House Call, MD: Health Carefully Explained

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 Tania Houspian, PharmD 2011 | houspian@myhousecallmd.com

You’re fiancé is sick. His nose is running, he’s sneezing every two seconds while concurrently coughing up a lung.  In between all these bodily functions, he still manages to complain about how sick he is.  On your side of the bed, you’re struggling to get a good night’s sleep because you have work early the next morning. You drag yourself out of bed and head to the local 24-hour pharmacy hoping to find something (really anything) to help his symptoms and your chance of getting some sleep.  Instead of finding the remedy to soothe his symptoms, you develop a symptom of your own: a headache.  As you look around the never-ending aisles of drugs, you realize you have no idea where to start.  They all promise to alleviate every symptom under the sun.  What’s the difference between them all?  Your head begins to pound.

Let’s back up the story to the point at which he caught the cold. It’s called the common cold because, well, it’s common.  It’s all around us.  It turns out that there are over 200 viruses that can cause the “common cold.”  So yes, you’re surrounded and outnumbered.  People usually get the common cold by touching the virus (i.e. touching something someone with a cold sneezed on) and then touching their eyes or nose (yes, you can get sick from touching your eyes with infected hands).  We hate to admit it but we are the ones giving the virus a free ride into our bodies.  Another way to catch the virus is by inhaling or swallowing a droplet that someone expelled via sneeze or cough.  Droplets from a sneeze can travel up to 30ft away (impressive and terrifying at the same time) and infect someone on the opposite side of the room. Now you see why your mother always told you to cover your mouth and wash your hands after you sneeze?

So let’s say your fiancé is a teacher and caught the virus from one of his students at school whose mother never taught him to cover his mouth when he sneezes (not a rare scenario since 75% of viral infections are transmitted by children).  About 1-2 days after catching the virus, he started to complain of a sore and scratchy throat. Day 2 started off with a symphony of sneezing and sniffling.  Then there’s the predictable transition in your nose: clear discharge slowly becoming hazy and booger filled later on as the infection progresses.  Day 2 -3 is when things heat up (i.e. you develop a fever).  Children and older adults are more likely to develop a fever while everyone else usually just gets that general feeling we medical professionals call “yuck + aches.”  Days 4 and 5 bring coughing.   Early on, nothing came out when he coughed (called a “dry cough”) but as the cold progressed he started coughing up sticky mucous clumps (predictably called a “wet cough”).  This is the general scheme of how the common cold progresses.  At the same time, every individual is different and every virus is different.  The common cold is also different from the flu which has similar but more severe symptoms that last longer.  The common cold usually last 5-12 days while the flu can last anywhere from 2-3 weeks.

Now lets go through each symptom and outline the medications of choice to minimize the suffering.  Remember, there is no cure for the common cold for many reasons, one of which being the fact that so many different viruses can cause it.  All the recommendations below help reduce symptoms so you can go on with your life (and stop his complaining) while his body fights off the cold but they are not “cures” for the cold.  Your body will take care of that on its own.  When shopping for medications, be sure to look at the Active Ingredients.  This is what you are paying for.  Active ingredients are the components of the medication that work to improve your symptoms.  As you browse, you may begin to notice that many of the medications contain similar ingredients…not a coincidence.  What matters when shopping for the right treatment is the active ingredient, not the fancy name and logo on the front of the box.

Symptom 1: Sore/Scratchy Throat

Complaint: “It hurts to talk. It hurts to swallow. It even hurts to breathe.”

A sore throat can make it hard to drink and eat, both of which are very important in helping your body fight off a cold.  Common components of medications that help soothe a sore throat are Benzocaine, Menthol, Phenols, and Dyclonine. Benzocaine and Dyclonine are painkillers and stop your nerves from feeling the sore throat. Menthols are extracted from peppermint or other mint oils and, similar to phenols, produce a cooling sensation in the throat.  They’re all equally effective and come in two different forms (pick whichever better suits your fancy).

