Tag Archives: side effects

STAT: Did Merck circumvent its duty to warn on ‘Fosamax fractures’?

How would you feel if you were harmed by a medicine you took as prescribed and then learned that the drug company wasn’t liable — even though it knew about the risk and didn’t tell you or your doctor?

This is exactly what has happened in the case of Fosamax (alendronate), a drug used to treat bone-thinning osteoporosis and osteopenia. After it was approved by the Food and Drug Administration and women across the country began taking the drug, the FDA and its maker, Merck, started receiving reports about spontaneous fractures of the thigh bone among women taking the drug. Read Su Robotti’s opinion piece here.

Senior Planet: Myths and Facts About Flu Shots

So what makes you afraid to get a flu shot? Most of the time those fears are based on myths, half-truths or fictitious ideas you may have heard or read about. I’d like to address some of these and explain why getting a flu shot is good not only for your health, but for others as well.

MedShadow Medical Advisory Board member, Dave Walker, RPh, explains the myths and facts about flu shots. Continue reading. 

Only You Can Decide If a Drug’s Risk is Acceptable

In trials for new drugs, adverse events are inevitable. When it comes to drugs that treat cancer, those potential harms are often downplayed in results, to the detriment of patients, according to a new study. Using vague terms about harms may not give a true impression of them and lead some to believe a new drug has a better benefit-risk profile than what is actually the case.

The study, published in the BMJ, looked at how adverse events were discussed in cancer drug clinical trials results published in several medical journals in 2006. Researchers examined 122 trials. They found that 43% (53) of those trials used terms that downplayed the harms.

What’s an example of a vague description of harms? Here are a few examples. An “acceptable adverse-event profile;” “manageable safety profile;” “tolerability was good overall.” To the first term, while one patient may be able to tolerate a side effect, others may not. The same goes for using a term like manageable. It’s very subjective, isn’t it?

The paper contains a chart about terms that are used to downplay the harms of cancer drugs in trial results and why this is concerning. I’ve republished it below:

  • Acceptable—Acceptable to whom? Were the patients asked if the toxicities were “acceptable” to them?
  • Manageable—Serious events and deaths can never be considered manageable. Even manageable toxicities incur burden and decrease patients’ quality of life.
  • Feasible—What is the threshold for feasibility of a treatment? Will the mention of “the treatment is feasible” be enough to obtain patient’s consent to a treatment?
  • Favorable toxicity profile—Favorable compared with what? The threshold of enduring toxicities and thus favorability is different from patient to patient.
  • Tolerable or well tolerated—Only the patient can decide whether any side effect is tolerable
  • Safe—Any cancer treatment that has resulted in a treatment related death cannot be considered safe.

Even worse, while cancer drug trial results tended to downplay the harms, serious adverse events were higher in the experimental – new drug – arm than in the control group. Another problem was that in many of the trials that downplayed harms, there was no data describing the severe or serious adverse events.

The BMJ paper was written by oncologist Bishal Gyawali, MD, PhD. Gyawali told HealthNewsReview’s Gary Schwitzer why he felt the need to write the paper.

“I felt it was inappropriate for us clinicians to label a toxicity our patients experience as acceptable,” Gyawali said. “My view is that only patients who experience those side effects can say whether it was acceptable or not. This downplaying of toxicities is very harmful because it makes us clinicians believe that a drug is safer than it actually is.”

In the paper, Gyawali also said that cancer drug trials should avoid subjective terms and fully report side effects. I couldn’t agree more.

“No cancer drug is safe, it’s always a trade-off,” Gyawali told Schwitzer. “This understanding is crucial because most cancer drugs provide only modest benefits. Very few are truly game-changers.

Gyawali’s paper is an important reminder that when reading about clinical trial results for a drug, many times, the benefits of a medicine are touted while discussion of side effects are minimized. This becomes even more problematic when the results are reported in the media, who far too often emphasize the benefits of a new drug without appropriately discussing risks.

It’s important to remember that all drugs have risks. No drug is completely safe. It’s why at MedShadow, we encourage you to ask questions of your health care professional and weigh the risks vs. the benefits of a medication before accepting a prescription. And it’s why only you can decide if a drug’s risks and potential harms are acceptable.

Many Believe Side Effects Exaggerated on Medication Leaflets

About four out of 10 patients believe the leaflets that accompany prescription medications exaggerate side effects and only a third of them always read the printed information, according to a new study conducted by a pharmacists’ trade group.

