SCI Forum Report
From Ambien to Zanaflex: Making Your Medications Work for You
This is a report of the SCI Forum presentation given on October 10, 2006, by Debra Page, PharmD
Clinical Pharmacist, Neurology and Rehabilitation Medicine, Harborview Medical Center.
- Research evidence and SCI medications
- Side effects
- Principles for managing side effects
- Medications that may cause drowsiness
- If you can't sleep
- Sleep apnea
- Anticoagulant medications
- Neurogenic bladder
- Bowel management
- Complementary and Alternative Medicine (CAM)
- Guidelines for using CAM treatments
- Common CAM therapies used by SCI patients
- Discontinuing Medications Safely
- Pharmacist Tips
“In this country we practice what’s called ‘evidence-based’ medicine,” said Debra Page, Clinical Pharmacist in Neurology and Rehabilitation Medicine at Harborview Medical Center. “This means that we use the best evidence available to make decisions about treating individual patients.” The most desirable evidence comes from large randomized controlled trials, in which subjects are randomly assigned to receive either medication or placebo, and effects are compared between the two groups. When studies are properly conducted, any differences in outcome between the two groups at the end of the study can be attributed to the drug. “This is the gold standard of evidence, and it is what the FDA requires for a drug to be sold in this country.”
Once a medication is approved for a condition, physicians can prescribe it for any problem—which is a common practice in SCI, because it’s so hard to get a sufficient number of study subjects with SCI to participate in a large-scale clinical trial. “In SCI, we have to rely more on smaller clinical trials, and even a method that’s less scientific—‘expert opinion’— which is physicians’ experience using a medication and seeing how it affects patients”, Page explained. “That’s why it’s important for you to tell your physician about the experiences you’re having with a drug. It’s our main source of information about whether these drugs are effective or useful in SCI patients.”
A side effect is any unintended consequence—usually undesirable—of a medication or therapy. “Medications aren’t as specific as we’d like them to be,” Page said. “They act all over the body.” When you take morphine for pain, for example, the processes that work to relieve the pain also make you sleepy and can cause constipation.
All medications have side effects. Everyone reacts to medications a little differently, and each individual must decide if the benefits of any particular medication outweigh the undesirable consequences. Page recommends telling your doctor if the side effects are intolerable. “Often they can switch you to a slightly different drug.”
- Non-drug treatments such as lifestyle modifications may reduce side effects when used in combination with a drug.
- Use your medication as directed.
- Know your options. There is usually more than one medication available for any problem, and if one doesn’t work out, another slightly different one may be better. Although it can be frustrating, some trial and error may be necessary before finding the right medication and dose.
- Speak up! “If you start to have side effects, you and your family are going to be the first ones to notice. Tell your doctor— things can be done to manage these.”
Many of the medications used by people with SCI cause drowsiness, including antidepressants (Zoloft, Prozac, etc.); antihistamines (Benadryl, etc.); anxiolytics (Valium, Xanax, etc.); pain medications (Vicodin, Morphine, etc.); and spasmolytics (baclofen, tizanidine, etc.). What can you do to manage it?
- Take the medication in the evening, when drowsiness will be more beneficial and less noticeable.
- Talk to your physician about decreasing the dose. “Meds are not ‘one size fits all.’ Taking a slightly lower dose may still give the benefit without the side effect.”
- Discuss trying a different medication “If Prozac makes you sleepy, Paxil, a similar medication, may not have that effect. It’s worth trying.”
For those with frequent problems sleeping, a first step is to practice the basics of “good sleep hygiene”, which consists of these practices:
- Use your bed only for sleeping and sex. Don’t eat, watch TV, or read. This helps you associate your bed with sleeping.
- Go to bed and wake up at same time each day. “This can be tough, but it’s important if you want to regulate your sleep.”
- Avoid naps during the day. “You’ll get more restful sleep at night.”
- Make sure your bedroom is dark, quiet, and not too hot or cold.
