by Tania Houspian, PharmD 2011 | houspian@myhousecallmd.com
Most patients know their medications by one of their two names. Even more patients will wonder why their medications need two names. Is it a first and a last name? Are they having an identity crisis? Why in the world can’t we just pick one name and all call it that? The answers to the questions above: are no, no and we do. For further explanation keep reading.
by Georgina Lee, PharmD 2011 | lee@myhousecallmd.com
Does your mind wander when you’re trying to study or read the newspaper? Do you tend to switch the subject often when you’re having a conversation? Do people call you “hyper” or “energetic” when you go out? If the answer is yes to any of those questions, 
we’d like to congratulate you on being just like the rest of us who exhibit normal behavioral tendencies (like constantly flipping between radio stations while driving). Then how exactly is one diagnosed with ADD or ADHD (Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder)? Currently, about 3-10% of children and 4% of adults worldwide have ADD/ADHD with a strong propensity for boys over girls (4 boys to every 1 girl). According to the DSM-IV criteria (Diagnostic and Statistical Manual of Mental Disorders), ADD/ADHD is considered a childhood and adolescent psychiatric disorder in which the person has either inattention or hyperactivity-impulsivity (or both) as defined by the following:
by Tania Houspian, PharmD 2011 | houspian@myhousecallmd.com
You’ve may have noticed that your grandmother takes an aspirin everyday as part of her arsenal of medications. You may wonder why she’s taking aspirin when she’s in no apparent pain. When you asked grandma she replied with her sagely tone, “The doctor said its good for my heart.” You nodded, pretending to understand, and wrote the answer off as another one of grandma’s “senior moments.” Well, it turns out that this time grandma is right. Although her answer is a simplified version of the truth, it is the truth nonetheless. Before you start popping aspirin yourself, read on to find out who should take daily aspirin and how it works to help your heart.
by Tania Houspian, PharmD 2011
It’s inevitable and happens at least twice a month. Plans will be made to go out to a bar with friends and, as the first cocktail is being ordered, someone remembers that they’re on antibiotics for an infection they’d rather not talk about. 
The question is raised about whether or not it’s OK to drink alcohol with that particular medication. At that point, everyone turns to the friend with some form of medical training and asks, “So can I drink or what?” Members of the House Call, MD staff have experienced this so often we’ve started to avoid going out for drinks with infection-prone friends. What a loaded question! If the answer is, “No”, then the friend will spend the rest of the night pouting about not being able to drink and secretly blame the messenger for it. To avoid those awkward conversations, we’d like to take a moment and explain why sometimes it better to put the drinks aside when on certain medications. We apologize in advance for your drink-less night out.
Why does alcohol interact with certain medications?
Alcohol is broken down by two parts of your body: your stomach and your liver. When that shot of whiskey reaches the stomach some of the alcohol is broken down and the rest is absorbed into your blood stream. 
From your bloodstream, the alcohol is delivered to your liver via the portal vein. In the liver, about 10% of the remaining alcohol is broken down. The remaining alcohol is passed back into your bloodstream and is free to create all those magical affects alcohol has on your brain (i.e. thinking you’re a better dancer than you really are, being exceedingly friendly with strangers, etc.). At any of those stops that alcohol makes in your system (stomach, liver or brain) there is a possibility for it to interact with any medications that may possibly be taking the same path (1). Below we’ll go through different classes of medications, covering specific medications from each class and how they interact with alcohol.
Class: Antibiotics/Antifungals
Medications: Metronidazole, Nitrofurantoin, Tinidazole, Ketoconazole, Cycloserine, Cefoperazone, Cefotetan, and Griseofulvin
Just a shot of vodka along with any of these medications and you may be hugging the porcelain throne earlier in the night than you had planned. When mixed with alcohol, these medications can cause a violent reaction in your stomach called a “disulfiram-like reaction.” 
This reaction results in a sudden increase in heart rate, turning beet red, upset stomach, nausea, vomiting and, in worst case scenarios, death (2). Antabuse is the name of a medication whose main component is disulfram. When people want to quit drinking they are prescribed Antabuse so that if they do give in to their urge to drink they’ll have a violent reaction to the alcohol. The smart alecks in the crowd are now thinking, “Well I’ll just make sure to separate my antibiotic and alcohol by a long enough interval so that they’ll never meet in my stomach! I win!” We hope you can define a “long enough interval” (and if so, let us know) because everyone’s stomach empties these medications at different rates. As such, we can’t even being to make recommendations as to how much time you should allow for so that none of the antibiotic will meet the alcohol. The bottom line is that if you mix the above medications with alcohol, you’re asking for some serious punishment. You can’t say we didn’t warn you.
