Antidepressants and High Blood Pressure

Unfortunately, you may have to try several different antidepressants until you find the one that is right for you and your symptoms.  If you have depression and high blood pressure, you have to find the right med that won't exacerbate blood pressure. A good physician will find out several things.  First, he/she will examine you and your symptoms and take into consideration medications that have worked for others in your family.  Usually someone presenting with blood pressure and depression will have someone else in their family suffering with the same thing.  He/she should ask what other medications you are taking.  You don't want to select a drug that will interact with something you are already on.  For example, if you are taking imitrex for headaches, I wouldn't want to see an SSRI added, or maybe change the imitrex to something else.

A good physician should also ask what other conditions you suffer from, if you are pregnant or breastfeeding, what symptoms you are experiencing, and even what insurance you have or what will be covered.  I know this last one is overlooked, but if a patient can't afford a medicine, what is the point of even seeing a physician if cost isn't taken into consideration DURING the visit.

There are a few antidepressants that are documented to possibly cause an increase in blood pressure.  Bupropion (Wellbutrin, Zyban), venlafaxine (Effexor), and duloxetine (Cymbalta) are a few.  Ironically enough there are some studies out there to show that depression itself can cause a decrease in blood pressure and treating depression an increase.

Keep in mind, these medications are not off the table for treating depression, your physician just may have to adjust your blood pressure medications while you are taking antidepressants.  Close monitoring, adherence to regimen and lifestyle changes can make this situation a lot better.

Ambien and _______ Do Not Mix

Have you ever had the rare opportunity to have ambien (zolpidem) prescribed to you and experienced how quickly this medication takes effect? According to pharmacokinetic properties of this medication, zolpidem is rapidly absorbed after oral administration. Peak medication effects of the immediate-release tablet occur within 90 minutes of a single oral dosage. In single-dose studies in subjects administered 5 mg and 10 mg zolpidem, the mean peak concentrations (Cmax) were 59 (range: 29—113) and 121 (range: 58—272) ng/ml, respectively, occurring at a mean time (Tmax) of 1.6 hours for both strengths. The presence of food reduces the amount of absorption and increases the time taken to achieve maximum concentration, delaying sleep onset. Therefore all formulations of zolpidem should be taken on an empty stomach versus after a meal... unless of course you are out driving then by all means eat first, or do the right thing and don't take ambien and drive!

This medication has now been implicated in a car crash two weeks ago, when Kerry Kennedy, the daughter of Robert F. Kennedy, swerved into a tractor-trailer on New York's Route 684 and kept driving. Witnesses said she had been weaving in and out of lanes for miles before the accident.

Toxicology reports showed 14 nanograms per milliliter of zolpidem in Kennedy's blood, according to the Associated Press. Both her blood and urine samples were negative for alcohol or other drugs.

Police found Kennedy slumped in her white Lexus on the morning of July 13, according to Reuters. She was unsteady on her feet and slurring her words. Initially she told police she may have accidentally taken the sleeping aid earlier that day, mistaking it for her thyroid medication.

At a court appearance July 17, she pleaded not guilty to a charge of drunk driving and said the hospital where she was treated found no trace of drugs and doctors had suspected a brain seizure. She is due back in court Aug. 14.

In 2006, her cousin Patrick Kennedy, the former congressman from Rhode Island and the son of the late Sen. Edward Kennedy, was sent to alcohol and drug rehab, after crashing his car while on Ambien in Washington, D.C.

Ambien is a sedative-hypnotic that works by slowing activity in the brain, according to the National Institutes of Health. It is prescribed for those who have difficulty falling or staying asleep. It's meant to be taken immediately before bedtime and its effects last about seven to eight hours.

Sometimes patients can experience memory problems on awakening. Some have reportedly taken Ambien, left their bed and driven cars, prepared and eaten food, had sex or made phone calls while under the influence of the drug and not fully awake, according to the Food and Drug Administration.

The drug has a risk for anterior-grade amnesia, as well, according to Doering. "Memory never burns from RAM to ROM."

"The things that happen to a driver can be very scary," he said. "You are in a state where you are dreaming, but you are not quite sure whether you are awake or dreaming."

