetes, illness may still lead to excessive blood glucose levels in both groups.

Alternatively, some patients may need a lower dosage of diabetes medication while sick because of decreased appetite.

Talk to your doc or diabetes educator about creating a “sick-day plan,” so you’ll know exactly what to do in case of illness.

5. Herbal supplements. “Most patients don’t think to tell their clinician or pharmacist that they’re using herbal supplements because they appear ‘safe’ and natural,” notes Amy Gustafson, PharmD, manager of ambulatory pharmacy at the Cleveland Clinic Twinsburg Family Health Center. But many natural products can decrease blood sugar and lead to too-low levels when combined with diabetes meds, she says, including garlic, ginseng, fenugreek and cinnamon. No need to worry about the herbs when used as spices, the concern is the concentrated amounts found in supplements.

“Other agents that could interact with diabetes drugs are aloe vera, andrographis paniculata, karela (Momordica charantia), Lycium, St. John’s wort, and herbs with glucosamines, isoflavones or levocarnitine,” adds Mohamed A. Jalloh, PharmD, assistant professor at Touro University California College of Pharmacy and a spokesman for the American Pharmacists Association. “St. John’s wort and ginseng are the worst because they induce the same enzyme that processes most diabetes drugs” and therefore decrease their effectiveness.

6. Alcohol. Hitting the sauce can mess with your meds and your glucose, though maybe not in the way you would expect. It is well-known that alcohol can increase blood sugar in small amounts, but in larger doses, it “can increase the risk of hypoglycemia by reducing the liver’s natural glucose production — and alcohol plus medication can add up to a low glucose level,” explains Freeby. “Therefore, patients taking diabetes medications should be cautious with alcohol intake and need to consult their doctor” regarding safe limits for their specific situation.

In many cases, people with diabetes can drink alcohol in moderation, but you should never do so on an empty stomach or when you know your blood sugar is already low. People taking insulin or sulfonylureas are especially vulnerable to the glucose-lowering effects of alcohol.

How to Stay Safe

One of the most important ways to minimize such risks is to keep close track of all drugs you are taking, including OTC drugs and natural supplements, advises Jeff McClusky, BS, RPH, a hospital pharmacy manager and American Pharmacists Association spokesperson in Houston, Texas. “Verify that both your physician and pharmacist have these details, and ask them first if you are looking to change any OTC or medication practices,” he says.

It is best to use just one pharmacy so that they can maintain up-to-date and accurate records, and this helps the pharmacist get to know you as a patient and fully understand the various medications you may be taking. “Having all of these details in one place allows them to provide comprehensive medication reviews every time you visit them,” McClusky adds.

Need to Know: Corticosteroids

Corticosteroids are often used in the treatment of joint pain or inflammation (arthritis), as well as irritable bowel disease (ulcerative colitis and Crohn’s disease), skin diseases, allergies, asthma and even brain tumors. However, this class of drugs can cause many complications. Knowing and understanding the facts can improve corticosteroid use.

Common Names

Celestone (betamethasone), Cortone (Cortisone acetate), Decadron (dexamethasone), Cortef (hydrocortisone), Aristocort (hydrocortisone), Medrol (methylprednisolone), Prelone (prednisolone), Deltasone (prednisone)

Side Effects and What to Do About Them

Corticosteroids can be taken in tablet form or through inhalation, and the side effects will differ based on what form of medication is used.

The most common side effects of inhaled corticosteroids include a sore mouth, hoarse voice, and infections in the throat and mouth. To avoid or reduce these side effects, it’s highly recommended to rinse the mouth out with water after taking the medication.

The most common side effects of corticosteroids in tablet form include bruising of the skin, weight gain, weakening of the bones, high blood sugar levels, cataracts, and swelling of the feet or ankles. Side effects can lessen during treatment as your body adjusts to the medicine, but if these side effects continue or are bothersome, you may want to check with your doctor to discuss alternative medications.

Diet is very important if you take a corticosteroid for a long time. Doctors might want you to follow a low-sodium or a potassium-rich diet.