Class: Antihistamines
Medications: Loratadine, Fexofenadine, Diphenhydramine, Desloratadine, Loratadine, Brompheniramine, and Cetirizine
Having read Attack of the Common Cold, you know that antihistamines can help with a lot of cold symptoms. Since they’re available to buy at the pharmacy without a prescription, some people make the mistake of assuming they’re completely safe and won’t interact with other medications or alcohol. We are sorry to say that this assumption is wrong. On their own, antihistamines can cause some drowsiness. When mixed with alcohol, you might as well tuck yourself in for the night. Aside from making you drowsier, it’s also possible to become dizzy from a drop in your blood pressure. Dizziness can lead to falling and falling leads to all sorts of serious injuries (i.e. broken bones, concussions, etc.)(2). Antihistamines are found in all sorts of cough, cold, and allergy combination drugs like Nyquil so read the back of the label and see if any of the above medications are in there. We don’t recommend that you take antihistamines and drive until you know their affect on your level of alertness. If you’re going to drink and take antihistamines, absolutely do not drive (not that you need to be reminded that you should not drink and drive!).
Class: Cough Medications
Medication: Dextromethorphan (Robitussin)
If you’ve ever had a cough and taken Robitussin, you know how sedating it is. Imagine mixing alcohol with that. Two words: lights out. Mixing the two can lead to hallucinations and strange behavior (more so than alcohol alone). While this may sound like fun to some people, believe us when we tell you that it is dangerous and harmful to your brain (2). Don’t do it.
Class: Heartburn Medications
Medications: Nizatidine, Metoclopramide, Cimetidine, and Ranitidine
Heartburn is very unpleasant and we completely understand your need to alleviate that toxic feeling with medications. You pop a Zantac (Ranitidine) and start to feel better so you decide you will join your friends at the pub. What can you expect to happen after your second vodka tonic? 
Nothing good. Your heart rate will increase suddenly and so will your blood pressure. Imagine how the heartburn made you feel and amplify that ten-fold. In addition mixing alcohol with these medications can increase the affect alcohol has on you. If you’re someone who usually feels tipsy after six drinks you may start feeling not so great after two. This happens because the heartburn medications decrease the breakdown of alcohol in your stomach so your body is exposed to more alcohol than it normally would be. In turn, alcohol inhibits the metabolism of the heartburn medications so you experience more severe side affects from those medications (the increased heart rate and blood pressure) (2).
Class: Pain Relief
Medications: Ibuprofen, Naproxen, and Aspirin
Whatever the source of pain (cramps, muscle pain, hangover, headache, etc.) most people reach for one of these trusty painkillers. Aspirin has lost some of its popularity as a painkiller but Ibuprofen and Naproxen are gaining in popularity due to their anti-inflammatory properties that help with lots of different sources of pain. How do these trusty pain-alleviating friends of ours interact with alcohol? Ibuprofen, Naproxen, and Aspirin all disrupt the lining of your stomach and add to the erosive affects of alcohol. Combine the two and you asking for some serious stomach pain. Together they can completely disrupt the lining of your stomach and allow the acidic contents of your stomach to reach the stomach tissue. Long-term combination of alcohol and these agents can lead to bleeding in your stomach (a.k.a. gastrointestinal bleeding). Not fun and filled with long-term consequences. It’s generally recommended that you separate these agents and alcohol by 8-10 hours or play it safe and don’t combine them in the same day (1).
Class: Antipyretic (Anti-Fever)
Medication: Acetaminophen (Tylenol)
Tylenol can be used for both pain relief and to reduce fever. It gets its own separate section from the other pain relievers because it comes with an entirely different risk when combined with alcohol. Tylenol, like alcohol, is broken down by the liver. When Tylenol and alcohol meet in the liver, the alcohol causes Tylenol to be broken down into a toxic compound. This toxic compound causes the death of liver cells! Did your liver just quiver out of fear? We don’t blame it. Long-term combination of alcohol and Tylenol can cause liver failure, meaning that you’ll ultimately need a liver transplant. Not good. Avoid taking more than 4 grams of Tylenol a day and absolutely do not drink when taking Tylenol (1).
