Tuesday 30 December 2008

Side effects

Drugs have side effects. Heck, even placebo has side effects.

Some arise almost instantly (the one sticking in my mind was when, as a House Officer, I injected an IV penicillin on a weekend on-call to a surgical patient, who then went grey and collapsed). Some more typically arise after longer term use (especially in mental health, e.g. with lithium knackering kidneys/thyroid/parathyroid and antgipsychotics causing the movement disorder of tardive dyskinesia which lasts forever, even/especially when the offending drug is stopped). Some are serious (like neuroleptic malignant syndrome which unfortunately I've seen twice, now).

This has instilled a healthy scepticism of drugs. I like them, if they're used appropriately. But they're not a free lunch. Rational prescribing practice has to be central to use of medication.

But what about me? The Northern Doctor has posted about how busy life is in GP land at this time of year. He's a better man the me, hacking it in Primary Care. His last paragraph comments on the proportion of health care professionals who've used the 'flu vaccine.

Got me thinking. What're the bad medicines I've taken? A relatively short list, since I've not been to see my current GP ever (and last saw a GP some 20 years ago) on the premise that many doctors like to meddle/do stuff/fix things/intervene so are best avoided unless necessary. I delude myself into believing that not seeing a GP is fine because I can suss out myself if/when I need medical attention and, if that ever happens, that's when I'll darken their doors. But I know in my heart of hearts that mostly doctors are awful at looking after themselves.

Anyway, it means my exposure to prescribed medication has been modest. The last time I had a 'flu jab was when I worked in General Practice and, after that jab, I felt awful. It wasn't as bad as 'flu, I'm sure. But it was worse than any cold I'd ever had. So, for me, it seemed that the 'flu jab an a medication to take when well, to reduce risk of a possible infection, wasn't a smart idea for me. If I had health problems so the risk/benefit was different I'd think again, but for now, for me, it's nto something I'm keen on.

Rabies jabs were worse. I was abroad in a third world country, fiddling around in patients brains and spinal cords, so needed rabies jabs before going. They hurt. A lot. And made me feel really grotty.

The worst medication I've ever taken has been an antimalarial. I'm almost never nauseous/vomitting but my wife and I were so sick on them we were hurling up daily. Urgh. Felt so wretched on them we had to stop taking them, which made us much more paranoid about netting and safety so overall worked out well enough for us.

All this no doubt has coloured my conceptions of a medication's risk, benefit and role, which is why I'm wont to stop medication more often than I am to start it.

PS : Zealots in "proper" English, do tell . . . should a full stop go before or after the brackets in the opening sentences of the second paragraph?
I could write (with comments like this.)
Or, I could write (with comments like this).


madsadgirl said...

You have the full stop in the right place; it should go outside the bracket in these sentences.

I have been on a wide variety of drugs in the last 10 years and the side effects have sometimes been horrific. One antidepressant caused me to suffer hallucinations and nausea after only a few days, while another gave me dizzy spells so severe that I could be seen bouncing off the walls of the corridors at work. But perhaps the worst side effect that I have encountered in my experience of side effects is the weight gain that I experienced while taking Amitriptyline and the difficulty that I have had in trying to lose that weight since.

Anonymous said...

I could write pages about side effects. I am one of those lucky people who have to use the medication advice insert as a check list for problems rather than a warning about "potential" side effects.

However, once one actually works, it all seems worth it. It's just trying to get the experts to believe side effects are not just me being difficult which seems to be the problem!

Lola x

XE said...

Healthy skepticism with regards to drugs is certainly a good thing :) Not seeing your GP in 20 years though may not be such a good idea... I've no clue how old you are but if I recall you have young children, so 30s-40s I'll presume. Not old enough to require more rigorous medical screening but often good to get a baseline of what your lab values are and make sure all's well from time to time! (Why in the world am I telling you this, you know full well, much more than I, and used to be a GP for heavens sake, but the health promoter in me can't help it).

With regards to the brackets, punctuation follows the bracket (like this).

La-reve said...

An interesting post- and just as I thought all shrink's were on comission from the pharma giants!! Glad you are so cautious with your patients.

Catherine said...

As long as it is an aside, outside the bracket. If you were to do it as a thought in between paragraphs or before the first paragraph/after the last paragraph, it would go on the inside.

Spirit of 1976 said...

Off-topic, welcome back to the blogosphere Shrink.

