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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.

Episode 10: Disease Mongering

This week, Su Robotti and Jonathan Block discuss Disease Mongering. That’s when pharmaceutical companies take an everyday discomfort and promote it to a disease — and then seel meds to cure the disease.

Su Robotti: Hi. I’m Su Robotti and this is Jonathan Block. We’re both from MedShadow. I’m the founder and Jonathan is the content manager.

Today, we’re going to talk to you about conditions of life that somehow are becoming elevated into diseases. When I was a kid, watching TV, there was this terrible disease that was going through a scourge of the nation. It was halitosis. And everybody had to use Listerine to get rid of it. When my vocabulary expanded, I found out it was bad breath and that good dental care and brushing your teeth and not eating onions would take care of most cases, most times, of bad breath. So it wasn’t really necessary to take medicine or anything.

But that was the beginning of a wave of products that pharmaceutical companies had developed, to take everyday aging or life occurrences and are turning them into diseases. And were very concerned about this, aren’t we?

Jonathan Block: Yeah. What you’re talking about is something called disease mongering, which is taking conditions that are just common, everyday occurrences — sometimes they’re just the consequence of aging — and turning it into something where you think it’s a serious medical condition that if you don’t have it treated, it’s going to significantly impact your health or well-being. You were just talking about restless leg syndrome.

There’s a drug out there called Requip and that was originally developed for Parkinson’s disease and it got a secondary indication for restless leg syndrome. And in most cases, most people that have been diagnosed with restless leg syndrome really don’t have that condition. A very small percentage of people actually have it. Most of the time, if you have restless legs, it might be because you don’t have enough sleep, you’re suffering from stress or anxiety, or you’re maybe drinking or smoking too much.

SR: You mean too much coffee?

JB: Exactly, so put that cup down.

SR: Sorry. You’re right. What about esophageal reflux disease?

JB: AKA acid reflux?

SR: You mean gas?

JB: Exactly.

SR: And do you have to take a medicine for that?

JB: No, that could be a consequence of eating spicy foods. Some people are just more sensitive to eating certain foods. There’s a very easy way to take care of that.

SR: Do you imagine there are 5 jalapeno poppers?

JB: Probably not because not only would that affect your stomach it will probably raise your cholesterol a great deal.

SR: Thank you for taking care of me. What else is a made-up disease or an exaggerated symptom into a disease?

JB: A good one is the drug called Addyi which is for something called, I have to look at this, hypoactive sexual desire disorder. This made the news last year when the drug was approved. It called the “female Viagra.” The drug company decided that since men had Viagra and other similar drugs for erectile dysfunction, that there should be a similar drug for women. It had very tenuous–

SR: Research.

JB: Research, thank you, conducted for it. And the good news with this one is that since it’s been on the market, the drug has kind of bombed. It hasn’t really been selling very much as doctors realized that it’s not a real condition and the drug itself doesn’t work at all.

SR: The issue with a lot of these diseases are that once you start with the cure, with the medicine, even sleeping aids, there’s a rebound effect that will keep you from not using it. If you quite often, if you use a sleeping aid, and by then the other kind of ones or the prescription ones, the next night, you will have more trouble getting to sleep, and therefore, need it again, and the following night, and so forth, because you’ve interrupted your natural sleep pattern.

What about overactive bladder?

JB: Well, that’s another condition that is a consequence of getting older. There were pharmaceutical companies that decided to elevate that from just kind of an inconvenience or annoyance to, again, something more serious that required medical attention and necessitate taking a prescription drug.

One thing that we haven’t addressed with all of these drugs for questionable conditions is that many of them have side effects. Another class of drugs that has come on the market recently are so-called Low T or low testosterone drugs, which is really more of a “lifestyle drug” but doctors have said that Low T isn’t even a real condition. And taking one of these gels which you would actually just put on, rub on your skin, it gets absorbed that way, actually doesn’t do much in terms of increasing your sexual health. And they do come with several risks, most seriously is the risk of coronary artery disease. So it’s important that for some of these conditions that are very, very questionable, that there are serious side effects with the drug associated with them.

SR: If you like to learn more about the side effects associated with the drugs that you’re discussing with your doctor or that you’re seeing on TV, please go to www.medshadow.org, and just search for the drug. It’s very likely, we have something to say about it.

In the meantime, taking a drug for a condition that is not serious and not life threatening or that can be treated in a lower tech way, is just plain dangerous. So please, think carefully and balance the risks and the benefits of every drug you take. Thank you.

Twitching From Parkinson’s or Levidopa?

Although there’s no cure for Parkinson’s Disease (PD), it’s not a death sentence. Despite the tremors, rigidity, fatigue and a potentially dramatic cycle of on and off periods in which one’s ability to move with ease is greatly affected, it is possible to live a fairly normal life — with the right medication.

