The latest updates on prescription drugs and ways to save from the GoodRx medical team

More Bad News for Ambien (Zolpidem)?

by Dr. Sharon Orrange on February 28, 2014 at 12:22 pm

Zolpidem is the generic version of Ambien, which is also available in a longer acting form known as Ambien CR. These sleep medications (zolpidem, Sonata, Lunesta) are widely popular and known for their lack of hangover effect the next morning. These “atypical” benzodiazepines are different from “typical” benzodiazepines like Ativan, Xanax, or Valium in that they are used to treat insomnia but not anxiety.

Weird things can happen to people who take them, especially if you take one and continue to walk around and do things in your house. Now there is more concerning information that emergency department (ED) visits for adverse reactions related to zolpidem increased by 220% in a recent 5-year period. That’s important.

Scared or not? Know these things about zolpidem:

  • Talk to your doctor about other medications you are taking with the zolpidem.
  • Think of this medication as a short term solution and try alternative strategies for treating insomnia: avoiding caffeine, exercising regularly, sleeping in quiet darkened surroundings, and limiting TV and computers at night, which are stimulating.
  • In 2010, 13,180 zolpidem-related emergency department visits involved adverse reactions among women, which was more than double that for men.
  • The FDA recommends we halve the recommended dose for women. Zolpidem comes in 5 and 10 mg doses, and an extended-release version comes in 6.25 and 12.5 mg doses. For women the 5 mg dose is recommended because women metabolize the drug differently than men and 8 hours after taking the drug women still have higher levels of zolpidem in their system. The elderly should also take half of the recommended dose.
  • Almost half of the ED visits occurred when folks were taking zolpidem combined with other medications. People got in to trouble when mixing zolpidem with narcotics, other anti-anxiety medications, or alcohol.
  • The bad reactions that brought people to the ED were daytime drowsiness, dizziness, hallucinations, bizarre behavior, and sleepwalking.

Think of zolpidem as a short-term solution to insomnia, don’t take it with alcohol or other medications, and think about taking the lowest doses possible.

Dr O.

Constipation From Your Meds: What’s the Best Treatment?

by Dr. Sharon Orrange on February 27, 2014 at 10:41 am

Medications are a major reason for constipation. Pain medications are the biggest culprit with opioids (Vicodin, Norco, Tylenol with codeine, etc) and non steroidal anti-inflammatory drugs (NSAIDS) leading the pack. Constipation can become a bigger struggle for you than the illness that led you to take the medications causing it, and will make any post-operative course miserable. So, why does this happen and what works for the treatment of medication-induced constipation?

Why does this happen?

Opioids and other medications affect parts of the stomach and intestine (particularly the colon), altering nerve input to the gastrointestinal tract which inhibits movement. Opioids also increase the absorption of electrolytes and water (making drier and thus harder poops), increase anal sphincter tone, and reduce sensitivity to the presence of stool. These factors lead to constipation, hard stools, and misery.

What really works?
1.  Stimulant Laxatives: Senna (sennosides, Ex-Lax) and bisacodyl (Dulcolax) increase intestinal motility and help with the flow of water INTO the bowel which improves constipation. SENNA is more commonly used and slightly more effective than BISACODYL for opioid-induced constipation. Both are available over the counter and cheap.

2.  Osmotic Laxatives: These include magnesium or phosphate-containing laxatives, non-absorbable sugars (lactulose, sorbitol, glycerin), and polyethylene glycol (Miralax). Osmotic laxatives work by increasing fluid accumulation in the colon and small intestine, which improves constipation. These are all effective for treatment of opioid-induced constipation but some evidence shows that lactulose is better than sorbitol, and Miralax is better than lactulose. Hmmm, so is Miralax the best?

3.  Emollient Laxatives: These include Colace (docusate), or mineral oil. Know that emollient laxatives are inferior to the osmotic and stimulant laxatives for the treatment of drug-induced constipation. So, this should be your third choice.

4.  The newest: Methylnaltrexone (Relistor) is an injection and the newest medication for opioid-induced constipation. Relistor is expensive, but has been found to provide good relief of constipation in terminally ill patients who do not respond to laxatives. Relistor is your last choice if all else has failed.

What doesn’t work?

Fiber and bulk laxatives (psyllium, metamucil, bran, fibercon, Citrucel, etc.) are generally not effective for the treatment of drug-induced constipation. Don’t go there.

Dr O.

More FDA Oversight for Over the Counter Drugs?

by Elizabeth Davis on February 26, 2014 at 2:23 pm

The FDA has announced a public hearing in March 2014 to discuss updating the review and approval process of over the counter (OTC) drugs.

The hearing itself doesn’t mean there will be any changes to the process, but the FDA hopes to address issues like misbranding, the large number of non-prescription drugs on the market that haven’t been evaluated at all, and the current limitation on the FDA’s ability to require changes to products or labeling.

They also hope to streamline and modernize the review process, allowing for quicker approvals and changes to existing products.

One reason why the process needs to be fixed? The FDA recently asked that prescription manufacturers remove all products containing more than 325 mg of acetaminophen (Tylenol) from the market, due to concerns about accidental overdoses and liver damage. However, OTC Tylenol and acetaminophen are still available in 500 mg extra strength formulas. (See our previous post for more information.)

Better (not just more) oversight from the FDA on OTC products could help ensure that you stay safe, and that you’re getting what you expect from your medications, whether you need a prescription or not.

For more information on the FDA hearing, see the announcement here—and watch for more developments after the meeting in March.

