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

These Drugs Can Mess With Your Potassium

by Dr. Sharon Orrange on October 17, 2017 at 3:48 pm

It’s not being overly dramatic to say that abnormal levels of potassium may actually kill you. Serum (bloodstream) potassium is an electrolyte, and imbalances are called hyperkalemia (when too high) and hypokalemia (when too low). Cardiac arrhythmias are a known serious outcome of both hypo- and hyperkalemia, and national statistics indicate that almost half of 1% of emergency department visits and 2% of hospitalizations for high potassium end in death.

High or low potassium may occur as a result of your medications—and older folks and women are more likely to be affected. Here’s what you need to know.

What are electrolytes?

Electrolytes like sodium, calcium, and potassium control the fluid balance in the body and are important for muscle contraction. You may not have any symptoms when electrolytes are abnormal so your doctor needs to check a basic metabolic panel blood test when you are on medications that may alter these.

What might happen with LOW potassium (hypokalemia)?

Muscle weakness that begins in your lower extremities then moves to your trunk and upper extremities, decreased appetite and nausea, and a variety of heart arrhythmias are seen in patients with hypokalemia. While it’s hard to say how low your potassium has to be to contribute to heart arrhythmias—generally speaking potassium levels lower than 3.0 (normal is 3.5-5.0) put you at much greater risk.

What might happen with HIGH potassium (hyperkalemia)?

The scary truth is high potassium, at levels over 5.5, may present with life-threatening complications that go unrecognized (there are few symptoms) prior to cardiac arrest. Non-cardiac related signs and symptoms include altered mental status, confusion, muscle cramps, and weakness.

Which medications may lower your potassium (hypokalemia)?

  • Diuretics are water pills with two familiar forms: loop diuretics (furosemide/Lasix, bumetanide/Bumex) and thiazide diuretics (hydrochlorothiazide or HCTZ, chlorthalidone). Used to treat blood pressure, heart failure, and lower extremity swelling, diuretics are the main cause of low potassium. Think of potassium as following water out of the kidneys—so increased urination from diuretics may lower your potassium.
  • Albuterol (Proair, Proventil) inhalers used in the treatment of asthma may lower your potassium. Albuterol stimulates the release of insulin which “pushes” potassium into the cells, thus lowering the amount of potassium in your blood. This may cause hypokalemia. Know that nebulizer treatments lower potassium more than inhalers.
  • Sudafed (pseudoephedrine) is available over the counter as a decongestant. It also pushes potassium into the cells, lowering your blood/serum level of potassium.
  • Insulin at high doses also may lower potassium in the blood by shifting potassium into the cells.
  • Laxatives and enemas at large doses can cause loss of potassium in the stool. Intestinal loss of potassium due to diarrhea may occur if you are using high doses of laxatives or enemas.
  • Risperdal (risperidone) and Seroquel (quetiapine) are antipsychotic meds that may cause hypokalemia, but it’s a rare complication.

Which medications may raise your potassium (hyperkalemia)?

  • The ARBs (angiotensin II receptor blockers): losartan, telmisartan, valsartan, irbesartan used to lower high blood pressure may raise your potassium. Simply put, these medications decrease aldosterone, which impairs release of potassium from the kidneys. As many as 10% of patients taking these meds may experience at least mild hyperkalemia, and your electrolytes need to be checked after you are started your prescription.
  • ACE Inhibitors are blood pressure lowering medications ending in -il like lisinopril, enalapril, quinapril. They also raise potassium similar to ARBs.
  • Important to note: many combination pills exist with ACE inhibitors or ARBs and HCTZ (lisinopril/HCTZ, valsartan/HCTZ). Those two medications together in one pill help normalize potassium—one raises it and one lowers it. The upshot is that the combinations carry less risk of potassium abnormalities.
  • Aldactone (spironolactone) is a “potassium-sparing diuretic” that may raise potassium by inhibiting the effects of aldosterone. Spironolactone may be prescribed for acne, cirrhosis, PCOS (polycystic ovary syndrome), and heart failure.
  • NSAIDs. Ibuprofen (Motrin, Advil) and naproxen (Aleve) may raise potassium by inhibiting the hormone renin, which impairs the release of potassium by the kidneys.
  • Cyclosporine and Prograf (tacrolimus) are used in organ transplant patients to prevent rejection. High potassium is a common problem in patients treated with these drugs.
  • Heparin is a blood thinner given intravenously for blood clots or heart attack, and it may also raise your potassium.
  • Propranolol and labetalol are beta blockers that may bump up your potassium a bit, but not significantly. Beta blockers inhibit the uptake of potassium into the cells causing an increase in your serum (bloodstream) potassium. This does not occur with atenolol, another beta blocker.

Bottom line: don’t mess with potassium, make sure you are having it monitored.

Dr O.

Reference: HCUPNet: Healthcare Cost and Utilization Project. Rockville , MD : Agency for Healthcare Research and Quality, 2010.

10 Things Your Primary Care Doctor Does That Should Worry You

by Dr. Sharon Orrange on October 6, 2017 at 10:55 am

Many of my patients express frustrations with our offices or previous doctors they’ve come across—and they have the same concerns over and over. After 17 years as a physician and learning from folks what drives them crazy, I have a list of things doctors do that should make you run for the hills.

  1. The waiting game. Dr X leaves you waiting more than 45 minutes once you’re in the room (often in a flimsy gown) on more than one occasion without an explanation or even a quick apology. Easy ways for a busy doctor to handle this are walking in and saying, “I’m sorry to keep you waiting,” or having the nurse let you know, “Dr X is running 30 minutes late today,” so you can grab a coffee or a magazine. It’s about expectation and the recognition that your time is important.
  2. After-hours. Dr X’s office provides no way for you to reach a HUMAN VOICE after-hours or on the weekends if you have a medical issue that requires attention. When you meet a doctor ask them: “What will I do if I run into trouble after 5 pm or on the weekends?”
  3. Do as I say, not as I do. Dr X smells like cigarette smoke. I have great respect for what a hard habit tobacco is to kick, but you can’t smell like cigarettes when you are going to counsel your patients about modifying their risk factors for stroke and heart disease. Your doc should cut it out during the clinic day at the very least.
  4. Lack of touch. Dr X doesn’t touch or examine you. Now, it’s not always necessary, but if you have a specific complaint (shortness of breath, knee pain, sore throat) and your primary care doctor doesn’t look, touch, or listen to the affected area, that’s not right. I may be old school but the answer so often lies in the physical exam.
  5. The money talk. Dr X doesn’t offer or discuss generic or cheaper options for your brand name prescription drugs. Many of you come to me paying high out-of-pocket costs for your medications and are always surprised to hear there are cheaper (and just as effective) options. If you feel uncomfortable discussing the cost of your meds with your doctor, or don’t feel you have the relationship to do so, move on.
  6. Empathy-less. If you are tearful when talking about feelings of sadness or depression, or discussing a painful life event (the recent loss of a parent, etc) and you notice Dr X appears uncomfortable and tries to change the subject, this is bad news. Run for the hills.
  7. Me me me me. Dr X talks about themselves during your visit. One study showed that during 30% of primary care visits the doctor spent more time talking about themselves than they did the patient. This visit is about YOU and we are already limited in what we can do in 15 to 20 minutes.
  8. Deal with it. Dr X says, “That’s just part of getting old” when you have a complaint, but offers no plan. It’s true: arthritis, visual changes, decreased hearing, and sun damaged skin are among the fun things that go along with getting old—but we can still come up with a plan to deal with them and alter their course.
  9. Rushing. Dr X delivers bad news (a new cancer diagnosis, loss of a pregnancy, a positive STD test) with language that is short, sharp, rushed, and without emotion. Some news will change a person’s life forever and they will always remember that moment . . . a cold delivery is painful and unacceptable.
  10. Acknowledging the unknown. Dr X can’t say, “I don’t know what that is, but let’s make sure it’s not something worrisome.” Often a patient has a pain, skin lesion, or weird symptom that occurs only when they are doing such and such activity and I don’t know WHAT it is. But it’s your doc’s job to admit that, and say they will do their best to monitor it and rule out worrisome things.

What am I missing?

Dr O.

12 Medications to Avoid During Pregnancy

by Dr. Sharon Orrange on October 4, 2017 at 2:12 pm

Of the non-genetic causes of birth defects, medications are a well-known offender. Early in the first trimester, many women don’t yet know that they are pregnant. This is a high-risk time to be taking certain medications as this is the major period of organogenesis or development of the organs.

While the science is very limited (pregnant women are generally not included in medication safety studies) there are a handful of medications that are considered category X drugs, or drugs that should not be taken in women who are or may become pregnant. If you are of reproductive age, and not using a reliable form of birth control, know this list of category X medications and avoid them.

