Table of Contents (hide)
- 1. Is That the Right Med for Me?
- 2. Don’t. Just Don’t.
- 3. Timing is Everything
- 4. Don’t Mix Business with…No, it’s Carbs and Fat. No…
- 5. Take Two of These and Call Me in the Morning
- 6. Talk to Your Doctor About
Most of this is about figuring out which med is the right one for you to take. In this instance we assume you have a prescription for an appropriate medication for you. You’re probably overwhelmed and heard five, ten, maybe more drug names, and have it together just enough to make it to the pharmacy and get whatever is on that slip of paper. The question is, are you going to get the med your doctor meant for you to have?
I can’t find any good numbers on it yet. This review cites almost all of the articles I could find, it all adds up to around 2% of prescriptions have some kind of error, from an incorrect dosage to an utterly inappropriate medication. So drug identification errors happen far more often than they should.
- If you are seeing a specialist, like a psychiatrist, psychiatric nurse practitioner, or neurologist, it’s unlikely, but not impossible, they’ll write down a med that that looks or sounds like the one they want you to take.
- But if you’re seeing someone who treats everyone for anything? Then they could have written something that looks or sounds like the med the two of you, or at least the doc/nurse thought was the best drug for you.
- Either way, prescribers’ notoriously bad handwriting can lead to confusion at the pharmacy.
- Which means your prescription for Lamictal could be filled with Lamisil, or Inderal with Adderall (which would really suck).
- Like it or not we need to be on top of which meds we take and everything about them1. Which is one of the reasons why I created this site in the first place.
- While this survey of students found that pharmacy students were better at spotting prescribing/identification errors than nursing or medical students2, those numbers aren’t as high as we’d like them to be.
- So check the labels and all the paperwork before signing the screen (or whatever you need to sign) acknowledging that you received the medications.
- I don’t expect anyone to carry around this excellent poster of look-alike & sound-alike meds, even if I wish such a thing were required to be posted in pharmacies where consumers can see it. But this gives you an idea of how many, and which meds can be confused with each other. If you see any meds you take now, or may take, then you know which ones you have to be extra careful about.
Medicated For Your Protection
I Forgot Why I Cake Topamax
OK, you’ve got the right meds, let’s get on with taking them…
- Never, ever, cut, split, crush, chew, dissolve, fold, spindle, mutilate, or otherwise mess with any med that is labeled/described as controlled/sustained/extended release. I.e. there’s a CR, ER, SR, XR, or XL after its name to denote there’s also an immediate release version of the med.
- Unfortunately it might not be that obvious. Doctors and pharmacists are supposed to understand that Lithobid is an extended-release product based upon its name, as BID means “twice a day” in medicinespeak.
- There are other meds that aren’t necessarily controlled/sustained/extended release, but shouldn’t be cut, split, etc. Topamax is one. Splitting it messes with the rate at which it’s absorbed. For some people that won’t matter, for others it will.
- If the pill isn’t scored (has an indentation where it’s rather apparent that is where you slice it in two), you aren’t supposed to cut it. For example:
|T is for Trileptal. It’s OK|
to split Trileptal tablets.
|Stop! Never split Depakote ER|
or Wellbutrin SR tablets!
- You should try to take your meds at the same time every day. For some meds, especially those with long, multi-day half-lives (e.g. Prozac, Abilify) this isn’t all that big of a deal. For others, while it rarely makes a difference between working and not working3, I’ve read plenty of reports from people who experienced all sorts of problems if they waited too long before taking their scheduled dose of Effexor or Paxil.
- Plus it just makes your life easier to designate 4:20 p.m. - or whenever - as “pill time.”
- We do our best to tell you if you should take your meds in the morning, at night, or both. Obviously you should do whatever your doctor tells you to do, as well as discuss changing your dosing schedule (when you take your meds). The PI sheet/patient information leaflet/sticker on the bottle should tell you. If taking a med in the morning makes you really tired all day, or taking one at night prevents you from sleeping4, then you can always try taking it the other way around.
