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Take As Directed: Getting the Most from Your IBD Medication

Peter Higgins, MD

Volume 27,

July 01, 2011

by Peter Higgins, MD

Uma Mahadevan

Dr. Peter Higgins received his bachelor's and medical degree from Duke University, where he also completed a Ph.D. in molecular cancer biology. He completed a fellowship in Gastroenterology at the University of Michigan in 2004 and an M.Sc. in Clinical Research Design and Statistical Analysis at the University of Michigan School of Public Health. He then joined the University of Michigan faculty the same year. Dr. Higgins currently serves as the inflammatory bowel disease editor for the American Journal of Gastroenterology. His research focuses on inflammatory bowel disease (IBD), including studies on patient-reported outcomes in IBD, medication holidays after long-term remission in IBD, and biomarker-guided therapy in IBD. Dr. Higgins' research interests are complemented by his clinical interest in improving the quality of care of patients with IBD.

Table of Contents

Introduction

Getting Organized

Partnering with Your Doctor

Filling and Refilling Your Prescription

Traveling with Medication

Conclusion

Introduction

When you have ulcerative colitis (UC) or Crohn’s disease (CD), taking your medication as directed can help reduce inflammation, relieve symptoms, maintain remission, and prevent flare-ups. Because there is no cure for inflammatory bowel disease (IBD), you will likely need long-term treatment. It is important to remember that taking your medication even when you are feeling well can lengthen your time in remission. This newsletter will provide tips about how to keep your IBD medication organized, partner with your doctor, fill and refill prescriptions, and travel with medication.

I take so many medications. How can I keep organized?

For starters, keep an updated list of all your medications and their dosages and frequencies. Be sure to share a copy of your current list with your physicians and pharmacist. This is important to avoid interactions between the different drugs you take. To help prevent mistakes, keep your medication in its original container (or use a pill box), and take care to read the label every time you fill a prescription, and check expiration dates monthly. Finally, quickly dispose of expired medication to eliminate confusion between new and old prescriptions.

How can I remember to take my medicine, especially when I’m in remission?

It can be challenging to remember to take your medication when you are in remission. Many people find it helpful to take their medication at the same time each day and to keep their medication visible, instead of hidden away in a cabinet. Pill boxes can help you organize daily doses, and you can program electronics, like your cell phone, computer, or watch, or use pill bottle reminder caps to alert you when it’s time for your next dose. It can help some people to group their pills into fewer (1 or 2) times per day. Discuss with your doctor whether you can group your medications into fewer times per day.

Where is the best place to keep my medication?

Typically, the best place to keep medication is in a cool, dry place. But always be sure to check with your pharmacist about any temperature or humidity requirements for your specific prescriptions. Ironically, you should avoid keeping medication in your bathroom medicine cabinet, since the heat and humidity in bathrooms can cause drugs to break down.

What is the best way to dispose of expired drugs?

There is no easy answer to this question, since proper medication disposal is an emerging environmental issue. Even experts and officials disagree about what should be done. First, check with your pharmacy and physicians, since some drug stores and clinics will take back unused medication. Also check with the local household hazardous waste facilities in your community. As a last resort, putting expired medication in the trash is safer than flushing it down the drain or toilet. Diluting medications by adding water to solid medications or flour to liquid medications helps reduce the risk of accidental poisonings of a child or pet. It is best to dispose of medications in a tightly sealed, preferably childproof, container.

What questions should I ask when my physician prescribes a new medication?

When your doctor writes you a new prescription, your instinct may be to grab the slip of paper and head for the door. But each time you are prescribed a new drug, it becomes your responsibility to have a clear understanding of what you are taking. Bring the following list of questions to your appointments to help guide the discussion.

What is the brand name and the generic name?
What is this medication for? What are the benefits? Out of 100,000 people like me, how many will actually get this benefit in 1 year?
What is the dosage? Is a dose increase often needed?
How long before I should notice improvement? How long should the improvement last? Does the improvement decrease with time?
Of the people who start on this medication, how many are still doing well on it at 1 year? Five years?
What is a reasonable time to wait before trying something else?
What side effects may occur? What should I do?
What should I do if I miss a dose?
What are the consequences of stopping this medication? Will I be able to restart this drug later if I do?
Are there any precautions I should take while on this medication?
What are the risks? Out of 100,000 people like me, how many will actually experience an adverse event in 1 year?
Is any testing/monitoring required? How often?
How should I store the medication?

I was just diagnosed with IBD and my doctor has already changed my medication several times. What’s going on?

Medicine is not an exact science, and it may take time for your physician to determine the best medication and dose for you. Some IBD medications require dose adjustment, and recent research has shown that some patients can benefit from combinations of medications. Finding the right dose and combination of medications for you can take time. By keeping a symptom diary, you can help your doctor track your progress as you try different medications.

What should I consider when buying prescriptions online?

A reputable online pharmacy will require a valid prescription from your doctor and should be licensed in your state or licensed to dispense medication to residents of your state. It will also have Verified Internet Pharmacy Practice Sites (VIPPS) accreditation. You can find a list of VIPPS online pharmacies at the National Association of Boards of Pharmacy Web site. Remember that purchasing medication from an illegal Web site puts you at risk of receiving contaminated or counterfeit (really!) medication or incorrect dosage.