Before giving corticosteroids to children or teenagers, doctors should discuss the possible side effects. They may cause infections like chickenpox or measles, or slow growth in children and teenagers.

According to a Cochrane review, clinical trials cannot prove that inhaled corticosteroids reduce inflammation in the lungs of cystic fibrosis patients. However, one trial reveals that inhaled corticosteroids can inhibit a child’s growth when used in high doses.

Older patients who take corticosteroids may be at risk of high blood pressure or osteoporosis. Women, in particular, are at risk of developing bone disease. Because of this, women should ensure they are getting enough calcium and vitamin D in their diet. If not, they should consider taking supplements. In severe cases, bisphosphonates may be prescribed to treat the osteoporosis.

In another Cochrane review, there is convincing evidence that corticosteroids can reduce the rate of erosion progression in rheumatoid arthritis. Unfortunately, there is some concern that the long-term effects of corticosteroids, such as increased cardiovascular risk and osteoporosis, may outweigh the benefits.

Drug Interactions

Other medicines can interact with corticosteroids, and as a result the side effects of either medicine can be altered.

Mixing corticosteroids and anticoagulant medicines (such as heparin, warfarin, dabigatran, apixaban, and rivaroxaban) can make anticoagulants less effective. Additionally, it can cause bleeding inside the digestive system.

If you need to take both corticosteroids and a diabetes medication, then your blood glucose levels should be checked regularly and your dose of diabetes medication might need to be adjusted.

Combining NSAIDs (non-steroidal anti-inflammatory drugs) such as aspirin, ibuprofen, Voltaren (diclofenac), naproxen and corticosteroids increases your risk of developing stomach ulcers and internal bleeding. If you need to take both medications, you may be given a proton pump inhibitor (PPI) to minimize the risk of stomach ulcers.

Effectiveness & Considerations

Corticosteroids are intended to provide relief for inflamed areas of the body. They are used to lessen swelling, redness, itching, and allergic reactions. Typically, corticosteroids are used to treat severe allergies or skin problems, asthma, and arthritis.

The body naturally produces cortisone-like hormones to maintain good health, but if your body doesn’t produce enough cortisol, then your doctor might suggest corticosteroids to help make up the difference. This type of medicine is available by prescription only. The duration of corticosteroid treatment depends on the condition being treated.

Alternatives to Corticosteroids

Corticosteroids are the most popular therapy to treat inflammation, but patients should consider the safety concerns. Herbs and dietary supplements might offer just as effective results as prescribed corticosteroids. Natural anti-inflammatory treatments include omega-3 fatty acids (fish oil), white willow bark, curcimin (turmeric), and green tea. Always make sure your health care providers know all the medicines, herbs and supplements you are taking or considering taking. Every product you put in your body can cause interactions you may not know to expect.

Since the late 18th century, fish oil has been used to treat muscular, skeletal, and discogenic diseases. The therapeutic benefits of fish oil have shown to be an effective, natural anti-inflammatory agent. The active ingredients in fish oil can directly reduce inflammation in cartilage. There have been positive clinical studies that show the efficacy of fish oil in treating arthritis.

One of the oldest herbal remedies for pain and inflammation is bark from a white willow tree.  White willow bark works similarly to aspirin by blocking swelling. Usually, the dose of white willow bark is 240 mg/day. White willow bark is available as a supplement in a pill form, as well as a liquid extract.

Curcumin is yellow in pigment and derived from turmeric, a plant of the ginger family. Curcumin is considered to inhibit inflammation by suppressing NF-kB, a protein complex that controls transcription of DNA. Clinical studies have shown that curcumin has anti-inflammatory effects. It’s possible to be a viable natural alternative to nonsteroidal agents.

Green tea is used in the treatment of arthritic disease as an anti-inflammatory agent. The constituents of green tea have shown to inhibit aggrecanases, enzymes found in cartilage, which degrade cartilage. Research on green tea demonstrates anti-inflammatory effects.