Legal Euthanasia: a discussion

I use the term "discussion" lightly when referring to this topic, but in 2002, the Netherlands became the first country to legalize euthanasia as an option for patients who were terminal.  The practice had been taking place since the 1970s, but finally it was signed into law.  There were strict laws and licenses that must be in place for it to take place, and Dutch doctors had a long list to check. Patients must be adults.  There must be suffering.  There must also be no other alternative for the patient.  A second doctor must be consulted to concur with the desires of the patient and the conclusion of suffering and terminal disease.

Christians immediately have thoughts of suicide and how this is a sin.  We classify life as human and it is wonderful that someone took their beloved pet to the vet to end their life humanely.  I did this for my dog, and I can say, it was the most amazing experience to know that he was in my arms and that I did not allow him to suffer as he would have in the last maybe two days of his life.  But wait.  He was a DOG.  We are different, or are we?

I know that personally there was a young lady that I met through one of my jobs years ago.  She was in her twenties, had never been married and had no children.  She had an older boyfriend.  She had been diagnosed with breast cancer and had waited a little too long on having a double mastectomy.  She did not have clean borders of the tumor.  The cancer had spread, and she had gone through many rounds of chemotherapy and radiation.

By the time she became my patient as a home infusion pharmacist, I was intrigued by her case.  Her age (she was four years older than me), her name (we had the same initials), and the thought of how she would probably never marry and definitely never have her own biological children.  I knew she was terminal based on the pain pump I was in charge of filling and keeping running for her so she would be in no pain during the months of her life.

We spoke on the phone weekly, sometimes two to three times a week.  She was always upbeat and positive, and after ten years, I can still hear her voice.  She was going on a trip to Florida with her boyfriend and wanted to jet ski in the ocean. She wanted to take her pain pump with her and jet ski.  We made it happen.

And now years later, The Lancet releases an article basically saying legalizing has not added more cases of euthanasia in  Netherlands.

The introduction of legalised euthanasia in the Netherlands has not led to an increase in the number of cases according to a team of Dutch university researchers, writing in The Lancet magazine.

While there was a slight decrease in the years after euthanasia was made legal in 2002, assisted suicide has now returned to pre-legalisation levels of around 2.8% of all deaths, the researchers from four Dutch teaching hospitals and the national statistics office CBS found.

And while opponents of euthanasia had warned the legislation would lead to a sharp rise in involuntary euthanasia among terminally-ill patients, there has actually been a reduction in this sort of deaths, professor Bregje Onwuteaka-Philipsen from Amsterdam's VU university told the Volkskrant.

Based on interviews with 6,000 doctors and research into 7,000 deaths, the team found just 300 cases of euthanasia where the patient had not given explicit consent in 2010, compared with around 1,000 in the years prior to legalisation.

Openness

'This is probably because there is more openness and doctors talk to their patients at an earlier stage,' Onwuteaka-Philipsen told the paper.

The researchers also found some 600 people forced an end to their own lives in 2010 by stopping eating and drinking. In around half of these cases, euthanasia had been refused.

Euthanasia is legal in the Netherlands under strict conditions. For example, the patient must be 'suffering unbearably' and the doctor must be convinced the patient is making an informed choice. The opinion of a second doctor is also required.

Although it's not legal in the US, believe me, it sort of goes on.  It is an unspoken way to die or at least comfort in the very very end.  I know that my patient "BB" went peacefully.  I know that there were many times she kept urging me to come meet her.  I was leery because I knew that I was already attached. Her pump would beep for whatever reason, she would call me.  I had specific orders from the oncologist that I could basically freely increase her dilaudid based on her pain level.  There was a trust thing between the three of us.

I finally did go meet her.  She was laying in bed at 33 years old with just a little bit of time yet.  Her sweet family brought out pictures of her before the cancer changed her so much.  She was beautiful.  I just hope to see her again, shake her hand (or hug her) and tell her how much of an impact she had on my life.  She missed out on so much yet she impacted others in ways she probably never knew.