• Lozenges: Hard candies you can suck on which release the medication into your mouth and help relieve the pain.  Some common brands include Halls, Cepacol, or Cholraseptic. You can take one lozenge every 2 hours to relieve the soreness.

• Liquids: Usually sprayed, swished, or gargled then spit out. You can use them up to four times a day.

Whichever formulations you choose, remember to try not to eat or drink for an hour after using the medication since doing so will wash away the medication.

Symptom 2: Runny Nose (or “Sniffles” for the under 10 crowd)

Complaint: “My nose has turned into Niagara Falls and I’ve gone through enough Kleenex to fill a landfill!”

You can either blow your nose or do what you did in second grade (remember taking a big sniff and swallowing your spoils…yum).   You can also try something that will stop the flow (the more socially acceptable approach).  The class of medications usually used to relieve the sniffles is called decongestants.  Decongestants cause your blood vessels to contract so that less fluid is allowed to leak out of the capillaries in your nose and, viola, the sniffles go away.  One problem with decongestants is what is called “reflexive vasodilation.”  When the medication wears off, the blood vessels in your nose dilate causing the return of Niagara Falls.  An unfortunate side effect of temporary relief.  Decongestants come in two forms: topical and oral.

Topical decongestants come in little spray bottles that you insert in your nostril, delivering the medication directly to your nasal capillaries.  Some common topical decongestants are:

• Short-Acting (will relieve runny nose for 4-6 hours)

  • Ephedrine

  • Epinephrine

  • Naphazoline

  • 
    

    Phenylephrine

  • Tetrahydraoline

• Medium-Acting (8-10 hours)

  • Xylometazoline

• Long-Acting (12 hours)

  • Oxymetazoline (Afrin)

When shopping for your decongestant, take into account how long you want the medication to work.  They are included in many different brand name decongestants so be sure to turn the bottle around and read the back where it tells you the “active ingredients.”  Oxymetazoline is a popular one since it works the longest and can be found as the brand name “Afrin.”  An important note about topical decongestants is that using them longer than 3-5 days will actually cause a condition called rhinitis medicamentosa (fancy word for your runny nose will get WORSE…a much more severe form of reflexive vasodilation).  Take Home Message: don’t over these medications and start to wean yourself off of it after 3 days.

Oral decongestants come in tabs and take longer to work since you don’t apply them directly to your nose.  The two most common ones are Phenylephrine and Pseudoephedrine.  Phenylephrine is shorter acting (about 3 hours) while pseudoephedrine can work for up to 12 hours with one dose.  All pseudoephedrine-containing medications (brand name is usually Sudafed) are stored behind the counter at the pharmacy.  You have to show your ID to prove you’re over 18 and sign a document in order to purchase it.  Why?  It turns out that people have figured out a dangerous way of making an illegal drug using pseudoephedrine and the government would like to discourage such activities.  If you have high blood pressure or are pregnant/breastfeeding, avoid using this product since it causes blood vessels to constrict which is unfavorable in any of those conditions. Also, oral decongestants can cause you to become more alert and energized so avoid taking them close to bedtime…unless you want to pull an all-nighter when you’re sick.  We wouldn’t recommend it.

Symptom 3: Sneezing

Complaint: “AAACHOOOOOO! If I sneeze one more time my head may explode.”

Sometimes a sneeze feels great.   When you’re sick, it just hurts. So what can you do to make them stop?  Antihistamines are typically used for allergies but they also decrease mucous production throughout your body.  Take an antihistamine and you can say goodbye to sneezing, runny nose, itchy throat, and runny eyes. Yes, antihistamines are amazing. The downside is they can be very sedating.

