When you hear the phrase “a rare but serious side effect,” what comes to mind? With so many pharmaceutical commercials on television these days you may be be used to hearing that phrase.
Statins like Lipitor (atorvastatin), Zocor (simvastatin), and Crestor (rosuvastatin), are some of the most popular cholesterol medications, and they come with this “fine print” phrase. Statins can cause a rare but serious side effect called rhabdomyolysis.
What is rhabdomyolysis?
Rhabdomyolysis often characterized by muscle aches and pains is a rare but serious side effect caused by muscle injury which leads to the breakdown of muscle tissue that can cause harm to the kidneys. Rhabdomyolysis can cause kidney failure and, in rare cases, death.
What are the common signs and symptoms of rhabdomyolysis?
The common signs and symptoms of rhabdomyolysis include:
- Muscle pain
- Muscle weakness
- Stomach pain
- Rapid heart rate
- Dark red or brown urine
- Reduced or no urine output
Just how rare is it?
Clinical studies have found the incidence of rhabdomyolysis as a side effect to statin use to be low—only 0.1 – 0.2 percent if you’re taking a statin alone, though it may be higher in combination with other medications. So, very rare.
Why is rhabdomyolysis a serious side effect?
Rhabdomyolysis can can lead to complications like kidney failure or death. Kidney failure occurs when the filtering systems of the body (the kidneys) are unable to remove waste products and urine. If waste products build up in the body they can become toxic.
Should I discontinue my statin if I experience muscle aches or pains?
Always talk to your doctor before making any changes to your prescription regimen. Muscle aches or pains may be a result of many things, but it’s important to bring any side effects you experience to the attention of your doctor.
Keep in mind that rhabdomyolysis is not a subtle ache or pain, and it is a rare reaction—but contact your doctor immediately if you think you may be experiencing it.
Your doctor may have you discontinue your medication for two weeks to see if the symptoms resolve, or perform a blood test that can confirm a diagnosis of rhabdomyolysis.
Can any other medications cause rhabdomyolysis?
Are there any causes of rhabdomyolysis that are unrelated to medications?
Yes. Among several other things, the breakdown of muslce tissue can be also be caused by muscle strain, alcohol and illegal drugs, muscle compression, injury, or immobilization, electric shock or lightning strike, diseases of the muscle, and metabolic disorders like diabetic ketoacidosis.
I feel fine—do I still need to take my cholesterol medication?
Yes. High cholesterol, like high blood pressure, usually can’t be felt. Your doctor can help you determine your cholesterol level with a blood test.
The generic versions of Ambien and Sonata (zolpidem and zaleplon) have dominated the market of insomnia medications. Zolpidem is available as a 5 or 10 mg tablet and Zaleplon 5, 10, or 20 mg tablets. If your insurance company covers one and not the other, how easy is it to change? How do the Z drugs compare?
Both are “atypical benzos” that have a high affinity for alpha 1 GABA receptors. This sets them apart from other “typical” benzodiazepines (Ativan, Valium, Xanax) because they working to promote sleep, but not to treat anxiety.
Why are they so popular?
They both have been shown to improve sleep with no evidence of tolerance seen with long-term use. Tolerance is the loss of effect with repeated use of a standard dose, and is not seen with the Z drugs. Importantly, they have been shown to improve aspects of daytime function in those suffering from insomnia.
How are they different?
Zaleplon has a very short half-life of about one hour, shorter than zolpidem. Zolpidem has a half-life of approximately 1.5 to 2.4 hours. More specifically, zolpidem 5 and 10 mg tablets reach maximum concentration (Tmax) at 1.6 hours, with a half life 1.4 – 4.5 hours. Zaleplon 5, 10 and 20 mg tablets reach maximum concentration at an hour, with a half life of 1 hour. Zaleplon will act more rapidly and be gone from your system more rapidly.
Who should use what?
Both are effective for patients who have difficulty falling asleep (sleep onset insomnia), but may not be as effective for patients who have difficulty maintaining sleep. For difficulty maintaining sleep you would think about a longer acting option in the same class like zolpidem CR (generic Ambien CR) or eszopiclone, the Lunesta generic. The upside to the very short half-lives of the Z drugs is the reduced potential for hangover sleepiness after normal sleep periods.
Which one is stronger?
Probably because it hangs around longer, zolpidem use has been shown to affect performance on measures of attention and verbal memory and psychomotor speed, while zaleplon has not shown those effects.
What’s the upshot?
For patients with sleep onset insomnia, a short-acting medication is a reasonable choice for an initial trial of medication therapy. This should improve the insomnia with less residual sleepiness the following morning. Zolpidem and zaleplon are both good examples of short-acting medications with a duration of effect of less than 8 hours.