- If you’re taking any other medication, crazy med or not, on a regular or semi-regular basis, including over-the-counter (OTC) meds like low-dosage aspirin to prevent heart attacks, talk to your pharmacist about potential drug-drug interactions. Pharmacists tend to be far more up-to-date on this sort of thing, and it’s one of the things they specifically teach about in pharmacy school.
- Sure, they’re far from perfect, but they get it right eventually, as it’s the pharmacists who are better at catching these errors when it counts, like in emergency room visits.
- Also far from perfect, but way better than ignorance or nothing, is a good drug-drug interaction checker.
- While serious (or clinically relevant/significant) drug-drug interactions happen in less than 1% of all filled prescriptions, “clinically relevant” can result in anything from your meds not working to the very rare, but still possible death.
- There’s one somewhat under-reported clinically relevant drug-drug interaction, and that’s when you mix two or more meds with the same side effect. You’d think everyone would expect that side effect to be more likely to happen and/or be more severe, but you’d be surprised.
- Let’s not forget drug-herb/supplement interactions.
- Here’s a nice table of some, relating to the section immediately below this one…
- Then there are drug-food interactions, the best known of which is grapefruit juice and drugs metabolized by CYP450 3A4, AKA: a hell of a lot of meds, crazy or otherwise.
- Of course grapefruit juice isn’t the only offender. Pomegranate juice, which is in everything these days, can also slow down your clearance of the same drugs.
- The current list of foods to avoid if you take any medication, or where you need to check to see if you’re taking a medication that requires you to avoid these foods are:
- All grapefruit products: whole grapefruits, juice, soda, and seeds.
- Orange marmalade and anything else made Seville oranges
- Pomegranate juice
- Earl Grey tea (a cup or two a day should be fine, depending on which meds you’re taking)
- Pummelos/pomelos/Chinese grapefruit (Citrus maxima)5
- Black mulberries
- Black raspberries.
- This page has the best list of meds that interact with grapefruit juice, pomegranate, Earl Grey tea, Fresca, etc. I’ve found to date, as it organizes them from “Don’t look at a grapefruit in the produce section” (including crazy meds BuSpar, Geodon, and Orap (pimozide)) to “Tested and found to not care that you drink Fresca.” It is not perfect, as Celexa (citalopram) isn’t on there, and Celexa is metabolized by CYP3A4 as well as CYP2C19.
- The above page is, unfortunately, a bit dated. From December 2012 is Grapefruit: A Nutritional Fruit Fraught with Danger of Severe Drug Interactions. While it covers only “major” drugs I so love the title.
- Here’s some interesting things you’ll find in the more complete patient information leaflets:
- Don’t take immediate-release stimulants with orange juice. Most extended-release versions (e.g. Adderall XR) have overcome this problem.
- Don’t mix or follow Risperdal oral solution with tea or cola. The PI sheet expressly states the oral solution is compatible with low-fat milk, but doesn’t expressly prohibit real milk. I’ve taken the stuff. You don’t want to mix it with anything. It’s one of the worst tasting things on the planet6. Best to swallow it as is to get it over with as quickly as possible.
- Drinking milk can substitute for eating if you need to take a med with food. But not always.
- There’s an entire topic on the Crazy Talk forum dedicated to drug-anything interactions. That’s a good place to check and to ask about any you’re not sure of.
Pile of Pills
Vaccines Cause Immunity
Medicated For Your Protection
So complicated it has its own page now.
And if thing’s weren’t complicated/strange enough, being obese can mess with how you metabolize meds.
- Turns out that being obese decreases the amount of CYP450 3A4 you produce, thus slowing down the clearance of medications metabolized by that enzyme.
- Altered CYP expression and function in response to dietary factors: potential roles in disease pathogenesis
- Effects of obesity on the cytochrome P450 enzyme system
- It can be bad enough to affect a single med. I.e. it’s as bad as grapefruit juice. Being obese is all that is required to affect the clearance of a drug.
