Take Steps To Avoid Drug Interactions

After all the tragic news the past year or two about celebrities who have died after using a combination of legal prescription drugs, it’s enough to make someone wonder how you can avoid becoming a victim, yourself.

Today — with the internet — it is relatively easy to find out which drugs can be dangerous if mixed.  And if you get your drugs from a pharmacist, you can accept the “counseling” offer and ask specifically about interactions.
I hate to say it, but asking your doctor may be a distant third place in finding out the right information.

I don’t claim to have invented the internet, and I doubt I could be considered a pioneer of the ‘net, but wherever I have traveled to help out clinics and institutions over the past ten years, I insisted that I needed internet access to practice medicine.  At the time, I only needed access to one site.  It was a database sponsored by a major drug company and it had drug-drug interactions. Now it charges a fee for access and the data isn’t as good.

If people want to check their own drugs out, I usually send people to a database which has a database where you can check out interactions among all the drugs you take, with foods, etc.

Now some MDs have told me they “assume” pharmacists take care of this but patients may use more than one pharmacy (because of pricing) and as far as I am concerned, my name signed at the bottom of a prescription is downright sacred.  It means “the buck stops here.” My husband had brought the internet into our home in the mid-90s, before there was much going on really, so I was experienced in using on-line services.

In the early days of my rambling and consulting – starting about 1998 — if someone gave me internet access at my own desk in my office, I felt lucky.  Otherwise, my major aerobic exercise consisted of running to the office with the nearest computer.  With some luck I could print out a copy for the chart. After a little while doing this, I knew most common drug interactions involving the psychotropics I used regularly by heart, so I did not have to do it for everybody.

There was one little man, who was very pleasant, and he was on one of the standard Selective Serotonin Reuptake Inhibitors (SSRI).  I am pretty sure it was Zoloft.  He was also on a lot of drugs for heart and cholesterol and such. He had a strange complaint for a guy who was built like a fireplug and obviously had been working out.

He said he was tired, and he could not work out as much as he wanted to because his muscles ached.  He had told this to his doctor, who had said it was nothing. (Sigh!) I told him since I was not acquainted with the drugs that he was on, I would ask him to wait while I ran some drug interactions through the computer.  I would type in his whole list.

Well the database I was using practically went “tilt.” One of the drugs he was on was simvastatin — brand name Zocor.  Pretty standard — Not a bad drug recommendation for cholesterol.

This is one of the statin drugs — also known as Hmg CoA reductase inhibitors, after the enzyme they work on.  We scientist-types even know the place on the DNA to find the gene for the enzyme so this drug can go to work.

His dose was high end, but ought not to have presented a problem.  Unfortunately, he was also on clofibrate — current most popular brand name Atromid-S.  Well, the drug data base I was using at the time pretty much lit up the screen red.  These two drugs together are perfectly capable of causing rhabdomyolysis, a medical condition that can end up in muscles breaking down, and the breakdown products going through the kidney — causing kidney failure. People can — and have — died as dead as doornails.

This was not new or secret information.  It had already been published in medical journals.

There are a lot of drug interactions that could cause this. Of course, I like massive databases and a smidgeon of clear thinking better than lists. There are a bunch of different ways drugs can interact.

This was not the time to check the mechanism.  This was the time to go ballistic, order a bunch of blood tests to make sure the patient was not already in trouble (he had complained of weakness and muscle pain), and to get him to sign a release, call his primary care MD, send him a letter with a copy in the chart, and tell the patient he probably needed to stop one of these two drugs, but the doctor who prescribed it had to decide, since I was just an interested bystander in cholesterol treatment and was only supposed to renew his Zoloft.

I did renew the Zoloft, which had never been reported to cause rhabdomyolysis.

I talked to the physician’s Physician Assistant, a pleasant young man right out of the military who obviously had never any experience or training in drug interactions.  He agreed to see the patient the same day, and to notify the prescribing physician. I documented everything.

When I saw the patient later, I logically assumed that the physician’s assistant had seen him by now.  I was proud that my checking for drug interactions could have saved this patient’s life.

To my horror, when I saw the patient, he was still on both drugs.  He told me his doctor had said something about me being a “wacko” and he was still on both drugs.

I called the physician’s assistant.  He told me that the patient’s cholesterol was lowering, and the interaction was probably a rare thing only a “wacko” pharmacologist like me would worry about. So they had decided not to listen to me.

I remember crying in my husband’s arms that night and sleeping little if at all.  I remember writing a three page note for the chart. Documenting all I had said to the Physician’s Assistant.  The doctor, curiously enough, never even thought it was worthwhile to speak with me on the phone.

I only saw the patient one more time before I left the town and the facility. I explained to him that I disagreed with his doctor, being very careful not to cast aspersions on a colleague. I made sure the patient had a copy of the interactions printout, to give to another doctor, if he so desired.  I said he might also want to show it to his pharmacists.

Pharmacists, I knew then, had access to a LOT of databases.  More than physicians, I think.  But as lovely as pharmacists are, It is my name on prescriptions, and if the patient doesn’t do well – I’m the one with the cooked goose.

I spent over an hour with that patient that day.  He was not very educated and it was hard for him to understand his doctor could have been wrong.  As a matter of fact, he thought the physician’s assistant was a doctor.  (I believe this misinformation is actually promoted in some clinics to make patients feel more secure).

The PA functioned with a pad of prescriptions pre-signed by the doctor and could write anything he wanted without oversight or supervision.   Both of these things are, incidentally, wildly illegal in every state of the union, although they are also very common practices in the rural or semi-rural places where I have spent a fair part of my practice life.  Many times I have tried to report things to people in charge, but many more times I have not.  If I reported everything I saw, I would never have time to practice medicine. So the lesson from all of this is, no matter what drugs you are on, run an interactions check.

If you are on 3 different prescriptions, there is about an 80% chance of interaction. If you are on 5 of them, there is a good solid 100% chance of interaction.

Drug interactions are not always bad.  In the hands of a skilled pharmacologist, one drug can make another stronger or last longer. However, in the hands of somebody who is ignorant of interactions, that exact same interaction can prove disasterous.

You can ask your pharmacist to check interactions when you get your prescription filled.

If your medical plan ships your prescriptions by mail and you never see a pharmacist, you can check interactions yourself on drugs.com.  You can get some kind of a printout and put it under the nose of the correct health professional.

If that does not work, I have often recommended to patients who deal with other doctors who are not me, to send certified mail to the doctor that the doctor has to sign for.

Don’t wait to get sick from an interaction to think about taking a negative action. You do not have to know a lot about pharmacology to be a patient.  You may well want to know about what you are getting. While you are at it, check out non-drug ways to treat your condition.

There are lots of websites all equally bad, but try diet, exercise, and supplements.  At the very least, Omega 3’s, fish oil and similar compounds. While you are at it, make sure your doctor actually knows what your condition is.

Most doctors just treat cholesterol with an anticholesterol drug and only go further when it does not work.  Here is a British doctor with some better ideas.

Take your health into your own hands.  The information is there, on the internet. I needed a wall full of diplomas to get here.  You only need internet access and caring about yourself enough to ask questions of the right people.