The survey of just over 1,000 patients in the United Kingdom by the National Pharmacy Association (NPA), which represents community pharmacies, found that many patients may be ignoring the advice of their pharmacist and putting their health at risk. For example, 27% of respondents said they would go to another pharmacy to get a drug even if another pharmacist advised against taking it. And 15% said they lied about their health to a pharmacist in order to get a medicine.

One problem the survey found is that many people are uncomfortable questioning advice given by a health care professional. About 52% said they would be uncomfortable challenging their doctor’s advice, and 43% would not want to second-guess their pharmacist.

“If you aren’t satisfied with the advice given in the pharmacy, feel free to challenge it. A good pharmacist will not be offended and should welcome the opportunity to reassure you, to clarify, or to discuss alternatives,” NPA Director of Pharmacy Leyla Hannbeck said in a statement.

Recap: Raising Awareness About the Side Effects of Medicines

November 1 was an important day in the history of MedShadow Foundation. We held our first ever event, “Raising Awareness About the Side Effects of Medications,” in New York City. Patients, patient advocates, medical professionals, political leaders and others came together to listen to a diverse group of speakers. The objective was to bring together like-minded individuals to bolster efforts to inform the public about medicines to improve their health care.

A theme of the event was side effects impact all of us. Medicines are a part of life for most of us. About 55% of Americans take at least one prescription drug, and 75% of us take at least one over-the-counter drug regularly.

Opening remarks were made by MedShadow Founder and Executive Director Suzanne Robotti (above), who explained why you should care about side effects. She mentioned two sobering statistics. The first is that about two million people end up in the hospital each year as a result of an adverse drug reactions (ADRs) and about 100,000 people die each year as a result of ADRs. She also talked about her own side effects story involving the synthetic estrogen diethylstilbestrol, or DES, which was given to her mother and led to Robotti’s inability to have children. You can read more about Robotti and her side effects story here.

Joseph Ross, MD, MPH (above), a professor at Yale School of Medicine whose research has focused on how the FDA approves new drugs, was the first speaker. His remarks focused on a JAMA study he worked on that was published last year that found about a third of new drugs approved by the FDA have safety issues that don’t become apparent until after the drug is on the market. He also noted that the FDA approves more drug than any of its counterpart agencies around the world.

Lisa Saenz (above), a social worker who is also the development coordinator for ASHES (Advocating for Safety in Healthcare E-Sisters), a non-profit fighting to improve medical device safety, spoke about her experience with Essure, a birth control device that has harmed tens of thousands of women. Even though many women have had the device removed, they continue to suffer long-term health problems after removal. (Bayer, Essure’s manufacturer, has said it will stop selling the device by the end of the year). She also called for more education and advocacy to raise awareness about the safety of both medical devices and drugs.

Lillie Rosenthal, DO (above), a physician who focuses on lifestyle medicine, said that our current health system is broken because too many doctors believe treatment is a “pill for an ill” and visits last an average of six minutes. She noted that many chronic diseases can be prevented through a 5-point “prescription” focused on lifestyle medicine: eating the right foods; getting exercise; getting enough sleep; managing stress; and minimizing vices.

Noah Rubinstein (above), an acupuncturist, clinical herbalist and co-director of the YinOva Center, talked about how acupuncture can help reduce the need for medications, and how Eastern medicine can complement Western medicine. Rubinstein addressed this further in a piece for MedShadow last year.

Hospitalist Varun Verma, MD (above), of Jefferson Cherry Hill Hospital in New Jersey, discussed how patients can talk to their doctor about side effect concerns. It is important for patients to not only have an accurate record of the drugs they are taking, but supplements and over-the-counter medications as well. MedShadow has developed a downloadable guide with questions to ask your healthcare provider as well as ways to be smart and safe with medicines.

The evening’s final speaker was Rep. Carolyn Maloney (above), who represents New York’s 12th congressional district. Rep. Maloney spoke of MedShadow’s tireless work in educating the public about weighing the risks and benefits of medicine. She also mentioned that MedShadow provided her with important information about the deceptively named “Right-to-Try” legislation, a bill that protects drug companies more than it helps patients.

Robotti wrapped up the event by asking the audience to remember 3 things:

  1. 60% of us have taken a prescription medicine within the past month.
  2. Side effects can happen with any medicine, prescription and over the counter. They can happen with homeopathic medicines, and supplements.
  3. Side effects are personal. They can happen to you and your family.