A recent systematic review suggested that the incidence of rhabdomyolysis was 4 times higher for monotherapy with statins like lovastatin, simvastatin, or atorvastatin which are oxidized by CYP3A4 (mean-rate=0.73; 95% CI: 0.64–0.82/million prescriptions), compared to monotherapy with pravastatin or fluvastatin that are not oxidized by CYP3A4 (mean-rate=0.15; 95% CI: 0.09–0.24/million prescriptions, P50.001). --Non-traumatic rhabdomyolysis: the emerging role of CYP 3A4 in diabetes mellitus
So if you’re a guy (men are more affected by this than women), who is overweight to the point it caused diabetes type 2, this is the list of meds you need to look at. Just look at the far right column. You’ll probably need to scroll down to get them all.
Being obese also causes you to produce more of the CYP2E1 enzyme. That contributes to the metabolism of Tylenol (acetaminophen), alcohol, surgical anaesthetics, some obscure meds, and a few toxic substances. So, at least there’s an upside to carrying a few extra pounds, right? Except that in addition to speeding up how fast you can burn off that booze and whatever toxic waste is buried in your back yard, adding obesity to a Tylenol & alcohol cocktail just makes it all the more likely to get liver damage.
Of course you might be able fix all of this with plenty of salt in your diet and some delicious, char-broiled steak. No, really. Char-grilled red meat may increase the amount of CYP3A4 your liver produces, offsetting the inhibition caused by obesity and drinking grapefruit juice. Or may not, as the data are mixed when it comes to blackened red meat and CYP3A4/5. But the salt still works. As does smoking. And what could be better for someone who’s a bit heavy around the middle than smoking and eating a bunch of salt and grilled steak?
Medicine Is The Best Medicine
Vaccines Cause Immunity
Mental Illness is NOT Contagious
Medicated For Your Protection
- As with when you should take a med we also give you our best guess as to how much you should take when you start taking a med (initial/starting dosage) and the rate you should increase it by (titration).
- Check the PI sheet for the initial dosage of the med. Or if in your doctor’s office, ask to look it up in the PDR or whatever equivalent is handy. Are you starting out at the lowest dosage? If not, why not?
- When you’re switching from one med to another within the same class, say between first-generation antipsychotics (FGAs), benzodiazepines, or SSRIs, then it makes perfect sense to start a new drug at a higher dosage than you might normally, because your brain is already acclimated to the changes.
- But if you’re starting something you’ve never had before, e.g. you’ve never had an AED or an AP, then maybe should be starting at the lowest dosage, if not lower, and working your way up.
- If the really low dosage doesn’t work, you can always go up, but if you start out too high, it’s kinda hard to untake a med.
- Starting out low helps make dealing with side effects easier without getting in the way of how effective a med can be. Don’t just take my word for it7, Dr. Edward Faught, one of the most respected neurologists around, is all about low initial dosages and slow titrations.
- The other exception to the rule of “start low and go slow” is if you’re in a serious, batshit crazy/neurological crisis. But if you’re in a state like that I doubt you’re reading this site, as you’d be in a hospital. If you’re a family member/friend/spouse or spousal equivalent reading this site for someone who has been hospitalized, or you’re fresh out of the hospital, believe me, 5mg a day of Zyprexa (olanzapine) is tough to start at, but the alternative is much, much worse. Take it from someone who spent a week in the lock ward, and knows lots of people who’ve spent anywhere from three days to three months involuntarily confined in psychiatric hospitals.
How much you ultimately take of a med, and how fast you reach that point, also depends on your personal biology. This is an extremely complicated topic, so in its simplest terms:
- About 10–15% of the overall population - with a lot of variation across ethnicities - really do qualify as ‘medication-sensitive’ to various degrees, and aren’t necessarily a bunch of whiners like most other people who complain about the least little side effect.
- On the flip side around 2% - again with big differences in ethnic groups - metabolize meds so quickly they can run into insurance problems due to excessively high dosages.
- So look at the PI sheet (the full one, for doctors, which we provide for every med, and not just the information for patients leaflet) under the section titled “Use in Specific Populations”8 for any dosage adjustments your doctor should take into account. Most of the time it’s only for people with liver and/or kidney problems, and anyone over sixty. The more thorough drug companies, like Eli Lilly, will test for differences in gender and ethnic groups, and report if they found nothing.