Class: Antidepressants
Medications: Phenelzine, Isocarboxazid, and Tranylcypromine
The antidepressants listed above are from the Monoamine Oxidase Inhibitor class (MAOI’s for short, we love acronyms in the medical world). They have lost popularity in recent years because of the many interactions they can have with food and alcohol. 
Aged foods (think salami, aged cheeses, etc.) and aged drinks (wine is the main culprit here) contain a compound called tyramine. The metabolism of tyramine is prevented when someone is taking MAOI’s so the tyramine builds up in your body. When tyramine builds up, it causes a sudden increase in heart rate and blood pressure that we call a hypertensive emergency (1). Yes, the kind of emergency people end up in the hospital for. So if you are taking any of these antidepressants, do not drink aged alcoholic beverages.
Class: Sedatives
Medications: Diazepam, Lorazepam, Zolpidem, Eszopiclone, Estazolam, Ramelteon, Phenobarbital and Temazepam
The entire point of these medications is to help people fall asleep. Add on the sedating affects of alcohol and you’ll have an extremely un-alert person. This might not sound like reason enough not mix them with alcohol since being extra sleepy is something an insomniac may want. However, the downside is that you may become completely unaware of your actions and experience amnesia. On the other hand some people become aggressive and anxious due to combining these medications with alcohol (2). The reaction can vary from person to person. Even with the variance among individuals, all the manufacturers of these medications clearly warn against taking these medications with excessive amounts of alcohol.
Class: Opioid Pain Killers
Medications: Morphine, Oxymorphone, Meperidine, Methadone, Propoxyphene, Oxycodone, Hydromorphone, and Codeine
Generally prescribed for serious pain, the consequences of mixing these medications with alcohol are serious. Like with the sedatives, mixing these medications with alcohol can cause increased sedation, amnesia and loss of control. If that’s not enough to scare you then maybe the fact that you may stop breathing will. Opioid painkillers cause respiratory depression (decreased breathing) and alcohol adds to that affect (1). It is this combination of painkillers and alcohol that has claimed the lives of several celebrities in the past.
There are a lot of other medications that interact with alcohol but the medications above are the most commonly used in our society. Never assume it’s safe to combine medications or take medications with alcohol until you check with your pharmacist or doctor. One night of fun is not worth any long-term damage you may cause your self. The next time the answer is, “It’s probably best not to drink while on that medication,” trust us…we’re on your team. We’ll even take you out for a drink when you’re medication-free.
Questions? E-mail the Author: houspian@myhousecallmd.com
References:
1. Alcohol Related Drug Interactions. Pharmacist’s Letter/Prescriber’s Letter. Jan 2008. Vol 24.
2. Harmful Interactions: Mixing Alcohol with Medicines. National Institute of Alcohol Abuse and Alcoholism. 2007.
by Georgina Lee, PharmD 2011 | lee@myhousecallmd.com
Have you ever played a game at the arcade where the more accurately a person fires a steady stream of water into a target, the faster their object rises to the top? 
Imagine the person who sits down and pulls the trigger only to find the water stuck in the barrel. Do you blame the player for their inability to get their object to rise or do you blame the faulty water gun? For some men, having a faulty water gun can be both frustrating and debilitating, especially when it comes to bedroom activities. That’s probably why those little blue pills, otherwise known as Viagra, are flying off pharmacy shelves. These pills may not have Avatar-like abilities but they do serve as a miracle to some who suffer from one of nature’s most vexing problems.
What is erectile dysfunction (ED)?
The National Institutes of Health (NIH) defines male erectile dysfunction as the “inability to achieve or maintain an erection sufficient for satisfactory sexual performance.” Let’s not confuse ED, however, with other disorders such as premature or delayed ejaculation, anorgasmia (inability to achieve orgasm) or infertility. Essentially, there are four physiological systems that are necessary for a normal penile erection: vascular, neurologic, psychogenic and hormonal.
1. Vascular Stimuli
Erections are the result of shifting blood flow in the body. Most of the blood that is contained in the penis during an erection is in the corpora cavernosa (erectile tissues that lay along the penis shaft). Within the corpora cavernosa are multiple interconnected 
sinuses or sacs that can fill with blood to produce an erection. In the flaccid state (i.e. not erect), the arterial and venous blood flow into and out of the corpora are balanced. During an erection, however, arterial blood flow going into the corpora increases and blood fills the sinuses resulting in penile swelling and elongation. A neurotransmitter known as acetylcholine helps this process by enhancing production of nitric oxide and cAMP, which are substances that induce smooth muscle relaxation and vasodilation (widening of blood vessels). The erection is prolonged by a decrease in venous outflow from the corpora (so more blood stays in the penis). The take home message is that sufficient blood flow into the penis will cause an erection. Easy, right?