Please click here for more event photos. 

 

Can Artificial Intelligence Predict Drug Side Effects?

Marinka Zitnik is a postdoctoral computer science researcher at Stanford University with an interest in how artificial intelligence (AI) can help in the field of medicine. When she came across statistics about how taking multiple medications can lead to experiencing many side effects, she decided to do something about it.

She wondered if an AI system could mine information about these drug combinations and predict their potential side effects, which could then be used by prescribers as a tool to evaluate the risks of prescribing a particular cocktail of drugs.

The more drugs someone is taking, the more likely the risk of drug-drug interactions. Physicians prescribing the drugs cannot predict all the possible side effects that could occur because there is so much that is unknown about potential adverse effects from combining drugs.

The Problem of Polypharmacy

In the US, studies show that about 40% of adults over the age of 65 take five or more medicines, up from about 13% back in the late 1980s. Called polypharmacy, it’s most common among seniors, but is also prevalent among adults with intellectual disability and, increasingly, even among children and teens with certain conditions.

Zitnik learned that it’s difficult to perform experiments on a large scale to get reliable information on potential side effects from drug combinations, given there are more than 5,000 drugs on the US market, which makes it impossible to test different combinations of all these drugs.

Zitnik and her Stanford colleagues say that there are 1,000 known drug side effects, meaning there are 125 billion possible side effects if all potential drug pairs are considered.

“We don’t know much about how they interact, and we spend nearly $200 billion on treating the side effects,” she said, quoting a Journal of Pharmacy study.

When Zitnik and her colleagues embarked on this project, they found there was no existing model that could test for polypharmacy side effects. So they took data from the FDA Adverse Event Reporting System (FAERS) database and used it to develop algorithms. Their AI system, Decagon, first learns about side effects, becoming familiar with them. It then can predict them by studying how the drugs interact with the body’s 19,000 proteins.

“We get the adverse effects data, then training [of the system] happens in several rounds. In every round, the model makes predictions, we look at errors in the predictions and we change” information about the drugs and side effects “so that in the next round the predictions are more accurate,” Zitnik explained. “This is repeated many times until the model learns…well and can accurately predict side effects.”

It currently has about 80% accuracy in predicting side effects, which it ranks according to the top 50 possible drug interactions. The researchers’ goal at this stage is to clinically validate the predictions made by Decagon, by looking for real-life patient experiences that are comparable. The next step will be refining the system and making it user friendly for prescribers.

AI’s Potential Impact on Reducing Side Effects

“I don’t see how most prescribers can even begin to scratch the surface in understanding the potential for drug interactions,” said Dave Walker, RPh, a pharmacy veteran in Oregon who used to manage pharmacies for hospitals and grocery chains and owned his own store. “Deprescribing needs to happen, because less is better. I’ve seen people taking 18, even 27 medications from multiple prescribers.”

He said the Decagon system could have a significant impact on predicting and reducing adverse effects, for one main reason.

“In pharmacology and pharmacy, they don’t have the resources or time to analyze this for every patient. If we have an automated system doing this, I see a lot of good coming from it,” Walker, who also serves on MedShadow’s Medical Advisory Board, said.

Jeannene Strianse, PharmD, director of pharmacy at Stony Brook University Hospital in New York, finds Decagon to be an interesting approach to a critical problem.

“The older you get, the more drugs you are on, for various reasons,” Strianse said. “When we look at patients that are on multiple drugs, patients 65 and older tend to be on an average of 10 drugs each.”

Stony Brook Hospital has three pharmacists review drugs a patient is taking to see if any can be taken out of the mix. They also look at databases for drug-drug interactions to see if changes are necessary. In this way, they can stop using secondary drugs that are often used to treat the side effects from particular drug combinations.

“Drugs seem to be the quick answer to things,” she pointed out. “The AI system can help patients and physicians make informed decisions in starting a new drug, but they need to be careful because it’s an idea of what might potentially happen — which may not happen.”

She cautioned that side effects often occur only in a small number of people, depending on genetic and other factors, so in a doctor-patient discussion, it needs to be discussed as “it may happen, but probably won’t happen.”

Strianse said that the system can have a lot of potential to improve care once it’s further validated, and will be one more tool in the physician’s tool box to determine what the risk is in prescribing a specific drug to a patient.