- Avoid exercise and alcohol in the evening. Exercise stimulates your body and mind; and alcohol, which may help you fall asleep, disrupts the sleep cycle and lowers sleep quality.
- Limit caffeine intake. Caffeine is essentially “the world’s most popular drug.” Know the caffeine content of foods (like coffee, tea, energy drinks, cola, and chocolate) so you can limit it. People who are very sensitive to caffeine may need to stop all caffeine use after noon to achieve restorative sleep. Remember that even decaf coffee still contains caffeine.
If sleep problems persist, over-the-counter medications for sleep may help, such as Tylenol PM, Excedrin PM, and Sominex. These usually contain an antihistamine, which can cause urinary retention and constipation, so Page recommends using them only for short periods.
If you still have trouble sleeping, talk to a physician, “both to discuss what might be interfering with sleep, and to get prescription sleep medications, if necessary.” Many sleep medications— Ambien, Lunesta, Sonata, Rozerem—differ primarily in the way they are released in the body. “Ambien, Lunesta and Rozerem are good if you have trouble falling asleep and staying asleep, because they stay in your body a little longer,” Page explained. Sonata stays in the body only four hours, which makes it a good choice if your problem is limited to falling asleep, or if other medications cause morning grogginess.
“If you are waking up in the morning and don’t feel rested, and if your bed partner is complaining about your snoring”, you may have sleep apnea, Page said. In this disorder, the soft tissue of the throat collapses and closes during sleep, resulting in frequent, brief pauses in breathing that deprive your brain of oxygen. When the carbon dioxide gets to a certain level in the bloodstream, the sleeper jolts awake, gasping for air (although he or she may not remember or be aware of this).
“Sleep apnea is a serious condition that leads not only to daytime sleepiness but also to depression and health problems,” Page warned. “It needs to be diagnosed and treated.” Sleep apnea is diagnosed with a sleep study, and treated with continuous positive airway pressure (CPAP)—a mask worn over the mouth and nose at night that keeps the air moving continuously so the airway can’t collapse.
Sleep apnea is much more common in SCI than the general population, and many of the medications taken by people with SCI make it worse, as does alcohol. (For more information about sleep apnea and SCI, go to http://sci.washington.edu/info/newsletters/articles/01win_sleep_apnea.asp.)
Coumadin (warfarin) is an anticoagulant medication frequently given to SCI and other immobilized patients in the hospital to prevent deep vein thrombosis, or a blood clot in the leg. “Coumadin requires close monitoring (by your physician or pharmacist) because it has a narrow therapeutic range,” Page explained; too much or too little can cause serious, even life-threatening conditions. Also, “Coumadin interacts with vitamin K in foods,” so if you eat a lot of foods high in vitamin K—broccoli, green leafy vegetables, brussels sprouts—you need higher doses of Coumadin. You don’t need to avoid these foods, she said, but their consumption must stay at a consistent level while taking the drug.
Many people with SCI have pain that interferes with daily life. SCI pain tends to be complex and difficult to treat, Page admitted, and few effective treatments are available. People with SCI can have one or all of these types of pain:
- Musculoskeletal pain comes from problems in the muscles or skeleton. It often occurs in the neck, leg or shoulder joint and is due to overuse (such as pushing a wheelchair) or an injury (such as a fall).
- Visceral pain is located in the stomach and digestive areas and can be due to gastrointestinal problems that require the attention of a physician.
- Neuropathic pain is the most common type of pain in the SCI population and the hardest to treat. It is caused by abnormal signals from nerves that were damaged in the spinal cord injury. It is frequently described as burning, tingling, sharp or shooting pain and is felt at or below the level of injury.
Because SCI pain often has multiple causes and influences, Page recommends that patients “consider non-pharmacological treatments, either instead of or in addition to prescription medications. You may need more than one thing to treat this kind of pain.” In a 2004 study1 of non-pharmacological therapies for SCI pain (which included acupuncture, distraction, deep breathing, hypnosis, massage, heat therapy and exercise), subjects reported the greatest pain relief from heat therapy and massage.