• Most sedation: Diphenhydramine (Benadryl), Clemastine fumarate (Tavist)

• Intermediate sedation: Pyrilamine maleate (Theracof), Pheniramine, Brompheniramine (Dimetapp), Chlorpheniramine (Chlor-Trimeton), and Tripolidine (Actifed)

• Least sedating: Loratadine (Claritin) and Cetirizine (Zyrtec)

If you’re about to go to bed, taking Diphenhydramine may not be such a bad idea since it’ll help you fall and stay asleep.  If you’re about to go to work, Loratadine is the better choice.  It’s all a matter of what you need at that time.

Symptom 4: Fever

Complaint: “I’m hot then I’m cold. I feel like Katy Perry.”

Treating a fever is tricky because a fever can be an indication of a more severe illness than your garden-variety common cold. If you have a fever for more than 24 hours you need to see your doctor.  If you have a fever and you’re taking medications to help reduce it but the fever continues to get worse even after three days of treatment, definitely go see your doctor.  The best medications to take for a fever are Acetaminophen (Tylenol) or Ibuprofen (Motrin, Advil).  They both work equally well to lower a fever.  They both come in many forms including tablets, capsules, liquid capsules, liquids, and suppositories so pick whichever you’re most comfortable with.

Tylenol overdoses are more common than we would hope and are very dangerous (Tylenol can wreak havoc on your liver).   Be sure you are not taking too much and follow the directions on the bottle carefully. The maximum amount you can take is 4000mg (4 Grams) per day. Ibuprofen is safer but it’s recommended that you take no more than 1200 mg a day.

If you have a child with a fever, just go see your doctor.  Fever-reducers are much more complicated and dangerous in children so working with a pro is recommended here.

Symptom 5: Cough

Complaint: “Between sneezing and coughing I have no time left for breathing…which I can’t do anyway since my nose is so stuffed up!”

There are two types of cough (as we previously mentioned): nonproductive and productive. Nonproductive coughs are dry hacking coughs during which time nothing comes out (i.e. nonproductive).  Productive coughs are the ones where you get a nice surprise in your mouth at the end (yup, a gooey ball of mucous). These two types of coughs are treated differently.

For nonproductive coughs, try Dextromethorphan (Robitussin) or Diphenhydramine (Benadryl).  We don’t know how Dextromethorphan works and some doctors claim that it really doesn’t.  It’s one of those medications that has been around for such a long time and used so frequently that nobody bothered to study it.  Diphenhydramine (yes, our friend the antihistamine is back) is actually one of the best treatments for a cough caused by the common cold.  It’s great at bedtime if you want to fall asleep and will prevent you from waking up coughing. No cough and a good night’s sleep sounds pretty awesome to us.

For productive coughs, Guaifenesin (also called Robitussin) is the way to go. Guaifenesin won’t stop your cough but it will make it easier to cough up the mucus in your airway so that you will eventually stop coughing.  Out is better than in.  It’s important to drink lots of water when taking this medication (and when your sick in general).  Drinking water helps the drug loosen up the mucous, making it easier to cough out.  Getting rid of all this mucous will help eliminate the infection as opposed to stopping the cough and keeping the virus-infected mucous in your throat and lungs.

You now know the basic components of just about every cold and flu medication on the market.  There are tons of combination products that mix and match ingredients to suit the limitless permutations of symptoms.  Next time the common cold strikes, turn the bottle around read the ingredients.  You know how to treat each of your symptoms in a much more strategic fashion.  If you forget, you can always ask your friendly and knowledgeable pharmacist (or just print out this article and take it with you to the drug store).

We’ve gone over the most accepted treatments of common cold symptoms.   What about all that other stuff you find in the aisle?