What does this have to do with euthanasia?  I believe that it should be legal.  It's humane.  No one should have to suffer today.

Memorization, the Power of Mnemonics

Now that I have committed to the large mental task of taking on the BCPS exam, I'm finding memorization for the sake of memorization to be lacking. Rather than waste the moments I have studying repeating over and over what organisms doxycycline covers, I've started creating this microorganism world mentally that will connect all aspects through the use of mnemonics. Another technique I've debated is the use of songs. But creating songs still requires more memory time. Oh, and a different part of the brain.

Three things: association, memorization, and location. So, for example let's say that we want to memorize community acquired pneumonia (cap). I imagine a room full I healthy men wearing caps and their choices are a macrolide or doxycycline. To memorize the macrolide I imagine them with macro lenses (macrolide) and they are shooting pictures of dachshunds on cycles (doxycycline). They have no other illnesses going on, and the treatment is at least five days.

See the technique? Men wearing caps, no other underlying illnesses to interfere with shooting macro images of dachshunds on cycles.

You may never forget it! Or at least I hope I don't come October.

Google mind maps to gain more information about these techniques!

Aeromonas Hydrophila

CNN LINK: So I had to embark upon understanding this flesh eating necrotizing fasciitis causing bacteria that has the life of Aimee Copeland on hold and on a ventilator in a hospital in Augusta, GA.   Only 24 years old, Aimee fell from a zip line and had a gash in her leg that was stitched up only to return to an ER a few days later with a bigger issue.  Necrotizing fasciitis.

Aeromonas hydrophila is a heterotrophicGram-negative, rod shaped bacterium, mainly found in areas with a warm climate. This bacterium can also be found in fresh, salt, marine, estuarine, chlorinated, and un-chlorinated water. Aeromonas hydrophila can survive inaerobic and anaerobic environments. This bacterium can digest materials such as gelatin, and hemoglobinAeromonas hydrophila was isolated from humans and animals in the 1950s. This bacterium is the most well known of the six species of Aeromonas. It is also highly resistant to multiple medications, chlorine, and cold temperatures.

Because of Aeromonas hydrophila’s structure, it is very toxic to many organisms. When it enters the body of its victim, it travels through the bloodstream to the first available organ. It produces Aerolysin Cytotoxic Enterotoxin (ACT), a toxin that can cause tissue damage.

Most of the time, this organism causes gastroenteritis.

Aeromonas is usually found in freshwater and marine environments; it is most prominent in the Northern Hemisphere during the warmer months. The skin of the lower extremities is the most common site of infection, usually after traumatic exposure to contaminated water or soil. Aeromonas infection and cellulitis often develop within 8 to 48 hours of exposure, and systemic signs are common. Manifestations may include hemorrhagic bullae, subcutaneous bleeding, and purpura.

Aeromonas is typically highly susceptible to penicillins combined with β-lactamase inhibitors, second- and third-generation cephalosporins, aminoglycosides, and fluoroquinolones.

When patients do not respond to antibiotics for presumed common cellulitis, it may be prudent to obtain further imaging such as CT or MRI of the affected limb to rule out soft tissue collections, soft tissue emphysema, and necrotizing fasciitis. Surgical debridement may be indicated for deep soft tissue infection, necrosis, and purulent collections that are inadequately draining.

I do hope Aimee makes a full recovery.  You can follow here progress here.

Depakote and Abbott's $1.6 Billion Mistake

Abbott never had FDA approval to promote Depakote for aggression and agitation in the elderly or schizophrenia. The total includes a criminal fine of $700 million and civil settlements with the states and federal government totaling $800 million. Abbott pleaded guilty to a criminal misdemeanor for misbranding the medication. Abbott is also going to pay 45 states $100 million to resolve liability with consumer protective laws. Luckily the Justice Department found no deaths due to this crime.

The company admitted that from 1998 through 2006, it "maintained a specialized sales force trained to market Depakote in nursing homes for the control of agitation and aggression in elderly dementia patients, despite the absence of credible scientific evidence that Depakote was safe and effective for that use," the Justice Department said in a news release.