How They Work (Method of Action)

Corticosteroids imitate the effects of cortisol, a natural hormone in your body, to suppress inflammation. They also lower the activity of your immune system by reducing white blood cells, which help to prevent damage to body tissue.

What Worked for You?

Share your experience with bisphosphonates in the Disqus box below.

MedShadow Coverage on Corticosteroids

Further Reading

Corticosteroids Method of Action

A Glass of Cheer Can Impair Your Medicine

Everyone knows not to mix alcohol and prescription medicines, right? But the math indicates a lot of people are doing it. More than half of all Americans report having a drink in the past month or more frequently. Almost 70% of adult Americans are on prescription drugs. If you are taking Lipitor, Ambien or Xanax you need to think twice about the cocktail hour.

April is Alcohol Awareness Month, a good time to double-check the list of potential interactions.

Consider the effect of alcohol in your body: it’s a depressant so it slows the central nervous system. A little alcohol often helps a person feel more relaxed or less anxious. A little more results in slower reaction times, impaired judgment, low blood sugar, low blood pressure, and makes you feel depressed. It also challenges the liver. Any drugs with similar depressant properties will increase or even multiply the effects.

If you take a drug to lower your blood pressure, alcohol will lower it further. When blood pressure dips, expect dizziness, light-headedness and, possibly, fainting.

Antidepressants slow the central nervous system and so does alcohol, so expect even more impaired thinking and lack of alertness. They both make you sleepy. Fall asleep with alcohol and antidepressants slowing your central nervous system and you may stop breathing.

In addition, drugs for depression mixed with alcohol increase the risk for overdose and lead to increased feelings of depression or hopelessness in adolescents and raise the risk of suicide.

Alcohol intensifies the effectiveness of sleeping pills, causing such low blood pressure and severe sleepiness that you could be at risk of stopping breathing in your sleep. (Watch out for interactions with Ambien, Lunesta, Sominex, and herbal preparations including chamomile, valerin and lavender.)

Another factor to check: Certain medicines contain up to 10% alcohol. Cough syrup and laxatives often have some of the highest alcohol concentrations.

Over-the-counter painkillers like ibuprofen and aspirin aren’t usually a problem with light drinking. “Painkillers and booze are perhaps the worst to mix, because both slow breathing by different mechanisms and inhibit the coughing reflex, creating “a double-whammy effect… that can stop breathing altogether,” according to Scientific American. Alcohol and painkillers together impair thinking (potentially causing you to take more medicine or drink more) and motor skills. Alcohol increases their sedative effect, causing blood pressure to drop, sometimes leading to breathing problems and death.

Anti-seizure (anticonvulsants) are sometimes given for pain management. Combining them puts you at risk for seizures and will likely make you severe drowsiness or make you lightheaded.

Doctors are not in agreement about steroids like prednisone and alcohol. There isn’t much research on it and many doctors say light drinking is fine. However, others point out that both prednisone and alcohol have the ability to irritate the stomach, leading to possible stomach ulcers or gastrointestinal system irritation. Both prednisone and alcohol can suppress the immune system and the combination can make it worse. Some docs think that alcohol increases the side effects of prednisone: rapid weight gain, facial swelling, anxiety, acne, dry skin or skin discolorations.

Drinking any alcohol puts some stress on your liver. Statins like Lipitor, Crestor, Zocor and acetaminophen like Tylenol also clear your body through your liver. The combination can put you at risk for liver failure more quickly than you might think.

Acetaminophen is commonly included in allergy, cold and flu medicines. If you aren’t aware of that and take a couple of Tylenol for other symptoms, you can easily go over the recommended dose. Add a glass or two of wine and it increases the strain on your liver. (Delsym, Robitussin, Allegra, Alavert, Claritin, Dimetapp, Sudafed, Triaminic, among others, contain acetaminophen – be sure to check the label.)

Just because you take a pill every day doesn’t mean it’s your new “normal” or that one drink won’t hurt. How many Hollywood headlines do you have to see to realize it can happen to anyone, even you?