The “Other Stuff”

Airborne

When Airborne hit the market in 1999, who wasn’t swearing that it could cure the common cold?  Nine years later, Airborne Health, Inc. found itself waist-deep in class action law suits for making claims about therapeutic efficacy that it couldn’t support with medical research.  All the lawsuits were settled out of court and Airborne Health, Inc. paid truckloads of money to make the lawsuits go away.  The main problem was that Airborne claimed it could “prevent or reduce the risk of colds, sickness, or infection; protect against or help fight germs; reduce the severity or duration of a cold; and protect against colds, sickness, or infection in crowded places such as airplanes, offices, or schools.”  Not a single clinical trial was done to prove that any part of that statement was correct.  If you’ve checked out their website or commercials, you know that a lot has changed.  Now they only claim that, “The Airborne health formula helps to support your immune system through its blend of vitamins and minerals.”

The verdict?  Their new advertising campaign is much more accurate.  Airborne is simply a combination of vitamins and minerals that your body will generally be getting from a well-balanced diet.  It never hurts to take a multivitamin to compensate for any dietary deficiencies but that’s all Airborne is.  It has higher amounts of specific vitamins, like vitamin C, than your average multivitamin.  The adult tablets have 1000mg (1gram) of vitamin C.  If you took the tablets the way they recommend you do (every 3 hours while awake) you would be consuming up to 5 grams of Vitamin C per day.  Doses that high aren’t necessarily bad for the average person but they can cause kidney stones in certain individuals.  In addition, there is no benefit to taking that much vitamin C (unless you enjoy a good dose of diarrhea which doses that high can cause).  Doses of 2-3 grams per day have been shown to help reduce the duration of cold symptoms but do nothing for the severity of the cold.  Also, Vitamin C does not work as a preventative measure.

The Final Verdict: Sure, go ahead and take airborne as long as you realize you are taking an overpriced yet tasty (yum, pink grapefruit) multivitamin.  Oh, and it’s not a miracle cure.  Did we mention that?

Zicam

Zicam brand makes every form of medication you could ask for.  From nasal swabs to lozenges, they are working hard to please the full spectrum of consumers.  Their line of products called “Symptom Relief” contain the spectrum of medications we discussed earlier (from menthol to Tylenol) so make sure you read the back before you buy any of them.   You may be just able to buy a bottle of Tylenol and a decongestant for less money.  The Zicam uniqueness is found in their line of “Cold Remedy” products.  The active ingredients in this line of products are Zincum Aceticum and Zincum Gluconicum (different forms of Zinc). One line of zinc-containing products (Zicam Cold Remedy Nasal Gel, Zicam Cold Remedy Nasal Swabs, and Zicam Cold Remedy Swabs, Kids Size) was completely removed from the market because they caused people to lose their sense of smell (definitely not a good thing).  These were zinc-containing products that were applied directly to the inside of the nose.  NOTE: If you have any at home, throw it away!  The company is currently considering the FDA’s request to discontinue the product…until the controversy settles, don’t use them.

Back to the other zinc-containing products: The makers of Zicam believe that zinc prevents the rhinovirus (one of the viruses that causes a cold) from invading human cells.  Some studies have found that zinc-containing products can shorten the length of time cold symptoms last and minimize the severity of the common cold if they are taken within 24 hours of symptom onset.  Other studies claim that these initial studies were poorly designed and that zinc does little to help with the common cold.  Who should we believe?   Let’s think about this logically.  If Zicam prevents the rhinovirus from invading human cells but there are over 200 different viruses that cause the common cold, the odds of Zicam helping your particular cold seem slim.  On the other hand, rhinoviruses are the most common cause of the common cold so the odds go up a bit.

The Final Verdict: It really depends the particular virus you have.  If you take Zicam as soon as you develop cold symptoms and you don’t get better, you probably don’t have a rhinovirus.  At this point, refer to all of the medications outlined above that have been proven effective for your cornucopia of symptoms.

You are now officially an informed consumer!  Next time you’re in the pharmacy shopping for treatments for your cold symptoms, flip the box around and strategically target your symptoms of choice with the correct active ingredient.  No need to suffer any longer!  We wish you a sneeze-less, cough-less, and complaint-less night.  Go get some shut eye.

Questions?  E-mail Tania: houspian@myhousecallmd.com