Several types of medications are prescribed for neuropathic pain. Patients may need to try several before finding one that relieves the pain without causing too many side effects.
- Tricyclic antidepressants (such as amitriptyline and nortriptyline) These have been used the longest for neuropathic pain, and physicians usually try these first. Common side effects include dry mouth, constipation and sedation (sleepiness).
- Pain medications (narcotics) “Physicians often prescribe long-acting narcotics (such as MS Contin and Oxycontin) to keep a constant level of pain medication in your body, adding short-acting medication for breakthrough pain,” Page said. “Keep a record of the amount you’re using and share this with your doctor, who can evaluate whether you need a change.”
- Anti-epileptic medications (such as gabapentin) “are some of the more effective medications for neuropathic pain,” Page said. A new medication in this class, Lyrica (pregabalin), has been helpful for neuropathic pain in diabetic patients but has not yet been studied extensively in SCI patients.
Most medications for neurogenic bladder are aimed at decreasing hyperactivity (spasticity) in the bladder. Common medications, and their side effects, are:
- Alpha blockers, such as doxazosin and tamsulosin. These drugs can decrease blood pressure, “so you need to be careful if you’re already taking blood pressure medications; watch for dizziness, nausea and sweating.”
- Anticholinergics, such as Ditropan (oxybutynin) and Detrol (tolterodine) These medications tend to cause dry mouth. Detrol causes less dry mouth than Ditropan.
“Many medications commonly used by people with SCI interact with a person’s bowel program, causing either constipation or diarrhea,” Page said. Constipation may be caused or worsened by anticholinergics and narcotic pain medications, so it is important to use the lowest effective dose, to increase water and fiber intake, and to use a stool softener twice daily.
Diarrhea can occur when antibiotics have killed off all the "good bacteria" in the gut, and while the diarrhea usually goes away after the antibiotic treatment ends, Page warned of “a super infection called Clostridium difficile (C diff), in which the good bacteria is killed off but the bad bacteria increases aggressively.” This super infection can develop at any time between first starting an antibiotic and two-to-six weeks after ending it. “So if you are having a lot of watery stools and really bad pain, you need to be seen by a physician right away to get another antibiotic to clear it up. This diarrhea won’t go away on its own.” Antacids (Rolaids, Mylanta, Milk of Magnesia) may cause diarrhea because of the large quantities of magnesium that they contain.
Complementary and Alternative Medicine (CAM)
“When conventional medications don’t help with pain or other problems, some people turn to complementary or alternative treatments,” Page said. Such treatments have not been thoroughly studied or FDA-approved, so “safety and efficacy are questionable, and you are left alone to decide whether to use them.”
Nonetheless, a large percentage of the American public use CAM therapies anyway, so the National Institutes of Health (NIH) created the National Center for Complementary and Alternative Medicine (NCCAM) to provide information to consumers about different therapies, clinical trail information, and important warnings (for example, KAVA, an herbal remedy used for sleep, causes liver damage, Page said). (NCCAM: Web site: http://nccam.nih.gov/; phone: 888-644-6226.)
- Obtain objective information about the treatment.
- Talk to people who’ve recently tried it. Did they think it was worth it?
- Find out about the practitioner’s training and certification.
- Consider the costs—it may not be covered by insurance.
- Discuss all treatments with your healthcare provider. Many providers have open minds about CAM, Page said, so “you don’t need to hide it from them. You just need to make sure there won’t be interactions with other drugs or with food.”
- Avoid scams and rip-offs. “Watch out for commercials that advertise “amazing” or “breakthrough” products, that claim the product has a “secret formula,” or that feature testimonials from thin, attractive, extremely satisfied customers (they’re paid),” she warned.
- Cranberry extract is used to promote urinary health on the theory that it decreases bacteria in the urinary tract. Research evidence is conflicting, however. Although it looks promising in studies in the general public, it is unclear what form or dose is effective.2,3 Studies in SCI populations found no improvement with cranberry extract.4,5 “It works for some, but not others,” Page concluded. “Personally, I think it’s a reasonable thing to try. It’s not harmful.” She recommends AZO Cranberry Supplements (one tablet two or three times a day) or 100% pure (no sugar added; “not the cocktail”) cranberry juice (drink one 8 oz. glass a day).