In your absence, you got an award.

Feathers said...

Overdosed frequently in summer, before that was on antidepressant and beta blocker (anxiety), Psychiatrist was going to change them in hospital,now told too high risk, although not doing what did prior.

One Doctor said on notes a medication which was highly addictive, lots of conflicting things. Doctors will not prescribe without Psychiatrist recommendation.

Depressed returned severe, suicidal thoughts, so on, they have not ruled it out, is this how it progresses in someone who overdosed quite a lot with intentions of not waking up?, (was sectioned in end, although left two/three days later when made informal). Refused treatment all the time in overdoses which resulted in Police (who were very nice and understanding)

Now they say therapy is the cure, had depression anxiety two years, no medication at present time. Therapy is beyond me at present due to anxiety and level of depression.

Sorry to ask you questions, obviously you do not know my complete history so on, just you mentioning about drugs and so on.

Thought i may be cheeky kind of thing, wondered if they were some kind of guidelines they had to follow?

ditzydoctor said...

you're right, doctors are crap at taking care of themselves - i had to stop my anti-malarials because it was giving me heartburn! :\

HAPPY NEW YEAR dear shrink :)

Socrates said...

Welcome back.

I too have worried about the ). and .) thing.

Thankfully the issue seems to be resolved for both of us.

During my (very brief) time on your side of the counter, I was shocked by the side effects I saw from neuroleptics and these were trivial compared to NMS.

Not having spent anytime on an acute admissions ward and only having seen residual symptoms of schizophrenia, gives me a somewhat skewed perspective.

I kinda assumed there must be some very good reasons for giving people clozapine.

Unknown said...

Doxycycline? (sp). I did wonder why the GP strongly pushed me and DH towards Malarone in November, despite the cost. No side effects to speak of.

I did get nasty heartburn off the augmentin I ended up on after catching a sore throat abroad though.... (mind you, 3 weeks of lovely Chinese food and curry won't have helped there either).

And cimetidine has to be my most hated drug of all time. No question that I needed it, but I felt nauseous all the time and could barely eat anything (solved this with pints of milk). And it interacted with everything on the planet.

Funnily, I've never gotten a side effect from an MH drug other than being very tired and stiff after exercise when on promazine or chlorpromazine. But you could claim these are part of the action of those drugs.

Fingers crossed the lithium doesn't munch my kidneys, it is otherwise the best thing since sliced bread.

Unknown said...

Incidentally, are rabies jabs still administered as a series of jabs right into your intestine or some other such abdominal organ?

The Secret Life of a Manic Depressive said...

Welcome back! You might know; I take Seroquel, have done for a year and a bit, and I twitch a lot and has restless legs. Do you think it's the Seroquel?

I remember the days in which I got so sick from Lithium that my boyfriend would be poised to phone an ambulance. I hate medications.

Where to from here? said...

Dear Doc

There is a history of mental ill health in my family. I am on medication following several years of depression punctuated with the odd 'up' episode brought on by anti-d's notably Efexor. I have been stable for a while.

I have a problematic relationship with my older brother who suffers from depression and OCD (he is seeing an NHS shrink). Due to some unresolved family problems and following the death of my parents his response has been to retreat into depression after bouts of anger at my sister and I and recently has stopped taking medication, stop getting out of bed and generally doing nothing to get out of his black hole. My sister, a therapist (in the US) has said that he is manipulating me and that his 'illness' is a sham. I cannot walk away from him and I have exhausted my resources. What do you suggest. I feel sure that your blog is not for the purposes of answering questions such as this but I thought it worth a try.

The Shrink said...

Mad Sad Girl, amitriptyline's a drug that's notorious for side effects so whilst arguably it's perhaps slightly more effective than some newer antidepressants, it's seldom used 'cause the side effects are so common, varied and intense. A shame, since it's otherwise a useful drug which helps with mood problems, sleep problems and neuropathic pain problems very usefully!

Lola, indeed, the patient information leaflet is a source of useful information and a source of great anxiety!

XE, I'm in my 30's and don't believe in "baseline" tests and "screening" without thought. A screening needs to have sufficient sensitivity, specificity, rationale and treatment interventions (if positive) to merit the screening. I'm all for health promotion, but I'm not for medical review if there's no purpose to it.