- Which, believe it or not, is going above and beyond what’s currently required of them. As it is now the starting dosage and titration of most medications is calibrated for white men between the ages of 25 and 549.
- How much of a difference can that make? A teenage Caucasian male who smokes needs to take six times as much Zyprexa to get the same effect as a non-smoking Japanese woman in her 60s or older.
- Tell your doctor about every medication you take on a regular basis, including over-the-counter (OTC) products like aspirin.
- As well as any supplements.
- Tell your doctor about any food, dye, or other allergies/sensitivities you have. While the amounts of the offending substances (lactose, corn starch, dyes, etc.) found in meds are usually miniscule, some people are super-sensitive to these things. A drug that might otherwise work for you could fail because of one or more inactive ingredients. If you know you’re highly allergic/sensitive to something and don’t already know about them, the answer might be a compounding pharmacy.
- As long as you can afford it, as compounded drugs aren’t covered by all insurance plans.
- And there’s a compounding pharmacy near you.
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2 The study was conducted by a pharmacy school and published in a pharmacy education journal. I wonder if that had any influence on the results. The phrase, "which is not surprising" used to describe the results is kind of a giveaway.
3 As far as meds discussed on this site are concerned. There may be medications that treat other conditions that absolutely need to be taken at the exact same time every day in order to be effective.
4 Although plenty of people have found that the same med will make them sleepy if they take it in the morning, and give them insomnia if they take it at night. And if you have to take it more than once a day you're probably shit out of luck in any case.
5 Not to be confused with Circus Maximus.
6 I should know about worst tasting things on the planet. I once made my own absinthe. Just the active ingredient really, with none of the flavorings that real absinthe has that became liqueurs in their right, like Pernod and Vermouth. I recommend never doing that. The guy I made it with invented the Green Russian by mixing said absinthe with milk. I really recommend never, ever doing that, as the milk curdled. I'm so lucky to be alive.
7 On this or anything. And that applies to all websites about anything. See the Know Your Sources section.
8 Older PI sheets may use different, but similar terms, like "Special Populations."
9 Called "healthy volunteers" in the PI sheets. Better known as "professional guinea pigs," as the overwhelming majority of people who test drugs for money, and qualify for the safety and other tests that aren't for efficacy, are white guys in their mid-20s through mid-50s.
Tips on How to Take Crazy Meds by Jerod Poore is copyright © 2011 Jerod Poore
|Last modified on Tuesday, 19 April, 2016 at 22:27:54 by JerodPoore||Page Author: Jerod Poore||Date created: 26 May 2011|
All drug names are the trademarks of someone else. Look on the appropriate PI sheets or ask Google who the owners are. The way pharmaceutical companies buy each other and swap products like Monopoly™ real estate, the ownership of any trademarks may have changed without my noticing.
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Almost all of the material on this site is by Jerod Poore and is copyright © 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014, 2015, and 2016 Jerod Poore. Except, of course, the PI sheets - those are the property of the drug companies who developed the drugs the sheets are about - and any documents that are written by other people which may be posted to this site will remain the property of the original authors. You cannot reproduce this page or any other material on this site outside of the boundaries of fair use copying without the express permission of the copyright holder. That’s usually me, so just ask first. That means if want to print out a few pages to take to your doctor, therapist, counselor, support group, non-understanding family members or something like that - then that’s OK to just do. Go for it! Please. As long as you include this copyright notice and something along the lines of following disclaimer, I’m usually cool with it.
All rights reserved. No warranty is expressed or implied in this information. Consult one or more doctors and/or pharmacists before taking, or changing how you take any neurological and/or psychiatric medication. Your mileage may vary. What happened to us won’t necessarily happen to you. If you still have questions about a medication or condition that were not answered on any of the pages you read, please ask them on Crazy Talk: the Crazymeds Forum.
The information on Crazymeds pertains to and is intended for adults. While some information about children and adolescents is occasionally presented (e.g. US FDA approvals), pediatric-specific data such as dosages, side effects, off-label applications, etc. are rarely included in the articles on drugs or discussed on the forum. If you are looking for information regarding meds for children you’ll have to go somewhere else. Plus we are big pottymouths and talk about S-E-X a lot.