Levoxyl Shortage: When Will It Return?

by The GoodRx Pharmacist on February 24, 2014 at 1:44 pm

Levoxyl is mainly used for the treatment of hypothyroidism or low thyroid hormone levels. It was voluntarily recalled by its manufacturer, Pfizer, in February of 2013, due to reports from consumers and pharmacists that the tablets had a strange smell.

When is Levoxyl expected to be available again?
According to the Levoxyl website the estimated date of availability is March 3, 2014, but the exact date is subject to change without notice.

Why was Levoxyl recalled, and is it safe to use?

An investigation was conducted and it was found that the source of the odor was an oxygen-absorbing canister that had been packaged with some bottles. Pfizer’s assessment indicated that this incident will not cause any adverse health effects for consumers.

What should I expect from similar recalls or shortages?

Drug shortages can occur for various reasons, including recalls, changes in supply and demand, or issues with raw material production, just to name a few. Patients usually do not find out about shortages until they go to the pharmacy to pick up their medication. Ask your pharmacist to explain to you and your doctor, if necessary, why this shortage has occurred. The next step would be for your doctor to decide on an alternative medication to prescribe for you, either temporarily or permanently. Understandably, a drug recall or shortage might leave you feeling skeptical and confused about your prescription, so make sure to speak with your healthcare provider to better understand each unique circumstance.

Does Levoxyl have any offers available from the manufacturer?

Yes. A FREE 30-day trial of Levoxyl for those who meet qualifications is available.

What if my pharmacy does not have Levoxyl in stock?

Patients can call Pfizer customer service at 1-800-533-4535. Pfizer will work with your pharmacy and the wholesaler to have the medication quickly shipped and available for you.

Are there any comparable thyroid medications currently available?

Yes. Ask your doctor if Synthroid, levothyroxine, or Armour Thyroid might be right for you. You can also see a list of more thyroid hormones here.

Sudafed: To Be or Not to Be . . . A Prescription?

by The GoodRx Pharmacist on February 21, 2014 at 11:35 am

What comes to mind when you think about where to find medications for treating symptoms of a cough, the common cold, allergies, or sinus problems? Most people imagine being able to walk through the aisles of their local pharmacy or grocery store to find cough syrup, nasal decongestants, or cold tabs. However, sometimes these items are not where you would expect to find them—like behind the pharmacy counter.

Most medications that are located behind the counter in the pharmacy require a prescription from your doctor, though it isn’t always the case. There are plenty of products stocked in the pharmacy that, surprisingly, may not require a prescription depending on which state you are located in. One of those products is pseudoephedrine, also known as Sudafed. Pseudoephedrine can be found alone for nasal congestion or in a variety of combination products used for cough, cold, allergy, or sinus problems.

What is Sudafed for?
Sudafed (pseudoephedrine) is a decongestant product used to relieve stuffiness or congestion in the nasal cavity due to the common cold, allergies, hay fever, or sinusitis.

Are products containing pseudoephedrine available without a prescription?

Depending on the state you reside in, the answer can be YES or NO!

If you live in a state in which a prescription is NOT required, you must still get these products from behind the pharmacy counter. Most of the time you will need to present your photo ID and sign for your medicine in an electronic or paper log.

If you live in a state in which a prescription IS required, your doctor must provide you or your local pharmacy with a valid prescription for the medication you need.

Which states require a prescription for Sudafed or pseudoephedrine-containing products?

Currently, only Oregon and Mississippi have state-wide laws in place which require a prescription for all products containing pseudoephedrine. However, there are local laws in place in a number of cities in Missouri and Tennessee.

Which cities in Missouri require that you have a prescription?

Cities that require a prescription in Missouri include but are not limited to Arnold, Branson, Cape Girardeau, Crystal City, Doniphan, Joplin, Perryville, Licking, Jackson, and Houston.

Which cities in Tennessee require that you have a prescription?

Cities that require a prescription in Tennessee include but are not limited to Huntland, Winchester, Estill Springs, and Martin City.

Why is Sudafed so tightly regulated?
Pseudoephedrine is the main ingredient used to make methamphetamine or crystal meth, an illegal and highly addictive drug. Because meth can be easily made with pseudoephedrine and common every day household products, law makers are trying to limit the access of pseudoephedrine in order to limit the illegal production of meth.

Does Sudafed come in other forms that are not located behind the pharmacy counter?

Yes. Sudafed PE products are located in the store aisles and do not require the same strict rules and regulations as the Sudafed products located behind the pharmacy counter. The active ingredient in Sudafed PE is phenylephrine, instead of pseudoephedrine.

Which product is more effective for congestion—pseudoephedrine or phenylephrine?

Most patients and healthcare providers will agree that pseudoephedrine is more effective for congestion than its counterpart phenylephrine. This is likely due to the fact that the intestines will absorb only about 38% of the phenylephrine in one tablet, while pseudoephedrine is 100% absorbed. Also, the effects of phenylephrine do not last as long as pseudoephedrine. Therefore, phenylephrine needs to be taken every four hours, while pseudoephedrine can be taken every four to six hours.

If I have high blood pressure, can I use pseudoephedrine or phenylephrine products?

NO, I would not recommend using these products without consulting with your doctor. This medication is a vasoconstrictor, meaning that it can tighten the blood vessels. This tightening or constriction can further increase the blood pressure of someone who has already been diagnosed with hypertension, leading to an increased risk of cardiovascular events such as heart attack or stroke.

Additional Information:

Learn about some of the various Sudafed and Sudafed PE products available here. Many other combination allergy and cough and cold products also contain pseudoephedrine or phenylephrine.

Learn more about the Combat Methamphetamine Epidemic Act of 2005.

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