James Morgan, a partner at global law firm Squire Patton Boggs, speaks for many people with PD when he says, “I would be nonfunctional without the drugs.”

Patients have found medications for Parkinson’s to be effective in easing symptoms, but the 2 main drugs prescribed to treat Parkinson’s disease — levodopa (brands include Sinemet and Sarcopa) and dopamine agonists — cause some surprising side effects.

Part 1 – Levodopa
Part 2 – dopamine agonists

Although drugs play a major role in reducing symptoms and enabling people to improve their quality of life, it’s worth being cognizant of the sometimes debilitating toll they can take. Levodopa can cause dyskinesia, hallucinations and even psychosis. And the side effects of dopamine agonists rank as unexpectedly bizarre. Impulse control disorders such as hypersexuality, gambling, binge eating and excessive shopping show up in between 17% to 20% of those undergoing dopamine agonist treatment, according to Daniel Weintraub, MD, associate professor of Psychiatry and Neurology at the Perelman School of Medicine at the University of Pennsylvania and an author of a study published in JAMA Neurology. Dopamine agonists can have very severe withdrawal symptoms, to the point that some people, desperate to stop taking these drugs, have undergone brain surgery to help withdrawal.

In this article, we focus on what PD is and the side effects of levodopa. Part 2 weighs the pros and cons of dopamine agonists.

A Brief Description of PD

Currently, at least 1 million people in the US and an estimated 10 million worldwide live with Parkinson’s, making it the second most common neurodegenerative disorder (Alzheimer’s ranks first). Parkinson’s disease, a disorder of the central nervous system, is caused by a degeneration of nerve cells in certain parts of the brain that produce a neurotransmitter called dopamine. Dopamine, commonly known for its role in controlling the brain’s reward and pleasure center, is partly responsible for starting a circuit of messages that coordinate normal movement.

In the absence (or with substantial reduction, more than 80% of the normal level) of dopamine, the neurons — called dopamine receptors — in the brain’s striatum are not adequately stimulated. In simple language, as a person’s brain slowly stops producing dopamine, a person has less and less ability to regulate his or her movements, body and emotions. The result is impaired movement with tremors, slowness, stiffness or balance problems. Lesser known symptoms include depression, apathy and dementia.

A new theory, called Braak’s hypothesis, hints at the possibility of new breakthroughs for treating PD. The theory suggests that the earliest signs of Parkinson’s may be nonmotor symptoms such as the loss of smell, sleep disorders and constipation. These symptoms may be serious red flags that precede motor features by several years. The new vanguard of PD research is increasingly focused on these “nonmotor” symptoms to both detect PD as early as possible and to look for ways to stop its progression.

The Two Most Common PD Drugs

Michael J. Fox Foundation’s Rachel Dolhun, MD, dicusses the 2 newest versions of levadopa and another in the pipeline

Dopamine replacement (Levodopa, carbidopa-levodopa, Sinemet): The main drug used to treat PD symptoms, levodopa is chemically very similar to the body’s natural neurotransmitter. The drug, which is taken by mouth, enables the brain’s basal ganglia to convert levodopa to dopamine — meaning levodopa acts like dopamine in the brain’s movement centers. Levodopa can produce dramatic results, especially in reducing rigidity and tremors and improving movement. It’s generally taken in combination with carbidopa, which keeps the levodopa from being broken down in the digestive tract before it reaches the brain. It also permits a lower dose of levodopa and reduces side effects, which can include nausea and facial flushing (a sense of heat in the face, somewhat akin to a hot flash). Two new extended-release carbidopa-levodopa drugs were just approved this year: Duopa, an oral medication approved for some patients in the later stages of Parkinson’s, and Rytary. In a clinical trial, users of Rytary reported that their amount of “off time” improved by more than an hour a day.

Dopamine agonists (Mirapex, Requip, Neupro): These drugs stimulate the dopamine receptors in the brain and mimic the effects of dopamine, compensating for the depletion of the neurotransmitter. Typically, dopamine agonists are often prescribed for younger patients who are in the early stages of the disease to delay the need for levodopa — and thus the eventual “on-off” syndrome (and unpredictable fluctuations in symptoms) that occurs after taking it for years. The need for delaying levodopa has been questioned, however. (Part 2 of this article, to be published on July 2, will focus on controversy regarding dopamine agonists.)

Howard Weiss, MD, director of the Parkinson’s Disease and Movement Disorder Programs at the LifeBridge Health Brain & Spine Institute in Baltimore, says the approach of delaying levodopa was fueled by a phobia, a scare that started more than 2 decades ago, based on the belief that levodopa accelerated disease progression.

“It’s no longer accurate,” he says. Dopamine agonists are also used in combination with levodopa when the effectiveness of levodopa treatment wanes and a higher dosage induces side effects.