This article was originally published Dec 23, 2013.
 

Corticosteroids Are Bad for Bones (and Health)

Not all steroids make you stronger. Some commonly prescribed forms of this powerful class of drug might actually make you weaker, especially when it comes to your bones.

With strong anti-inflammatory and immuno-suppressant properties, corticosteroids, the legal kind of “steroids,” have been prescribed since the 1950s to treat more than a dozen acute and chronic conditions, as both prescription and over-the counter drugs. When it comes to serious and potentially debilitating side effects, the method and duration of corticosteroid delivery matters.

Oral Corticosteroids

Systemic corticosteroids, because they are absorbed throughout the body, have the biggest potential for serious long-term health effects. Systemic corticosteroids are administered orally, by IV, and through some rectal applications and muscular injections). Prednisone, prednisolone, hydrocortisone and dexamethasone are some examples of commonly prescribed systemic corticosteroids.

Corticosteroids, also known as glucocorticoids because of their effect on glucose metabolism, may also lead to steroid-induced diabetes, which research has found could affect anywhere from 1.5 to 47% of patients taking steroids, depending on a number of variables. High-dose steroids, through various delivery methods, can also affect vision, causing cataracts and glaucoma, which may require surgery to prevent blindness.

“Oral steroids are horrible drugs in terms of side effects, both acute, when you take them, and long-term,” says D. Kyle Hogarth, MD, associate professor of medicine and director of bronchoscopy and of pulmonary rehab at the University of Chicago School of Medicine. “We need them for certain situations and conditions, but we should be viewing them only as a last resort. Nobody should ever be choosing oral steroids when there’s a better choice.”

Sometimes the Only Option

Despite their long list of ill effects, they are often necessary for emergency situations, such as an acute asthma attack; as a part of a cancer-fighting therapy; or to prevent organ transplant failure. In some inflammatory diseases, such as IBD, systemic corticosteroids are used to induce an initial remission. They may also be used as a last resort for pain and inflammation, such as that from the painful condition osteoarthritis.

In cases where corticosteroid use is part of or the only effective treatment for disease, reducing or eliminating their use may not be an option. “30 to 40% of patients with moderate to severe IBD have steroid dependent disease. That means that they are unable to taper off steroids without experiencing a flareup,” according to the Crohn’s and Colitis Foundation of America (pdf).

If you need to be on systemic or long-term corticosteroids, your doctor should monitor your cholesterol, blood sugar and bone density levels and offer treatment options that address the dangers of GIOP (glucocorticoid-induced osteoporosis) and steroid-induced diabetes.

Never stop steroids on your own. Corticosteroids steroids mimic the natural hormone cortisol, produced by the body’s adrenal glands. Stopping steroids abruptly, before the adrenal glands have the ability to once again produce their own cortisol, could result in a life-threatening adrenal crisis. Even if you experience severe side effects, you should still be under a doctor’s guidance to slowly reduce or stop your dosage.

GIOP: Glucocorticoid-Induced Osteoporosis

Use of systemic corticosteroids increases your risk for GIOP (glucocorticoid-induced osteoporosis). The longer someone takes systemic corticosteroids, also known as glucocorticoids, the greater their chance of developing GIOP and related fractures, especially to the hip and spine. Research has found that GIOP leads to fractures in 30 to 50% of patients.

“If you take an equivalent dose of prednisone at greater than 7.5 mg per day for greater than 3 months, you are risk for glucocorticoid induced osteoporosis,” according to the American College of Rheumatology.

It’s precisely because of this risk that systemic corticosteroids are no longer a first-line therapy for conditions such as asthma and dermatitis, though there are exceptions.

Cascading Adverse Events — a GIOP Story

Even when properly used, systemic corticosteroids start one problem that leads to others. That’s what happened to journalist and nonfiction author Caitlin Kelly: When nothing else worked for severe osteoarthritis pain in her left hip, her orthopedic surgeon prescribed a course of an oral steroid, shorter than the 90 days that would be a high risk for GIOP. Shortly after treatment began, Kelly says she experienced different, excruciating pain. “It was agony to take even a few steps,” she says.