Whether you use one medication or fifteen, it is important to know exactly what your doctor has prescribed for youto make sure you get the right medication and dose each time. You should also know why your meds were prescribed, and how you are supposed to take them.
It’s unfortunate but true that many people don’t know what they’re taking, let alone why. Playing a proactive role in managing your medications may not always be easy, but you can look for help from your pharmacist, doctor, or nurse.
Why should you be concerned? First, remember that your prescription (especially if it’s a generic) can be made by several different companies, and it can differ in color, shape, and dosage form from one manufacturer to the next. There are several factors that can play a role in whether or not you receive your medication in the same color or shape each time you fill. Because the appearance of your prescriptions can vary, knowing your medications inside and out can help prevent confusion.
Some possible scenarios in which you may not receive the same color or shape of your medication:
- If you use multiple pharmacies. Different chains (or even locations) may stock different packaging of the same medication.
- Manufacturer backorder. Your pharmacy may need to use a different manufacturer to fill your prescription than you are used to so that you do not go without medication during a backorder.
- Dose increase or decrease. The shape and color of your prescription may change.
Don’t depend on the color, shape, or even dosage form to keep your prescriptions straight! You are not alone if you keep track of your prescriptions this way (for example: the white round pill in the morning, the pink oval pill at night), but many medications can look very similar. For this exact reason it is so important not to rely only on the appearance of your medication.
This is especially true if you are on a complex regimen where you take many medications—it’s more likely that you may have some that look alike.
Examples of common medications that people often try to remember by appearance:
- Warfarin (generic Coumadin, a blood thinner). Tablets may be brightly colored, pink, green, blue, purple, etc, and oval or oblong—but the shade or exact shape can vary depending on the manufacturer.
- Levothyroxine (along with Synthroid and other thyroid meds). Most brand and generic levothyroxine medications have distinct colors for each strength, but all Synthroid tablets are round. Generic levothyroxine has much more variation in both shape and color.
- Trazodone (generic Desyrel, for depression). Both the brand and generic come in some distinctive shapes like bars and trapezoids—but most strengths and forms are still white, round or oval tablets, easy to mistake for other medications.
- Sertraline (generic Zoloft, for depression and other mental health conditions). Again, both the brand and generic come in some fairly distinctive oval shapes, but others are standard beige or blue oval tablets.
- Inhalers. This can be especially important if you have a both a maintenance inhaler and a rescue inhaler (for asthma, for example). While your inhalers may look different—Advair Diskus for maintenance, and Proventil HFA or Proair HFA for rescue—you should still always be able to keep them straight by more than appearance.
What are some good ways to keep track of your medications?
- Make a list and keep it up-to-date. Take the time to sit down and create a current list of your medications. This will help you get organized and play an active role understanding your medications.
- For each medication, your list should include:
- Medication name
- Strength and dosage
- Prescribing doctor
- Don’t try to go on memory alone. Line up your prescription and over-the-counter medications in front of you while you create your list.
- Don’t know a medication’s intended use? Contact your pharmacist for more information.
- Don’t forget to include any over-the-counter medications. This means vitamins and minerals, herbal treaments, topical ointments or creams, and seasonal meds like OTC allergy drugs.
Keep your up-to-date medication list on you and bring it with you to all health care appointments. Your list will help give you a reference if you have questions about your prescriptions, or if you forget what you are taking and why.
It’s also important to remember to keep your list current and update it when there are any changes, including dose increases or decreases, changes to your directions, or you start or stop taking a medication.
On May 15, 2015, the FDA issued a warning for the newest class of diabetes medications, SGLT2 inhibitors.
According to the FDA, the medications in this class may lead to a serious and life-threatening condition known as ketoacidosis.
Which medications are considered SGLT2 inhibitors?
These medications also contain SGLT2 inhibitors in combination with other active ingredients:
- Glyxambi (empagliflozin/linagliptin)
- Invokamet (canagliflozin/metformin)
- Xigduo XR (dapagliflozin/metformin)
What should I do if I am taking one of these medications?
If you are taking one of the medications listed above DO NOT stop your medication without talking to your doctor.
Monitor yourself for the signs and symptoms associated with ketoacidosis and if needed, seek emergency medical attention.
What are the benefits of SGLT2 inhibitors?
Not only have SGLT2 inhibitors been shown to lower blood glucose levels, but they can also help with weight loss, a reduction of A1C levels, and to lower blood pressure–all of which can be concerns for diabetics.
What is ketoacidosis?