"In addition, from 2001 through 2006, the company marketed Depakote in combination with atypical antipsychotic drugs to treat schizophrenia, even after its clinical trials failed to demonstrate that adding Depakote was any more effective than an atypical antipsychotic alone for that use."

Heaphy said Abbott earned about $13 billion from Depakote sales during the period investigated, but he said it was difficult to determine how much of that was the result of sales for illegal purposes. He expressed confidence that, once the fines are factored in, Abbott will not have profited from the improper practices.

Um... Ok. $13 billion minus $1.6 billion equals a profit.

No wonder this will keep happening.

Stroke and Prozac

Stroke victims who took the antidepressant Prozac for three months following the interruption of blood flow to the brain regained more mobility, and showed lower rates of depression, than those given a placebo pill, a new study has found. Of course, just as many other explanations, the clinical efficacy is unknown. The FLAME trial (short for Fluoxetine for Motor Recovery After Acute Ischemic Stroke) holds out an option for patients who do not reach the hospital quickly enough to receive clot-busting medication, and who lose movement or feeling in the during stroke. It found that after three months, subjects who took the antidepressant fluoxetine scored, on average, 10 points better on a 100-point measure of mobility and sensation than similarly affected subjects who took a dummy pill. Study here.

Shivers, Zaps, and Shocks... Part Two

I've had over 200 comments on a post I had three years ago. Back then, I was super frustrated with the side effect from withdrawing from commonly prescribed SSRIs, etc. Has much changed in tapering down these meds for the patients I am in contact with? No. But, I have been able to share the experience with others and in my own case have found that the shocks resolved on their own. I have never felt that way again, but at the same time you won't see me jumping up and down for joy for venlafaxine or duloxetine. I have no respect for the drugs and when filling the medications will actually have some four letter words pass through my thoughts. I would like to hear from those that commented all those years back. Are the zaps gone? Have you seen it with any other medication?

Are You Kidding Me?

My mouth just dropped open.  It's obvious to me that physicians do NOT read medication reconciliation forms for home meds at all.  The ones that do, kudos, but the ones that don't make my job more interesting and at times really get to me. Case-in-point:  50-something presenting to the hospital with lower GI bleed.

The doctor signed off to CONTINUE HER HOME MED OF PHENTERMINE FOR WEIGHT LOSS.  Are you kidding me?

I guess the nurse could have written "Purina Dog Chow - take one cup by mouth daily" and the physician would have signed off on it.

Way to go Joint Commission on putting in a requirement with no means of adhering to any sort of THINKING for anyone involved.

Except for the pharmacist of course to wade through the BS and find what is really needed.

I really like the one where the physician wanted to continue the patient's viagra while in the hospital.  THAT should keep the nurses on the floor on their toes running from a man who is looking for some fun.  Not good.

Medication reconciliation forms.  The bane of my existence.

Accutane and Side Effects

One of the news programs at night had a documentary on a murder that happened where the perpetrator had mental issues and had taken a few doses of accutane prescribed by a doctor a few years earlier.  He promptly discontinued the drug after experiencing headaches, etc... but spent the next few years on a message board ranting about the drug and ultimately tracked down the doctor that prescribed it and murdered him. If I remember correctly, the guy only took two days of it.  Having taken accutane myself for 6 months in 2000, I realize that there are some nasty things about accutane that have made it a very controlled drug as far as obtaining it.  But, for me the drug was very useful.  In my case, I had severely oily skin not so much acne.  What accutane did was to shrink my oil glands a bit.  I don't struggle in the same way but maybe being a pharmacist helped the dermatologist treating me (same age as me in fact) collaborate on a "cure" for what I was trying to accomplish.

When I saw the news last night showing this young man in his twenties literally having a psychotic breakdown, I could see how perhaps accutane could have had some role, but at the same time the murderer already had a history of mental illness.  Perhaps accutane and the doctor that prescribed it were merely a part of his obsessions with his instability.  I shudder to think that he could have included the pharmacist that filled the medication.  Luckily somehow, that person fell out of the loop.

Here's the link to the family's website about their murdered father (physician).

Here's a link to write a letter for the murderer to be extradited back to the US to face charges.