“This system will be able to say, based on how two drugs interact, that it could cause liver failure, but it can’t say if that will happen to you, me or someone else,” Strianse said. “It can just tell you there’s a potential risk, so that’s what the physician and patient need to understand — that it can’t predict exact risk, but it’s still more information than they had before.”

What’s Next for Decagon

Zitnik’s team is now collaborating with medical schools at Columbia University and Stanford to improve the model and test it so it’s accurate enough to be used in the real world.

The medical schools will look at electronic health records to see what drugs patients are on, the side effects they experience, and how that coincides with Decagon’s predictions.

“If Decagon predicts that a blood pressure lowering drug and another drug could lead to tachycardia [rapid heartbeat], they will see if there are patients who have experienced this, which then validates our system,” Zitnik said.

What she hopes to achieve with Decagon is to create user-friendly tools that provide guidance for doctors to help them make better decisions in prescribing drug combinations. Patients should also be able to enter the drug combinations they’re taking so Decagon can predict the side effects they should watch out for. Zitnik also wants to make it useful for clinical researchers, so they can develop drug therapies that have fewer side effects.

Why Medicine Often Has Dangerous Side Effects for Women

By Alyson McGregor, MD
Brown University

If you think that drugs interact in men and women the same way, you are wrong. Because of this, side effects can be different in men and women for a given drug. A prime example is the sleeping pill Ambien (zolpidem), which was largely tested in men. Yet, the drug is primarily used by women, who tend to have more sleep disorders. After reports came in of women experiencing a higher rate of side effects compared to men, the FDA recommended cutting the dose for women in half. Why? Women metabolize Ambien more slowly than men.

In a TED talk, Alyson McGregor, MD, with the Alpert Medical School of Brown University, explains how drugs can have major side effects for women and one of the key reasons why: Women are underrepresented in drug trials.

McGregor cites some sobering facts. Women have almost double the risk of experiencing an adverse drug reaction compared to men. A 2000 Government Accountability Office report that examined drugs pulled from the market over safety issues found that 80% had side effects that were more pronounced in women than men.

Video of McGregor’s TED talk is below.

 

Alyson McGregor, MD, is co-founder and director for the Sex and Gender in Emergency Medicine Division within the Department of Emergency Medicine at Warren Alpert Medical School of Brown University.

This video was reposted with permission of Dr. McGregor and TED Conferences. It originally appeared here.

Deprescribing: Beginning the Process (Part 2)

Deprescribing (as discussed in part 1) is the process of determining whether you are taking medications that may no longer be needed and identifying possible changes or reductions in dosage of any medications. Taking these steps may improve your health and reduce the chances of your experiencing side effects or having an adverse reaction to your medications.

It’s important you keep in mind a few medication facts while you approach this process:

  • Some medications should not be stopped. Recognize that your medical condition may require that you continue taking some medications to keep things under control. However, it may be appropriate to change a medication that is causing a problem.
  • There are medications that you should not abruptly stop taking. Some drugs need to be tapered off slowly to avoid problems. A gradual reduction of dose over a few weeks or months will usually prevent the problems experienced when suddenly halting a drug.
  • It’s important to not stop taking any medication without your doctor directing you to do so.

Taking prescription medications to treat your medical condition is serious business. Deprescribing isn’t something you can do on your own. The process of deprescribing is basically the same, whether for yourself or another member of your family you might care for. You’ll need to work with your physician or healthcare provider to determine the best course of action.

1. Prepare before talking with your doctor. Let the office know you want to discuss your medications when you make the appointment. Visits with your doctor are always time-sensitive, but being adequately prepared makes it easier. Before talking to the doctor, make a list of all prescription medications, non-prescription medications and vitamin or herbal supplements you take. Make sure you include medications that were prescribed by other doctors. Click here for a form you can use for your medication list (or click on the image of the form).

It’s important to include if the drug has a side effect that is bothersome — perhaps one drug upsets your stomach or another makes you feel jittery. Your doctor might be able to suggest an alternative drug or a way to minimize the side effect. A little gastrointestinal discomfort might be a small price for the benefit of the drug, but if it’s affecting your enjoyment of life, a change might be in order.

2. Know the names of your medications, the doses you take, how often you take them and what medical conditions they are prescribed for. If you are uncertain or have questions, you can consult your pharmacist or read the medication handouts included with each medicine. .