2 & 3. Neurologic and Psychogenic Stimuli
Of course blood flow is not the only important aspect of an erection. If you ask most men (or their wives), chances are some will have an erection while they are sleeping. This type of erection is mediated by a sacral nerve reflex arc. In the conscious person, however, sexual stimulation mediates erections via the central nervous system (the motherboard of nerves). In other words, someone who is awake can be stimulated by their senses (for example, if they see an attractive person, hear certain things, smell a particular scent, taste or touch a particular object…you see where this is going). 
No wonder the adult entertainment business is a billion dollar industry! The individual’s brain processes this sensory information and a nervous impulse is carried down the spinal cord to peripheral nerves (these nerves communicate via the neurotransmitter, acetylcholine). These nerves trigger an increase in the blood supply to the corpora and, like that, an erection is born! So what happens after an erection? The party has to stop at some point! A different neurotransmitter called norepinephrine is released. This chemical constricts vascular smooth muscle, decreasing arterial inflow to the corpora and increasing venous outflow (i.e. more blood leaves the penis). The end result is your standard flaccid penis, as good as new.
4. Hormonal Stimuli
The fourth system that is involved in the process of an erection has to do with testosterone which stimulates libido or sexual drive in males (or “Mojo” in the words of Austin Powers). Approximately one third of men older than 50 have a condition called hypogonadism that is characterized by low serum testosterone levels. When libido is decreased, a person may not develop erections and erectile dysfunction is considered secondary to a decreased libido. However, serum testosterone levels do not always correlate with ED so don’t kick down your doctor’s door demanding testosterone injections just yet.
Erectile dysfunction can manifest from any single or combination of abnormalities of the four systems necessary for a normal penile erection (and you used to think it was so simple). In addition, diseases that compromise vascular flow such as arteriosclerosis (stiffening of blood vessels), impair nerve conduction to the brain (i.e. stroke) or nerve conduction in the periphery (i.e. diabetes), mental disorders, hypothyroidism and others can all cause ED. Social habits such as smoking and drinking as well as certain medications have also been linked to performance problems (see it does happen to other guys).
How do I treat ED?
According to the American Urological Association (AUA), identifying underlying causes including disease states and psychosexual dysfunctions should be initiated followed by a heart-healthy lifestyle complete with a proper diet and regular exercise. If the person’s ED is not reversed after such changes, then the following pharmacological treatments can be considered by you and your primary care provider.
Phosphodiesterase Type 5 Inhibitors (PDE-5)
Most of us know what Viagra, Levitra, and Cialis are used for (thanks to their cuddly commercials) but how do they work? As mentioned earlier, acetylcholine helps release nitric oxide which causes vasodilation so more blood can flow into the penis in order to cause an erection. 
Nitric oxide does this by stimulating an enzyme that makes a substance called cGMP, which helps to produce a penile erection. Viagra, Levitra, and Cialis are all PDE-5 inhibitors meaning they block the enzyme (phosphodiesterase) that breaks down cGMP (making it inactive). When you take one of these medications, cGMP stays around longer and more blood goes into the penis to maintain an erection. In terms of efficacy, all three drugs are comparable depending on the person’s tolerance and satisfaction. Approximately 30-40% of patients do not respond to PDE-5 inhibitors mainly due to noncompliance issues. By “noncompliance issues” we mean:
Patients must engage in sexual stimulation for the best response
Sildenafil (Viagra) must be taken on an empty stomach at least 2 hours before meals (does not apply to Vardenafil (Levitra) or Tadalafil (Cialis))
Taking Viagra or Levitra with a fatty meal can decrease the absorption rate (Cialis is not affected)
Patients who do not respond to the first dose should continue with the drug for at least 5-8 doses before failure is declared, as increasing success rates are reported with sequential dose administration
Some patients require dosage titration up to 100mg of Viagra, 20mg of Levitra or 20mg of Cialis for a response
In general, Viagra and Levitra are similar in that they have a 1-hour onset of action, short duration of action and oral absorption that is significantly delayed when the drugs are taken within 2 hours of a fatty meal. In contrast, Cialis has a delayed onset of action of 2 hours, a prolonged duration of action of up to 36 hours and food does not affect its rate of absorption. People taking these medications should avoid alcohol as it may result in orthostatic hypotension (low blood pressure upon standing up) and cause symptoms such as lightheadedness and dizziness. The most common side effects for these medications include headache, facial flushing, dyspepsia (stomach irritation) and dizziness (super sexy, right?). Also, people taking nitrates (nitroglycerin or isosorbide dinitrate) for chest pain should not take these medications.