La-reve, I don't see any drug reps and we've banned them from our department. When I prescribe it's because I think it's the right thing and (through not seeing drug reps and taking nothing from them, ever) I can be absolutely certain it's not through any undue influence from Big Pharma.

Zarathustra, oooh, thank you! Hope you've had a good time through the holiday season and all's going well in your corner of CAMHS.

Feathers, I do agree that if things aren't totally simple, it's best for just one doctor to prescribe since there's then a consistent rationale to suggestions being offered (and a knowledge of what's happened with specific medications in the past). Although it's more work for me, I arrange to see and sort medication myself (and let the GP know of changes) rather than have a GP and me changing medications without planned consideration.
There are no guidelines they have to follow. Guidelines are, well, just a guide. The National Institute of Health and Clinical Excellence does issue guidelines on management but even they explicitly state that their guidelines should apply in just 2 out of every 3 patients. In person centred care I'd agree that guidelines giving the same treatment for everyone is wrong. What I'm more interested in is that the management plan is rational and purposeful (and as such has explicit goals) rather than being tried whimsically, or because that's whay's always done, or just because there's a desire to be seen to do something!

Ditzy, it seems that antimalarials have frequent and intense side effects, remarkably few friends I know have been able to tolerate them.

Socrates, as long as there are very good reasons for prescribing, I'm happy!

DeeDee, antibiotics commonly cause side effects, true. Cimetidine's hardly used nowadays - when I trained as a junior doctor on a gastroenterology team the Consultant felt that cimetidine should be banned! Either the problems was minor so didn't need medication, or it was significant and should be treated with a stronger (proton pump inhibitor) medicine! Lithium, as a simple salt, hopefully will serve you well over the long term, at least you're savvy about renal changes so can make sure it's looked for and thought through! Rabies vaccination was a few injections into muscle. I think the treatment of rabies (rather than vaccination to prevent) used to be ghastly, no idea if it's as you describe.

Seaneen, quetiapine doesn't usually cause a lot of movement problems. Quite the opposite, it's even been used outside of psychiatry in totally mentally well people with neurological movement problems to try and improve them (but results were poor). Rarely (in under 1% of folk) it can cause restlessness which can be both mental and physical (i.e. akathisia) so it's possibly related to quetiapine. But if you'd be betting on it, it's unlikely.

Twin Palms Road, I'd be expecting his mental health team to try and help him (erm, since that's their job!) so I'd be banging on their door to let them know how things were playing out, now. Whether it's his shrink or whether it's a community mental health nurse, whether it's an assertive outreach worker or a home treatment team, it should be mental health services providing the assessment, support and suggestions to help him move forward. You'd be welcome to have a voice in all that, but it shouldn't be your role to "sort it out," it should be your role to be a brother.

And thanks for all the comments on punctation, I'm now happy that all's good!

David said...

Nice to see you back. As for the really important issue of the punctuation of parentheses...

When it's a continuation of a sentence, then it goes outside (thus). (However, if it is a complete enclosed sentence like this, it remains indoors.)

As for side-effects... ever hear of withdrawal from quetiapine causing a burning sensation across the top, front and fore-sides of the head - that flares up with any intense sensation, stress or thought?

Right, off to read your other posts! atb D

Milk and Two Sugars said...

Hmph. Lucky men who don't have to bother with contraception or cervical cancer screening or vaccination programs so never have to see their GP's... grumble grumble grumble...

XE said...

Yes, come to think of it we spend a ton of time getting the word out for screening screening screening in health promo, and yet of course it's almost exclusively women that we're targeting... I've been trained to be "screening-happy", but of course what we're advocating for is breast cancer screening, cervical cancer screening, etc.

M&2S said it best... lucky men, grumble grumble grumble (we're jealous!)

You could at least agree that a DTaP every 10 years would be a good idea though, wouldn't you?

Unknown said...

Posting this here rather than on your most recent post.

First, I'm really flattered you like my blog (Actionreplay/DeeDee Ramona) - wow! That's a massive compliment. Will endeavour to keep the signal to noise ratio low but reserve the right to continue to post lolcats :).

Second: I managed to inadvertently post this using my real name gmail account, which, as you can imagine, is a big flashing google neon sign, you'll see it on the comment whose content is deleted.

I have no objection to you knowing my name but future employers/my mum/etc ahem, not so much, especially not linked to my livejournal!

The Shrink said...

Done :)

Unknown said...

Thanks :).