- St. John’s Wort is a popular herbal treatment for depression, anxiety and sleep disorders in the general population. “Like cranberry, clinical trial results are very conflicting,” Page reported. “I wouldn’t recommend this unless you talk with your doctor and you agree together to try it.” The recommended dose is 300 mg, three times a day. Side effects include increased sensitivity to sunlight (watch for sunburn), dry mouth and dizziness. St. John’s Wort interferes with many drugs— like anti-depressants, coumadin, and oral contraceptives—so it’s important to check with a physician or pharmacist before taking it.
- Probiotics are beneficial or “friendly” live microorganisms (usually bacteria), similar to those found in the human gut, available in dietary supplements or foods. Probiotics can be used to decrease diarrhea and restore healthy bacteria in the gut after taking antibiotics. “The key thing is to choose quality products,” such as Culterelle® and Florastor®, Page advised. “If you want to use yogurt (to restore beneficial bacteria), make sure it carries the symbol ‘live and active cultures.’ Do not take probiotics within two hours of taking a dose of antibiotics.” Possible side effects include stomach upset and bloating.
While patients can always decide for themselves whether to take or continue a drug, Page emphasized that “some medications should not be stopped abruptly.” In particular, antidepressants, baclofen and benzodiazepines (Valium, etc.) carry a small risk of seizures if discontinued too rapidly. “If you want to stop a medication, discuss it with your doctor, who will set up a schedule for you to taper off the drug safely.”
“Last year the CDC (Centers for Disease Control) added people with SCI to the list of high risk individuals eligible (and encouraged) to get the influenza vaccine early,” Page said. As a further precaution, caregivers and family members should also get the vaccine. Page recommends the injection form of the vaccine only; the flu mist is live and carries a small risk of actually causing the flu.
“If you do get a cold or flu, make sure you read the labels of over-the-counter cold medications before taking them,” she continued. “Some of these have three and four products in them that could interact with other medications you are taking. It can be very confusing and the best person to ask is the pharmacist in the store.” Before buying the same products you’ve always used for colds, “ask the pharmacist about new products that might have fewer side effects.”
Remember, pharmacists are part of your health care team. They are highly trained health care professionals, with a code of ethics and legal responsibilities, who assist individuals in making the best use of medications.
- Carry a list of your medications.
- Know the names of all your medications.
- Bring this list to all of your appointments.
- Update the list regularly.
- Include all allergies and intolerances.
- Use only one pharmacy. “Computers in different pharmacies are not connected and won’t know about medications you received elsewhere.”
- Don’t be afraid to ask your physician about the name, purpose and side effects of your medications, “even if he or she seems busy and is rushing out the door,” Page said in closing. “Ask questions and be an active part of your healthcare team to make your medications work for you.”
- Norrbrink BC et al. Non-pharmacological pain-relieving therapies in individuals with spinal cord injury: a patient perspective. Complement Ther Med 2004;(4):189-97
- Papas PN, Brusch CA, Ceresia GC.. Cranberry juice in the treatment of urinary tract infections.
Southwest Med. 1966 Jan;47(1):17-20
- Avorn J, Monane M, Gurwitz JH, et al. Reduction of bacteriuria and pyuria after ingestion of cranberry juice. JAMA. 1994 Mar 9;271(10):751-4.
- Waites KB, Canupp KC, Roper JF, et al. Evaluation of 3 methods of bladder irrigation to treat bacteriuria in persons with neurogenic bladder. J Spinal Cord Med. 2006;29(3):217-26.
- Linsenmeyer TA, et al. Evaluation of cranberry supplement for reduction of urinary tract infections in individuals with neurogenic bladders secondary to spinal cord injury. A prospective, double-blinded, placebo-controlled, crossover study. J Spinal Cord Med 2004;(1):29-34