Intra-Cavernosal & Intra-Urethral Alprostadil (Caverject, Edex, and MUSE)
Alprostadil is a drug that stimulates production of cAMP which causes smooth muscle relaxation of the arterial blood vessels of the penis, enhancing blood flow. 
It can be injected either directly into the corpora cavernosum (side of the penis) or into the urethra (front of the penis). Yes, we did just say “injected.” Although it is highly efficacious, 30-50% of patients voluntarily discontinue therapy during the first 6-12 months due to inconvenience of administration, an unnatural nonspontaneous erection, needle phobia, loss of interest, and cost of therapy. We would wager that “needle phobia” is the big winner in that group. Typically, the onset of action occurs within 5-15 minutes and the duration can last for up to an hour…assuming you don’t pass out from the needle.
Testosterone Replacement Agents
Testosterone replacement regimens restore testosterone levels to the normal range (300-1,100 ng/dL) which can correct symptoms of hypogonadism 
(symptoms include malaise, loss of muscle strength, depressed mood, and decreased libido). In addition, testosterone can stimulate nitric oxide which can enhance blood flow into the penis. Testosterone can be administered orally, parenterally (injection), or transdermally (gel or patch). Injectable testosterone is the preferred treatment for symptomatic patients because the injections are effective, inexpensive, and not associated with major side effects. Although convenient for the patient, testosterone patches and gels are much more expensive than other forms and should be reserved for patients who completely refuse injectable testosterone (you didn’t hear that from us). Side effects from gels/patches include weight gain, high blood pressure, gynecomastia (man boobs). Also, FYI, the patches and gels should not be used when in close contact with pregnant women.
Other Devices
Hopefully we’ve opened your eyes to solutions out there beyond the little blue pill. That being said, we have a few more tricks up our sleeve before we wrap up. First, the vacuum erection device (VED) is a pump that is activated by the patient producing a vacuum pressure to draw arteriolar blood into the corpora cavernosa. The onset of action is comparatively slow (30 minutes), which requires patience and planning 
from both the patient and the sexual partner. Not to mention the fact that VEDs are not very discreet (read: hard to hide). Other unapproved agents include trazodone, yohimbine, papaverine and phentolamine. The most invasive treatment for ED is the surgical insertion of a penile prosthesis used for people who do not respond to oral or injectable treatments. Penile prostheses provide penile rigidity suitable for vaginal intercourse and are associated with a greater than 90% patient satisfaction rate (generally higher than that observed with any other drug treatment or VED). Much easier to use, a number of device options to choose from but, at the same time, an invasive procedure to say the least. We’ll let you make the final call.
A possible and potentially dangerous side effect of all of the above treatments is known as priapism (a prolonged and painful erection lasting for more than 1 hour). This complication becomes most dangerous when an erection persist beyond 4 hours (sounds painful) and people are thus advised to seek medical attention immediately since priapism is considered an urological emergency. Most importantly, seek professional medical advice from your primary care provider before starting any treatment. Erectile dysfunction is a very personal issue and difficult to discuss yet the condition is very manageable with proper medical examination and treatment. With your ED under control, we’ll leave you with one more valuable piece of medical advice: Always remember to practice safe sex (don’t be a fool, wrap your tool)!
Questions? E-mail the Author: lee@myhousecallmd.com
Resources
DiPiro, Joseph T. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York: McGraw-Hill, 2008. 1369-385. Print.
American Urological Association Education and Research. “AUA Guideline on the Management of Erectile Dysfunction: Diagnosis and Treatment Recommendations.” AUA – Home. 2005. Web. 03 June 2010. <http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines>.
NIH Consenus Conference. NIH Consensus Development Panel on Impotence. Impotence. JAMA 1993;270:83-90.
Stimmel & Gutierrez. Counseling about sexual issues. Pharmacotherapy 2006;26: 1608-1615.