Ketoacidosis is a condition where there is too much acid in the blood, which can basically poison the body. These blood acids are better known as ketones.
What are the common signs and symptoms of ketoacidosis?
The common signs and symptoms of ketoacidosis may include but are not limited to the following:
Early symptoms of ketoacidosis may include thirst, dry mouth, frequent urination, high blood sugar levels, and high ketone levels in the urine.
Some other common symptoms to watch out for are difficulty breathing, nausea and vomiting, stomach pain, confusion, fatigue, and sleepiness.
What are the typical side effects of SGLT2 inhibitors alone?
Common side effects of SGLT2 inhibitors include female genital infections & urinary tract infections.
How is ketoacidosis treated?
Treatment for ketoacidosis takes place in the hospital where you may be given fluids, electrolytes, and insulin.
How can I prevent ketoacidosis?
Ketoacidosis usually be prevented with proper diabetes management. For example:
- Make responsible decisions when it comes to your diabetes. Make sure you get proper nutrition and adequate exercise, and take your medications.
- Check your blood sugar at least 3 to 4 times per day, possibly more often if you are sick or stressed out.
- Check your urine for ketones using over-the-counter ketone test strips, especially if you’re feeling sick or stressed. Moderate to high ketone levels warrant a call to your doctor or an ER visit.
You can find more important info about the FDA warning here.
Medications these days are not only limited to traditional routes like taking a pill by mouth. A variety of new and improved dosage forms have been created with your best interests in mind.
If you have trouble remembering to take your medication, or for example, if you’re a diabetic who doesn’t like needles, one of the newer dosage forms just might be right for you!
What types of new dosage forms now exist?
- Iontophoretic transdermal systems
- Long-acting injections
- Inhaled medications
- Dissolvable tablets and films
Are there advantages to using these newer forms?
Yes—some of these new forms can help you resolve common issues like:
- Problems swallowing medication. Newer dissolvable tablets and films can help with swallowing problems. Some patients may have trouble swallowing larger tablets or capsules, and a dose that can be placed under the tongue or in the mouth to dissolve can be beneficial.
- Remembering to take your medication. New longer acting injections can help with medication recall. Once the injection is administered you may not need another dose of medication for 1 week to 6 months depending on the medication. Several long-acting injection options exist for indications such as birth control, mood stabilization, or osteoporosis.
- Fear of injecting your medication. New inhalational dosage forms can help with medication fear. An example of medication fear are those patients newly diagnosed with type 2 diabetes that have a fear of needles and injecting themselves with insulin. Recently, the FDA approved Afrezza, an inhaled insulin which may help reduce some of the nervousness associated with using insulin for newly diagnosed diabetics.
- Faster symptom improvement. New iontophoretic transdermal medication systems can help suffering patients with pain control in situations where fast relief is desired. Pain can be a result of many things for example surgery or a migraine. Recently approved iontophoretic topical medication systems produce a mild electrical current in order to deliver the medication through the skin.
- Ease of use. “Set it and forget it!” a common catch phrase used for crock pot dinners can actually be applied to the use of medications as well. Most patients would probably prefer a medication that they don’t really have to think about such as a topical patch or monthly injection. These dosage forms allow a patient to receive proper treatment with the least amount of effort.
Which medications are available through an iontophoretic transdermal system?
The iontophoretic delivery system actually uses a mild electrical current to deliver a medication through the skin. These drugs will be available as transdermal patches that offer a set dose of medication. There aren’t any currently available at your pharmacy, but some examples of how the system is used include:
- Pain management. Ionsys was approved by the FDA for pain management on May 7, 2015, but it is for use in hospitalized adults only.
- Migraine relief. Zecuity was approved by the FDA in January 2013, and is coming soon for acute migraine relief.
What sort of medications are available as long-acting injections?
Rather than a taking a daily pill or injection, you may be able to receive a long-acting injection weekly, monthly, or even less often. The following are examples of some types of medications that have this form available:
- Birth Control (Depo-Provera, medroxyprogesterone)
- Mood stabilizing drugs (Abilify Maintena, Risperdal Consta, Invega Sustenna)
- Osteoporosis (Prolia)
Which medications can be inhaled?
While you may be familiar with inhalers for asthma or COPD, you may not be aware that an inhaled insulin (Afrezza) recently became available for diabetes patients.
What sort of medications are available as dissolvable tablets or films?
Alternative forms like orally disintegrating tablets and sublingual films can be especially helpful if you have a difficult time swallowing. Even better news here—many of these are also available as as cheaper generics. Some medications that can be dissolved in your mouth or under your tongue include treatments for: