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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.

FDA Approves Xhance for Nasal Polyps

by The GoodRx Pharmacist on October 11, 2017 at 4:31 pm

Nasal polyps are common in people with allergies and asthma. Treatment has included nasal sprays and oral medications, and now we have a new one to add to the list, Xhance (fluticasone propionate).

What is Xhance indicated for?

Xhance is a corticosteroid indicated for the treatment of nasal polyps in patients 18 years of age or older. It will be available as a nasal spray in the strength of 93 mcg.

The recommended dose of Xhance is one or two sprays per nostril twice daily. The Xhance delivery system is called the Optinose delivery system. It works to help deliver Xhance deep into the nasal cavity. Be sure to read the instructions before using the delivery system.

Who is at risk for nasal polyps?

Any condition that causes chronic inflammation in the nasal passages or sinus area may increase your risk of developing nasal polyps. The following conditions can put you at a higher risk for nasal polyps: asthma, aspirin sensitivity, allergic fungal sinusitis, cystic fibrosis and Churg-Strauss syndrome.

What are the common side effects associated with Xhance?

Common side effects include nosebleeds, nasal septal ulceration, nasopharyngitis nasal mucosal erythema, nasal mucosal ulcerations, nasal congestion, acute sinusitis, nasal septal erythema, headache, and pharyngitis. Be sure to speak with your doctor if you experience any of these symptoms for a prolonged period of time.

What is the difference between Xhance and Flonase?

There are several differences between Xhance (fluticasone propionate)  and Flonase (fluticasone propionate), including the following:

  • The strength of Xhance is 93 mcg per spray whereas the strength of Flonase is 50 mcg per spray.
  • Xhance is indicated for the treatment of nasal polyps whereas Flonase is indicated for the management of allergy symptoms.  
  • Xhance requires a prescription whereas Flonase can now be purchased over-the-counter without a doctor’s prescription.
  • Flonase is available in a generic version, as fluticasone propionate, whereas Xhance is only available as a brand name medication.

For more information on Xhance, see the press announcement from the manufacture Optinose here, and the Xhance website here.

FDA Issues Safety Alert for Ocaliva

by The GoodRx Pharmacist on October 5, 2017 at 12:49 pm

On September 21st, the FDA issued a drug safety communication for Ocaliva (obeticholic acid), a medication used to treat primary biliary cholangitis (PBC).

The FDA warns that using Ocaliva can cause serious liver injury and even death when improperly dosed. The FDA has reviewed the 19 cases of death potentially caused by Ocaliva, and determined that in several cases patients with moderate to severe liver disease were receiving too high of a dose. This can result in an increased risk of serious liver injury or death.

What is Ocaliva indicated for?

Ocaliva is indicated in adults for the treatment of primary biliary cholangitis (PBC) with or without ursodeoxycholic acid.

Primary biliary cholangitis (PBC) is a rare liver disease in which your body begins to attack itself and destroy the bile ducts in the liver, leading to liver damage or eventual cirrhosis.

What are the signs and symptoms of associated with liver function?

If you or someone you know is taking Ocaliva, be sure to seek medical attention for the following signs and symptoms:

  • New or worsening tiredness
  • Diarrhea
  • Weight loss
  • Stomach pain
  • Decreased appetite
  • Nausea and vomiting
  • change in behavior or confusion
  • Anxiety or unease
  • Stomach swelling
  • Yellowing of the eyes or skin
  • Bloody stool

What is being done to warn people about these serious side effects?

The FDA is reminding healthcare providers to determine patients’ baseline liver function before starting a patient on Ocaliva.

What does the FDA recommend prescribers do?

The FDA recommends the following:

  • Patients with moderate to severe liver impairment should be started on the approved dosing schedule of 5 mg once weekly, rather than the 5 mg daily dose. 
  • Healthcare professionals should monitor patients frequently for disease progression, and reduce the dosing frequency for patients who progress to moderate or severe liver impairment.
  • All patients treated with Ocaliva should be monitored frequently for liver injury (e.g. worsened liver blood tests and adverse liver-related reactions).
  • If liver injury is suspected, discontinue Ocaliva.
  • After the patient has stabilized, weigh the benefits against the risks when deciding whether to re-initiate treatment. Educate patients about the symptoms of potential liver injury.

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.

FDA Approves Duzallo for Gout

by The GoodRx Pharmacist on September 29, 2017 at 4:10 pm

Gout is a form of arthritis that affects the joints and can cause severe pain, redness, tenderness, and inflammation. Typically, gout is caused by a build-up of uric acid.

Recently, the FDA approved Duzallo, a new combination medication for the treatment of gout.

What is Duzallo indicated for?

Duzallo is a combination medication indicated for the treatment of hyperuricemia associated with gout. It is specifically for patients who have not achieved target serum uric acid levels allopurinol alone. 

Duzallo combines tw0 gout medications, Zurampic (lesinurad) and Zyloprim (allopurinol), into a convenient once-daily regimen. Duzallo is the 1st FDA approved fixed-dose combination treatment for patients with gout that addresses both the increased production of uric acid as well as the decreased elimination of uric acid.

Who is at risk for gout?

The following conditions may put you at risk for gout: led exposure, high blood pressure, kidney problems, hypothyroidism, psoriasis, cancer, Kelly Seegmiller syndrome, and Lesch-Nyhan syndrome. 

How is Duzallo to be taken?

The recommended dose of Duzallo is one tablet once daily. It is available as a combination tablet in the strength of 200 mg/200 mg and 200 mg/300 mg  Be sure to stay hydrated while taking this medication.

What are the common side effects associated with Duzallo?

The most common side effects associated with Duzallo include headache, influenza, higher levels of blood creatinine, and heartburn.

When will Duzallo be available?

The manufacturer of Duzallo, Ironwood Pharmaceuticals, expects Duzallo to be available early in the 4th quarter of 2017.  

For more information on Duzallo, see the press announcement from the manufacturer, Ironwood, here or visit the drug website here.

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