3. Expect to be a little uncomfortable. Many people find it downright difficult to have this conversation. Although most people have a desire to work with their doctor, they usually fear two things: They don’t want to “rock the boat” or offend their doctor, and they feel there isn’t time enough to ask questions. Don’t let this stop you from talking to your doctor. Both of these situations can be overcome with some preparation like alerting your doctor’s office ahead of time about reviewing your medicines and having the list ready to share.

I’ve worked with physicians to make medication changes for my pharmacy patients and my family members for years. Most of the time physicians appreciate the input because they have your best interests at heart. Often they can feel rushed and accidently overlook something during office visits. Sometimes they just want to keep the status quo if everything seems to be working. Other times they just get into a routine of prescribing certain drugs when there may be other options.

Don’t be afraid to ask your doctor questions. If you don’t feel comfortable doing this on your own, enlist the help of a companion or other family member to advocate for you at your office visit.

Use a Critical Eye When Reading Health and Medical Articles

News coverage of health and medical developments has proliferated greatly in recent years as more and more media outlets place more emphasis on this area. While this means there are more sources for the public to learn about health and medicine, the downside is that not all of the reporting gives a balanced look at the developments. This can mean patients are not fully aware of the negatives associated with medical developments.

During the recent Too Much Medicine conference in Helsinki, Finland, Gary Schwitzer, founder and publisher of the website HealthNewsReview, outlined many of the concerns regarding how health and medicine are covered in the media today.

HealthNewsReview — which is a nonprofit — is what I consider a must-read site, as it examines both health and medical news articles from major news outlets and news releases from groups and evaluates them based on accuracy and how risks and benefits are presented.

Schwitzer lamented several things about coverage of health and medicine in the media. He said that most of the coverage exaggerates or emphasizes the benefits of a drug or a procedure while glossing over the potential harms that may be associated with it. And he’s right. When was the last time you read an article about a drug, device or procedure that really discussed the potential side effects or risks associated with it?

A study HealthNewsReview conducted on 2,600 articles it has analyzed demonstrates how reporting on health care interventions often comes up short in discussing downsides. The study found that 63% of the stories did not adequately assess the scope of potential harms, 66% didn’t assess how big – or small – the potential benefits were and only 54% discussed alternative options.

At MedShadow, we report on medical studies all the time, and we aim to give you a balanced view of results so you get a complete understanding of what they really mean. Still, we understand that you may get health and medical information from many different sources.

With this in mind, here are some tips to use while reading about medical studies.

  • Take note of who funded the study. Studies are often funded by drug companies, and there can be bias in the reporting results.
  • If a study had a small number of participants, the results may not stand up in the real world.
  • It’s also important to be wary of study results that were conducted using animals, as an effect that was seen in a rat may not translate into the same outcome in a human.

Schwitzer also mentioned some things to look out for in an article. If an article portrays a drug or treatment as a “holy grail,” or calls a procedure minimally invasive, “head for the hills,” as neither situation is likely true. He also cautioned to beware of articles that focus on a single person’s experience, calling it the “tyranny of the anecdote.”

Schwitzer is also concerned that there are conflicts of interest in some stories. Some media outlets receive funding or advertising from pharmaceutical or health companies, yet don’t admit this can be a conflict of interest as it could influence coverage of stories.

The bottom line: When reading a health or medical article, use a critical eye.

Which Drug Side Effects Should Your Doctor Tell You About?

Once when my mother was visiting me, we went to a dollar store and she bought something that surprised me — a book about pills that discussed which medicines are for what conditions and what their side effects are. As soon as we got home, she pulled out the book and a pill bottle and searched the pages.

She nearly wept when she read that a very common side effect of a drug she had just started taking was depression. She had been hiding very sad feelings, lethargy and a lack of happiness. She now knew what was happening, and a simple phone call to her doctor got her a new prescription for a drug less likely to have that effect.

Since then, I’ve discovered that there are doctors who believe it’s better for a patient to not know the minor or less common side effects of medicines. Research has shown that simply by being aware that a drug you take might have a particular side effect — fatigue, for example — makes it more likely that you will feel tired when taking that medicine.

A 2003 study in the European Heart Journal enrolled 96 men with newly diagnosed cardiovascular disease that received a beta blocker, atenolol, for high blood pressure. Erectile dysfunction (ED) is a known side effect of beta blockers, though none of the men in the study complained of it prior to starting the study. Those who were told that ED might be a side effect of the drug were twice as likely to report experiencing it compared to those who were not informed about the side effect.

Many would say this is related to the nocebo effect. The more correct definition refers to being given a placebo (a harmless sugar pill) and then believing you have developed one or more side effects caused by being warned about those effects. Some doctors feel that by withholding information about side effects they are protecting their patients from a nocebo-like response to medicine they need. If patients aren’t told about a side effect, they won’t get it. Or if the patient has that side effect, then knowing about it might magnify the discomfort.

More commonly known is the placebo effect — when a patient is given a pill that can’t possibly cure their illness but yet it does, presumably because the patient believes in it.

Withholding pertinent information without a patient’s knowledge or consent is paternalistic and violates the concept of informed consent. Patients have the right to know what drug they are being prescribed, for what reason, what the anticipated outcome will be and what all the risks are of taking it.

Experiencing symptoms without understanding their possible cause can create considerable distress, as it did with my mother. She suspected that something was “really wrong,” in her words, and she feared this new, unmanageable psychological distress. Her anxiety mounted, but she was hesitant to call her doctor about something as vague and seemingly unrelated to her original diagnosis as depression. When she saw the reference book mentioning side effects, she connected the drug to her depression and felt justified in calling her doctor.

People are different, and doctors are called upon to use judgment all the time. Even doctors who try to relay all possible side effects are challenged to know when to stop. Listing all the rare adverse events could scare the patient out of getting needed care. Which side effects are common enough to be mentioned, and which are rare enough to be left unsaid?

This is a good discussion to have with your doctor. You might not want to know all the possible minor irritations that could be caused by a medicine. A warning of the most significant possible adverse events and a general comment that any new symptoms are probably from the medicine might be all the information you want.

Others might want to discuss the drug in detail and have a strategy for coping with side effects. It’s your body, your appointment, and the doctor is your consultant. Ask for the information you want and know when to say, “Enough.”

4 Drugs With Annoying Side Effects You Should Put Up With

Some really useful drugs have irksome side effects, but not all of those persist. Soldier through one or more unpleasant initial symptoms for a few days, weeks or months, and they may subside. What is left is an effective, tolerable treatment.

Norman Tomaka, a clinical consultant pharmacist in Melbourne, Fla., says initial side effects are to be expected when you incorporate any new drug into your body as it physically adjusts to the medication. However, in most cases, the body returns to normal functioning, and side effects subside.

“It’s just the way our bodies defend their normal patterns,” says Tomaka.

Here are common drugs that each have at least one major off-putting side effect that will likely go away:

  1. Metformin, a first-line drug for type 2 diabetes, causes diarrhea and other gastric distress with each change of dosage; typically goes away in a few days.
  2. Nexplanon, a progestin-only birth control implant, is 99% effective, but heavy or irregular bleeding can be a particularly off-putting side effect. It usually abates after 3 to 6 months.
  3. Zoloft (sertraline), a veteran treatment for depression, obsessive-compulsive disorder, panic attacks and social anxiety disorder, causes gastrointestinal distress that generally subsides within a few months.
  4. Ritalin (methylphenidate) is a common treatment for attention deficit/hyperactivity disorder. Common side effects include appetite suppression, which may go away but needs to be attended to while it persists, as it can lead to weight loss.

1. Metformin

Marie Brown, MD, a suburban Chicago internist, treats many type 2 diabetics. Her drug of choice for the condition is metformin, an old, inexpensive, first-line drug. Diet and exercise work best at controlling diabetes, says Brown, but as an effective treatment, “metformin stands alone.” It costs pennies a day, and Brown says it doesn’t cause weight gain, which can make diabetes worse.

There’s just one hitch with this miracle drug: Metformin almost always causes diarrhea. It typically goes away in 2 to 6 days, but will likely return for a few days with every dosage increase.

“It almost invariably resolves,” Brown says, but physicians should always warn their patients about metformin. “They will have loose stools. They should begin the medicine when they’re going to be near a bathroom.”

To minimize diarrhea, take a low dose, as low as 250 mg, with a meal, and persevere through those few days of diarrhea, says Brown. A week after the diarrhea stops, go up to the next dose, brace for a new bout of diarrhea, and repeat the process until you’ve reached the full dose the doctor has prescribed, a process that could take weeks or even months. Even resuming the maintenance dose after a drug holiday of 2 to 3 days may bring on diarrhea, Brown says.