Kelly was told of her risk for GIOP, but probably because of the short course she wasn’t closely monitored, nor was she put on any preventative measures, such as the use of bisphosphonates (osteoporosis drugs). In fact, her massage therapist was the one who suspected her pain was more than the original  osteoarthritis pain. Kelly had to push her doctor to order an MRI to find out what was going on. The result: She had developed avascular necrosis (AVN), death of the bone tissue, due to lack of blood supply caused by a fracture or dislocated joint. The joint damage was caused by GIOP likely brought on by corticosteroids; which is why AVN is also associated with high-dose steroid use. Kelly would eventually require a total left hip replacement at the age of 54.

“Living with 24/7 pain, which the AVN provided until my surgery 2-1/2 years later, was an utter misery. It really destroyed my life in some ways,” says Kelly, who urges all patients to challenge their doctor if they suspect something isn’t right.

Preventing GIOP

Within the first months of using glucocorticoids, patients experience a rapid decline in bone mineral density, according to research on how the drug affects bone loss. The decline in BMD peaks after 6 months of use, but continues with a slow, steady loss with continued use of glucocorticoids. This is according to the American College of Rheumatology 2010 Recommendations for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis (pdf). New guidelines are expected to be released in 2017.

New therapies, such as disease-modifying anti-rheumatic drugs (DMARDs) and biologics, have replaced glucocorticoids as a first-line therapy in conditions, one prime example of which is rheumatoid arthritis (RA). In instances of RA flare ups, short-term glucocorticoids, if used, are recommended at the lowest dose possible for the shortest duration possible, according to ACR’s 2015 Guidelines for the Treatment of Rheumatoid Arthritis (pdf).

Despite the known GIOP risks, patients often either aren’t aware of these treatment options or aren’t advised by their doctor to take precautions. According to ACR’s GIOP guidelines, “Many patients receiving long-term glucocorticoid therapy do not receive any interventions to prevent or treat osteoporosis. In some populations, less than one third received BMD testing or had documented use of calcium and vitamin D supplementation.”

Doctors may recommend mitigating the risks of GIOP through various treatment options:  Actonel and Reclast are FDA-approved for both the prevention and treatment of GIOP. Fosamax and Forteo are FDA-approved for the treatment of GIOP. Whether these drugs can reverse the damage isn’t known, and depends on pre-existing levels of bone loss, among other factors. At a minimum, the American College of Rheumatology recommends patients on corticosteroids should take at least 1,500 mg of calcium and 800 to 1,000 International Units (called IU) of vitamin D supplements each day.

Local Corticosteroids: The Better Option

Not all steroids can or should be avoided, as they are often a first-line therapy for many conditions. Local or site-specific corticosteroids, such as inhaled corticosteroids (ICS), those that are site-injected or those that come in a topical application, deliver a much lower steroidal dose and pose fewer and far less serious side effects and risks. Chances are you’ve used an OTC corticosteroid but may not have realized it. They are the main ingredient in many OTC anti-itch creams, and many OTC allergy nasal sprays, such as Flonase, Rhinocort and Nasacort.

For allergic rhinitis, an inflammation of the nasal passages caused by either seasonal or perennial allergies, steroidal nasal sprays are considered a first-line therapy for those with severe symptoms, and have been shown to relieve symptoms more effectively than first-generation oral antihistamines without the sedative side effects.

Common side effects of OTC steroid allergy sprays include headaches, nosebleeds, and dry or irritated nose and throat. If you experience severe or frequent nosebleeds, the drug label states that it’s okay to stop the medication. All inhalants can also cause mouth thrush. Rinsing your mouth out after each use reduces your risk. Other common side effects include dry mouth and some voice changes.

For children and adults with asthma, inhaled corticosteroids (ICS) are  the go-to drug for most doctors and patients because of their proven efficacy.  ICS drugs work by reducing airway inflammation associated with asthma. Because each patient is different, your doctor can help you determine the best ICS and dose for your asthma’s severity.