Shakedown: Side Effects of Levodopa

Hallucinations

Hallucinations and psychosis are a side effect of levodopa. They tend to manifest as disturbances of perception (seeing people or things that aren’t really there) as opposed to sound. According to a report published last year in Psychiatric Times, Management of Psychosis in Parkinson Disease by Dr. Weiss and Sam Adler, MD, “After having Parkinson’s for many years, benign hallucinations occur in approximately 10% to 20% of nondemented patients with PD who receive dopaminergic treatments.”

Christopher Hess, MD, assistant professor of Neurology at the University of Florida Center for Movement Disorders and Neurorestoration, says that “after having Parkinson’s for many years, some people feel like there is a presence in the house [when there is no one].” Or it may be a passage hallucination, which Hess describes as “fleeting images in the corner of the eye.”

As dependence on  levodopa progresses, visual hallucinations in direct vision occur. If the hallucinations are mild, says Dr. Hess, patients can stay on levodopa. But in rare cases, the hallucinatory experiences become increasingly vivid and frightening — that’s when the symptoms evolve into psychosis. Suspicions of harmful plots, spousal infidelity and financial impropriety are a common cluster of delusions encountered in patients with psychosis. In those cases, more monitoring is required, as well as a change in medication or dosage.

“Typically, you need to hospitalize a patient till they are stabilized,” Dr. Hess says.

Because the disease acts like a moving target, medication and dosage might change constantly. Regarding hallucinations, Dr. Hess points out, “This doesn’t happen to everybody or in the same degree. It’s something you deal with and there are other medications that can help.”

Most of the hallucinations remain benign, but because the potential for psychosis exists, clinicians should be extra cautious and vigilant when increasing dopaminergic dosage or adding new medications. To make this situation even more challenging, many patients may not readily admit to hallucinations for fear of being perceived as crazy. Not only do clinicians have to be proactively inquisitive — it’s important for patients to adopt a policy of full disclosure.

Wearing Off

After taking levodopa drugs for 5 years or more, many people find that the effectiveness begins to wane. More than half suffer “on-off syndrome,” a cycle of medication-induced motor fluctuations. “Off” times are a state of decreased mobility and “on” times are when the medication is working and symptoms are controlled.

Motor fluctuations usually happen when levodopa is waning. The effects of wearing off can happen surprisingly quickly. That’s why the timing of taking medications is so important. Morgan says, “You have to be religious about sticking with your meds, because they don’t work unless you are on top of it.”

Involuntary movements (dyskinesia)

Involuntary movements are often mistaken for a symptom, but in fact they are a side effect of Parkinson’s medicine. According to the Michael J. Fox Foundation, “Some patients report dyskinesia to be as debilitating as the disease itself.”

After many years of levodopa treatment, dyskinesia — muscle movements that can’t be controlled — may set in. They can include twitches, jerks, twisting or writhing movements, or restlessness. Because Parkinson’s is such an unpredictable disease, when and how often dyskinesia appears can be different for each person it affects. It might mean involuntary movements occur throughout most of the day, or it might be limited to brief spurts after taking medication or just before the next dose is due.

Despite the side effects, levodopa remains the gold standard of PD treatment. “People are less levodopa-phobic than they used to be,” says Dr.  Weintraub. For many, the controversies that surround dopamine agonists, which used to be the first line of defense against Parkinson’s, mean they have lost some of their luster. The shift signifies levodopa’s return to dominance.

“Although it’s no angel when it comes to side effects,” says Dr. Weiss, “it’s much more effective, less expensive, and has fewer side effects [than dopamine agonists]. That’s a good trifecta.”

As with any Parkinson’s medication, the biggest takeaway regarding levodopa is that close monitoring is essential.

“It’s a constant testing and retesting and reconfiguring the formula. It’s not static,” says Morgan. “You really have to talk to your doctor, so find someone you can relate to. Talk to him every time about what’s happening.” When the lines of communication are open, the probability of adjusting to Parkinson’s successfully become much higher.

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Mirapex can cause compulsive behavior

The following is from syndicated columnists Joe and Teresa Graedon, via the Seattle Times.

Q: I have endured restless legs syndrome (RLS) for years. I also suffer from extreme compulsive behavior, including shopping and gambling. I take Mirapex both evening and morning, as my RLS symptoms have become worse with age.

This medication has ruined my life. I discovered only recently that the compulsive behaviors are drug side effects.

A: Many people are surprised to learn that medicine taken for Parkinson’s disease or RLS is linked to bad behavior — gambling, hypersexuality or compulsive shopping. A reader reported that one of these, Requip (ropinirole), turned her into a big-time gambler. Another woman said this about Mirapex (pramipexole):

“I took Mirapex for a year. I was already taking Sinemet for Parkinson’s disease. I shopped compulsively, buying many things that I did not need. I filled closets with stuff, some of which I did not remember when I saw them later. Stopping Mirapex stopped the compulsive behavior. Not only was the drug itself expensive, I can only imagine how much it cost otherwise, in both money and health.”