  1. Absorica (isotretinoin) is a pill taken for acne, and must not be used by women who are pregnant or who may become pregnant. there is an extremely high risk that severe birth defects can result if pregnancy occurs while taking isotretinoin in any amount. If you are taking Absorica, you will be enrolled in the iPLEDGE program where you must meet certain requirements, and show proof or a reliable birth control method, to obtain the medication.
  2. Lipitor (atorvastatin), lovastatin, Pravachol (pravastatin), Zocor (simvastatin) and Lescol (fluvastatin are “statin” drugs used to lower cholesterol. They have been shown to cause fetal abnormalities in pregnant women and should not be used in women who are or may become pregnant. Why are statins so bad in early pregnancy? Cholesterol biosynthesis is important in fetal development and statins can affect that.
  3. Arthrotec (diclofenac sodium/misoprostolis used for joint pain due to osteoarthritis or rheumatoid arthritis. Arthrotec contains diclofenac and misoprostol which can cause abortion, premature birth, or birth defects.
  4. Migranal (dihydroergotamine mesylateis used for the treatment of migraine headaches. Dihydroergotamine is oxytocic meaning it is a medication that causes uterine contractions and increased tone of the uterus, which could be dangerous if you’re pregnant. 
  5. Coumadin (warfarin) is a blood thinner used to treat or prevent clots in the veins, arteries, lungs or heart. Warfarin crosses the placenta and serious fetal abnormalities have been reported following early first-trimester exposure. For women on warfarin who plan on conceiving, a switch to Lovenox (low molecular weight heparin) or at least frequent pregnancy tests are recommended so you can substitute Lovenox as soon as pregnancy is confirmed.
  6. Soriatane (acitretinis prescribed for the treatment of severe psoriasis. Acitretin must not be used by women who are pregnant, or who intend to become pregnant during therapy, or for three years following the discontinuation of therapy. Women of reproductive age who use Soriatane must prove they are using a form of contraception during treatment.
  7. Restoril (temazepam) is a benzodiazepine used for the treatment of insomnia in adults. All benzodiazepines are assumed to cross the placenta, increasing the incidence of premature birth and low birth weights.
  8. Danocrine (danazol) is used for the treatment of endometriosis, and for breast pain or tenderness due to fibrocystic breast disease. Danazol may result in androgenic (male hormone) effects on the female fetus.
  9. Arava (leflunomideis an immune modulator used in the treatment of Rheumatoid arthritis. Women of reproductive potential must use effective contraception during treatment due to the potential for fetal harm.
  10. Lupron (leuprolideis an injection used in women for the treatment of endometriosis and uterine fibroids and can be dangerous for pregnant women. Although leuprolide usually inhibits ovulation and stops menstruation, a non-hormonal contraceptive should be used in conjunction. 
  11. Rheumatrex (methotrexate) is used for the treatment of psoriasis and rheumatoid arthritis. It has been reported to cause fetal death and/or congenital anomalies and is not recommended for women of childbearing potential.
  12. Tazorac (tazaroteneis a creme used for the treatment of acne, wrinkles, and psoriasis. Tazorac may cause fetal abnormalities and a negative pregnancy test should be obtained within 2 weeks prior to treatment.

Hope this helps!

Dr O.

10 Things You Might Not Know About Vyvanse for ADHD

by Dr. Sharon Orrange on September 26, 2017 at 1:47 pm

Vyvanse (lisdexamfetamine),a long-acting stimulant medication used in adults with ADHD, is one of the most commonly prescribed brand name drugs in the U.S. Given that 60% of adults who were children with ADHD have symptoms that persist to adulthood, long-term treatment may be necessary. If you’re taking Vyvanse long term, or thinking about starting it, what are some lesser known but important things you should know?

  1. In addition to being FDA approved in the U.S. for the treatment of ADHD, Vyvanse was the first medication ever approved for binge eating disorder.
  2. How is Vyvanse different from Ritalin, Adderall, or Concerta? There are two types of stimulants used to treat adult ADHD: methylphenidate and amphetamines. Concerta and Ritalin (either short or long-acting) are methylphenidate, while Adderall and Vyvanse are amphetamine stimulants.
  3. What made Vyvanse stand out was the long-term release. Taken once daily, Vyvanse is released at the same levels over time, which allows for a similar effect 90 minutes to 14 hours after taking it.
  4. Abuse potential. Vyvanse carries a smaller risk of abuse than shorter acting medications like Adderall, Ritalin, or Focalin, due to the longer duration of action. The longer effect of Vyvanse also leads to less rebound symptoms throughout the day compared to the shorter-acting ADHD meds.
  5. It doesn’t matter if you take Vyvanse with food or not.
  6. It does matter if you take Vyvanse with acidic meds or supplements. Some examples include vitamin C, aspirin, penicillin, or furosemide, which will all decrease the level of Vyvanse in your bloodstream. The opposite is true if you take Vyvanse with basic drugs like sodium bicarbonate (found in Zegerid or Alka Seltzer), Benadryl, codeine, or metoprolol, which may increase levels of d-amphetamine, the active metabolite of Vyvanse. Your pharmacist can help you with potential interactions.
  7. Most common side effects? The most commonly reported side effects in adults taking Vyvanse are decreased appetite, dry mouth, and insomnia, which occur in 1 in 5 folks taking it.
  8. Will it affect blood pressure and heart rate? Vyvanse leads to an increase in noradrenergic and dopaminergic neurotransmission—sympathetic nervous system effects, which means your “fight or flight response.” While increases in blood pressure and pulse may occur, changes in vital signs are usually small and changes in ECG (heart tracing) are not clinically relevant.
  9. What about driving when taking Vyvanse? In young adults with ADHD, treatment with Vyvanse had a positive effect on reaction time with significantly fewer accidents. Studies show Vyvanse was associated with significantly faster reaction times (91% faster) and lower rate of simulated driving collisions.
  10. Parenting. Interesting studies have been done looking at treatment with Vyvanse when both parent and child (age 5-12) have been diagnosed with ADHD. The parents with ADHD taking Vyvanse showed a significant reduction in “negative talk” and an increase in praise of their children. Results also showed reductions in the ratio of commands to verbalizations—less yelling, more talking.