“Inhaled corticosteroids are actually one of the nice advancements for asthma because you get all the benefits of steroids without the side effects, due to their limited systemic absorption. You are getting the good benefit where you want it, without all the ugliness,” says Dr. Hogarth.

Taking ICS drugs long term may also increase your risk of pneumonia. But here, too, says Dr. Hogarth, the benefits of ICS drugs far outweigh the risks. “What we definitely know, is that not treating your asthma increases your risk for pneumonia,” he says.

Some research has found that inhaled corticosteroids (oral and nasal) may stunt bone growth in children, but that hasn’t been proven definitively, says Dr. Hogarth. Again, the danger is more likely with high-dose, long-term systemic use.

Further Reading

Treating Crohn’s Disease: A Balancing Act

Crohn’s disease, an autoimmune disorder that causes painful and often debilitating inflammation in the intestines, and which is incurable, is notoriously difficult to treat.

Diagnosis itself isn’t straightforward. Just ask Michael Weiss, a Crohn’s patient advocate from Brooklyn who went undiagnosed for several years, during which he faced doubt and disbelief from doctors, friends and even his psychiatrist. “I call it the diagnosis journey,” Weiss says. “It took me a long time to find a gastroenterologist who figured it out.”

A major stumbling block to diagnosis is that Crohn’s symptoms include abdominal pain, diarrhea, gastrointestinal bleeding and poor absorption of nutrients — all symptoms that occur with many other illnesses.

“The initial presentation [of Crohn’s] can be so common and so subtle,” says Irfan Hisamuddin, MD, a gastroenterologist with Christiana Care Health System in Wilmington, DE. “The disease can mimic other diseases, so there could be some period of time before patients are diagnosed, or they may be misdiagnosed with irritable bowel syndrome for a while.”

The Crohn’s and Colitis Foundation of America estimates that about 780,000 Americans have Crohn’s. Most individuals are diagnosed between ages 10 and 35, with about half of all cases diagnosed under 30. However, another peak of diagnoses occurs around age 50, possibly because other diseases also become more prevalent at this age. About half of all Crohn’s patients will have a complication in their gastrointestinal tract, likely requiring surgery, within 20 years of being diagnosed.

A Search for Treatment Options

Once the diagnosis challenge is overcome, next comes treatment — and Crohn’s is a notoriously difficult autoimmune disease to treat. For that reason, the search is always on for fresh possibilities and new combinations of treatments. The latest possible treatment involves a hydrogel which can potentially deliver drugs directly to the areas of inflammation on the colon, reported researchers in a recent preclinical trial. Although the gel has only been tested in human tissue samples and in mice — administered as an enema containing the anti-inflammatory corticosteroid dexamethasone — it reduced inflammation significantly more than using the dexamethasone by itself. It will take more trials before such a product could make it to market, but the hydrogel is 1 of several encouraging research directions in the treatment of Crohn’s.

Another drug already approved for treating psoriasis called ustekinumab (Stelara, Centocor) appears to reduce Crohn’s inflammation by blocking 2 immune cell proteins, and trials with a new targeted drug called mongersen look promising too. Participants with Crohn’s in a 2015 study reported in the New England Journal of Medicine who received mongersen had significantly higher rates of remission than those who received a placebo. Because Crohn’s is an autoimmune disease, the inflammation that causes symptoms occurs because the immune system attacks parts of the gastrointestinal tract. Mongersen, an oral medication, also blocks a specific protein, but the mechanism that makes it work isn’t clear, says Kian Keyashian, MD, an assistant professor of medicine at Oregon Health and Science University in Portland.

Dr. Keyashian says that mongerson looks good in smaller clinical studies so far, with minimal safety concerns. If larger studies show it’s effective and the Food and Drug Administration approves it, mongersen would join other biologics, a class of drugs that manipulate the way the immune system works.

Next: New Options Down the Road >>

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