Know your sources!
Nobody on this site is a doctor, a therapist, or a pharmacist. We don’t portray them either here or on TV. Only doctors can diagnose and treat an illness. While it’s not as bad as it used to be, some doctors still get pissed off by patients who know too much about medications, so tread lightly when and where appropriate. Diagnosing yourself from a website is like defending yourself in court, you suddenly have a fool for a doctor. Don’t be a cyberchondriac, thinking you have every disease you see a website about, or that you’ll get every side effect from every medication1. Self-prescribing is as dangerous as buying meds from fraudulent online pharmacies that promise you medications without prescriptions.
All information on this site has been obtained from the medications’ product information / summary of product characteristic (PI/SPC) sheets and/or medication guides - which is all you get from sites like WebMD, RxList,
NAMBLA NAMI, etc., the sources that are referenced throughout the site, our personal experience and the experiences family, friends, and what people have reported on various reputable sites all over teh intergoogles. As such the information presented here is not intended as a substitute for real medical advice from your real doctor, just a compliment to it. You should never, ever, replace what a real doctor tells you with something from a website on the Internet. The farthest you should ever take it is getting a second opinion from another real doctor. Educate yourself - always read the PI/SPC sheet or medication guide/patient information leaflet (PIL) that comes with your medications and never ever throw them away. OK, you can throw away duplicate copies, but keep at least one, as that’s your proof of purchase of having taken a med in case a doctor doubts your medical history. Plus they take up less space than a bottle, although keeping one inside of a pill bottle is even better.
Crazymeds is not responsible for the content of sites we provide links to. We like them, or they’re paid advertisements, or they’re something else we think you should read to help you make an informed decision about a particular med. Sometimes they’re more than one of those things. But what’s on those sites is their business, not ours.
Crazymeds is optimized for ridiculously large screens and browsers that don’t block ads. I use Firefox and Chrome, running under Windows 72. On a computer that sits on top of my desk. With a 23 inch monitor. Hey, at least you can make the text larger or smaller by clicking on the + or - buttons in the upper right hand corner. If you have Java enabled. Like 99% of the websites on the planet, Crazymeds is hosted on domain running an open source operating system with a variety of open source applications, including the software used to display what you’ve been reading. As such Crazymeds is not responsible for whatever weird shit your browser does or does not do when you read this site3.
Crazymeds now uses a secure server, but it is not so secure that you can discuss anything having to do with nuclear power facilities, air traffic control systems, aircraft navigation systems, weapons control systems, or any other system requiring failsafe operation whose failure could lead to injury, death or environmental damage. Just so you know. So if you’re mentally interesting and have a job that deals with that sort of thing, talk about said job elsewhere. Otherwise feel free to discuss your meds and brain cooties.
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1 While there are plenty of books to help you with hypochondria, for some reason there’s not much in the way of websites. Then again, staying off of the Internet is a large part of curing/managing the disorder.
2 Remember kids, Microsloth operating systems are like TOS Star Trek movies with in that every other one sucks way, way more. With TOS Star Trek movies you don’t want to bother watching the odd-numbered ones. With Microsloth OS you don’t want to buy and install the even-numbered ones. Anyone who remembers ME and Vista knows what I mean.
3 Have I mentioned how open source operating systems for commercial applications is one of the dumbest ideas in the history of dumb ideas?* I don’t even need my big-ass rant any more. Heartbleed has made my case for me. And that’s just the one that got all the media attention. The very nature of an open source operating system makes security as much of an illusion as anonymity on teh Intergoogles. Before you flip out too much: the domain Crazymeds is hosted on uses a version of SSL that is not affected by the Heartbleed bug. That’s one of the many reasons why I pay a lot of money and keep this site on Lunarpages.
* Yes, I know I’m using open source browsers. I also test the site using the now-defunct IE and Safari browsers. Their popularity - and superiority - killed IE and Safari, so that’s why I rely on the open source browsers. It’s like brand vs. generic meds. Sometimes the generic is better than the brand.