What has your experience been?

Dr O.

Weird Taste in Your Mouth? These Drugs Could Be the Cause

by Dr. Sharon Orrange on September 17, 2017 at 6:00 am

First, a little reminder about taste. Our sensory system for taste is remarkably sensitive, made possible by our taste buds. Taste buds are each made up of taste receptor cells which bind to small molecules related to flavor. Through sensory nerves, the receptors relay the taste information to the brain and this allows us to discern five basic tastes (sweet, salty, bitter, sour, and umami/savory).

An unpleasant taste or lack of taste can affect appetite, and even lead to depression. If your taste buds don’t seem right, rule out sinus or nasal issues, viral upper respiratory infections, or other common causes, then take a look at your meds.

With certain medications, these changes in taste may occur:

Bitter taste:

  • Stimulants used in the treatment of ADHD may cause a bitter taste in your mouth. Adderall and methylphenidate (Ritalin, Concerta, Daytrana) decrease the threshold for the bitter taste in your mouth, making you more sensitive to the perception that something is bitter.
  • Altitude sickness prevention in travelers can be overcome with Diamox (acetazolamide)—which may also leave you with a bitter taste in your mouth.

Metallic taste:

  • Many antibiotics cause a metallic taste in the mouth. Penicillin, amoxicillin, Augmentin, and cephalosporins (Ancef, Keflex) are commonly prescribed for acute sore throat, and ear and sinus infections, and they may lead to a metallic taste in your mouth. Why? The antibiotics listed above may affect the absorption of zinc, and zinc deficiency leads to a metallic bad taste in the mouth. Clarithromycin (Biaxin), metronidazole (Flagyl), and tetracycline are other antibiotics that may also cause metallic taste—but we don’t know why that occurs.
  • Allopurinol, used for the prevention of gouty attacks, may cause a metallic taste in your mouth.
  • Lithium is prescribed for the treatment of bipolar disorder and may also lead to a metallic taste in your mouth.

Loss of sour taste:

  • Isotretinoin (Absorica, Accutane) is used for the treatment of severe acne, and you may notice the loss of sour taste while taking it. Isotretinoin disrupts ion channels, leading to loss of sour taste.

Persistent sweet, sour, salty, bitter or metallic taste (aka dysgeusia):

  • Captopril, enalapril and lisinopril are ACE inhibitors used to lower blood pressure. They cause disrupted taste, likely by causing zinc deficiency.

Less or lack of taste:

  • Carbamazepine (Tegretol, Carbatrol, Equetro) is used for seizures, bipolar disorder, restless legs, and neuropathic pain. It may lead to diminished taste by decreasing calcium mediated neurotransmission (it keeps taste signals from getting to your brain).
  • Levodopa is half of the Parkinson’s drug Sinemet and it loves to cause decreased taste in those taking it. Levodopa/carbidopa (Sinemet) works to help increase levels of circulating dopamine in Parkinson’s patients—but one downside is that results in lowered taste transmission.
  • Used for the treatment of symptoms related to irritable bowel syndrome (IBS), Bentyl (dicyclomine) and Levsin (hyoscyamine) may cause loss of taste.
  • Diltiazem (cardizem) is a calcium channel blocker often used for heart rate control in patients with atrial fibrillation, and to lower blood pressure. Diltiazem also decreases calcium mediated neurotransmission, causing loss of taste or diminished taste.
  • Hydrochlorothiazide (HCTZ) is prescribed to lower blood pressure, and it can also cause loss of taste.
  • Spironolactone (Aldactone) is a potassium-sparing diuretic used in the treatment of heart failure, acne, and ascites from liver disease, and it may lead to loss of taste.
  • Terbinafine (Lamisil) is prescribed for the treatment of nail fungus. Terbinafine may cause loss of taste to the point where it results in weight loss and depression in as many as 3% of folks taking it.
  • Methimazole (Tapazole) is used to treat hyperthyroidism associated with Graves Disease, and may cause loss of taste due to zinc depletion.

Remember if your medications are altering your taste, discontinuing them should fix that. So ask your doctor about alternatives.

Dr O.

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