Maryann Collins of Oak Park, Ill., now a patient of Dr. Brown’s, has been on metformin for her type 2 diabetes for more than 20 years. She takes the maximum dose — 1,000 mg — twice a day, a total of 2,000 mg, as part of her regimen. In the beginning, she recalls, she was surprised and distressed by the bouts of diarrhea, especially since at the time she was commuting 35 miles to work.

“It was only for about a week, but I felt like, ‘Ooh, am I going to make it?’ After that week, though, it was not a significant issue,” Collins says, although she still tends “to want to be near a bathroom in the morning.”

Brown says many providers don’t walk their patients through the process of adjusting to metformin, don’t tell them what to expect and don’t tell them the diarrhea is only temporary. Many patients conclude they’ll have to stay close to a bathroom for the duration, and stop taking metformin, possibly moving on to a less effective, more expensive drug with its own side effects. Sometimes patients don’t even mention to their doctors why they’ve stopped, she notes.

The truth is, many providers don’t know that diarrhea is only temporary with metformin, Brown says. She knows this because she often speaks about drug adherence at medical conferences.

“Metformin has been around so long, it’s not taught in detail like the newer drugs that are coming out,” Brown says.

2. Nexplanon

Another effective drug with a distressing side effect is Nexplanon, a birth control implant. A rod the size of a matchstick inserted under the skin of a woman’s upper arm releases etonogestrel, a type of progestin, a hormone that helps prevent pregnancy. Placed by a trained physician or other provider, Nexplanon works for 3 years and has a 99% success rate.

That’s why Emily Gregory, an obstetrics-gynecology resident at the University of Tennessee Graduate School of Medicine in Knoxville, uses Nexplanon. “It’s more effective than a tubal ligation but completely reversible,” she says. Gregory also likes that, in her case, Nexplanon controls the pain and mood swings that can accompany menstrual periods.

If a Nexplanon user decides she wants to have children, she can have the implant removed and expect to return to her normal fertility pattern within days, says Nikki Zite, MD, a Knoxville ob-gyn and a professor at the school of medicine there. That’s a popular benefit, too.

The problem with Nexplanon is that patients typically experience, among other symptoms, irregular and often heavy bleeding. This side effect usually goes away after 3 to 6 months, but in the interim, for the patient, the bleeding can seem like a continual period, interfering with sexual relations and other aspects of daily life.

Gregory experienced spotting for a few weeks about a month after the implant was placed, “then nothing,” she says. However, 10 to 15% of women who get the Nexplanon implant have it removed because of bleeding, Zite says.

“Give it 3 to 6 months,” Zite says. If women can take daily birth control pills in addition, the estrogen in those pills can help. Ibuprofen (Advil, Motrin), an over-the-counter NSAID (nonsteroidal anti-inflammatory drug), may ease bleeding, too. Sometimes, “reassurance and time” are all a woman needs, Zite says.

3. Zoloft

Tomaka says that another effective drug with troublesome temporary side effects is the depression treatment Zoloft (sertraline). This antidepressant, also used for anxiety, can cause gastrointestinal distress. However, the common nausea, diarrhea and stomach pain ordinarily go away after a few weeks, he says.

4. Ritalin

Ritalin (methylphenidate), the popular stimulant prescribed for ADHD (attention deficit/hyperactivity disorder), may cause decreased appetite, a common symptom that may resolve with time. Meanwhile, eat plenty of healthy foods to prevent weight loss. If the patient is a child, offer fruit, whole grains and appealing proteins (don’t forget about peanut butter!), and try providing a bedtime snack. If a child’s appetite doesn’t return, re-evaluate the use of methylphenidate.

More Than One-Third of Adults Take Meds That Have Depression Risk

An estimated 37% of adults use medications where depression is a potential side effect, according to a new study. Researchers looked at 26,192 adults who participated in a national survey between 2005-2014.

Results, published in JAMA, indicated that more than one-third (37.2%) of adults use medications that have depression as a possible side effect. Over time, the percentage of people using these medications has steadily increased, going from 35% in 2005-2006 to 38.4% in 2013–2014. People were more likely to experience depression while using multiple medications that listed depression as a side effect.

Additionally, the percentage of people using medications that are associated with suicidal symptoms increased from 17.3% in 2005-2006 to 23.5% in 2013-2014.

Overall, adults reported using more than 200 medications that have been associated with depression or suicidal behavior as adverse effects, including anti-hypertensives (blood pressure meds), proton pump inhibitors (used to control acid reflux), pain medications and hormonal contraceptives.