How can I avoid pharmacy errors?

To avoid pharmacy errors, make sure you know the name, dosage, and prescribing instructions for every medication you take. When you pick up a new prescription at your pharmacy, compare the pills in the old and new bottles. The color, shape, and imprint(s) on the pills should be identical. If they are not, ask why.

How can I remember to refill my prescription?

Check to see if your pharmacy has a refill reminder program. If they don’t, be proactive—each time you get a new prescription, make yourself a note in your calendar or electronic device to refill it 2 weeks before you anticipate running out.

What should I think about when I have to travel?

When traveling, be sure to bring extra medication, as well as contact information for your physician and pharmacist, a list of all medications and dosages, and backup prescription(s) in case there are questions at the security checkpoint or your return trip is delayed. If you are traveling by plane, pack your medication in your carry-on luggage instead of your suitcase (x-ray scanning will not affect your medication), and pay attention to changes in time zones that will affect your dosing schedule. And if you are traveling outside of the United States, ask about medication equivalents, since brand names can differ by country. Finally, if you are traveling by automobile, don’t leave your medication in the car, since heat can rapidly destroy it.

What if I need to bring liquid medication that exceeds the Transportation Security Administration’s (TSA’s) 3-ounce limit?

If you are flying with 3 ounces or more of liquid medication, you must declare it to a TSA officer and keep it separate from the other items you submit for x-ray screening. TSA recommends, but does not require, supporting documentation, such as a letter from your doctor. They also recommend that the name on your medication match the name on your identification.

What is the best way to travel with injectable biologic medication?

In general, you should transport this kind of medication at the temperature of a refrigerator (36-46°F). If the medication freezes, or warms above 46°F, it is no longer stable and should not be used. To keep the medication at the required temperature, store it in a zip-top plastic bag in an insulated cooler with several ice (not gel) packs that are frozen solid. (Do not use dry ice, as this can freeze the medication.) Consider purchasing a small refrigerator thermometer (with a 30-50°F range) to track the temperature of your medication while you travel. Place the thermometer in the zip-top bag with your medication or tape it to the outside of the medication box.

Be sure to consider the complete travel time from your refrigerator at home to a refrigerator at your destination (including the possibility of delays), and make sure you have enough ice packs. Carry extra zip-top bags to pack with ice once your ice packs thaw, and think about where you will be able to get ice (e.g., in the airport, on the plane, or in a restaurant). Note that ice packs must be frozen solid, or TSA will not allow them on a plane. It is a good idea to test your cooler and ice packs at home without the medication, to determine how long it will maintain refrigerator temperatures. If the temperature reaches 43°F while traveling, you should already be looking for ice.

Conclusion

Failing to take your IBD medication as directed can be costly—both financially and in terms of your well-being. Remember that it is typically easier to keep your IBD under control than to get it under control. While it may be challenging to remember to take your medication regularly, you will find that the payoff—better health—is worth the effort.

If you found this article interesting, you may also be interested in our previous newsletters:
Volume 17: Bring Out the Best in Your Healthcare Team
Volume 16: Mind Your Meds – An Updated Review

Important Safety Information about AZASAN

WARNING: Chronic immunosuppression with this purine antimetabolite increases risk of neoplasia in humans. Physicians using this drug should be very familiar with this risk as well as with the mutagenic potential to both men and women and with possible hematologic toxicities. See WARNINGS section in complete Prescribing Information.

AZASAN® (azathioprine tablets) 75/100 mg is indicated as an adjunct for the prevention of rejection in renal homotransplantations, and also for the management of active rheumatoid arthritis to reduce signs and symptoms.The most commonly reported side effects associated with AZASAN therapy are leukopenia and/or thrombocytopenia, secondary infections, neoplasia, nausea, vomiting, diarrhea, fever, myalgias, skin rashes, and hepatotoxicity. AZASAN therapy should be given cautiously when used concomitantly with allopurinol, ACE inhibitors, and other agents affecting myelopoiesis. AZASAN is contraindicated in pregnant and lactating women and in patients who have shown hypersensitivity to this product.

Consult with your physician to see if this product is right for you.

Complete Prescribing Information for AZASAN, including BOXED WARNING

Important Safety Information about METOZOLV® ODT

WARNING: TARDIVE DYSKINESIA

See full prescribing information for complete boxed warning.

Treatment with metoclopramide can cause tardive dyskinesia, a serious movement disorder that is often irreversible. The risk of developing tardive dyskinesia increases with the duration of treatment and the total cumulative dose.

Metoclopramide therapy should be discontinued in patients who develop signs or symptoms of tardive dyskinesia. There is no known treatment for tardive dyskinesia. In some patients, symptoms may lessen or resolve after metoclopramide treatment is stopped.

Treatment with metoclopramide for longer than 12 weeks should be avoided in all but rare cases where therapeutic benefit is thought to outweigh the risk of developing tardive dyskinesia.

METOZOLV® ODT (metoclopramide HCl) is indicated as short-term (4 to 12 weeks) therapy for adults with symptomatic, documented gastroesophageal reflux disease (GERD) who fail to respond to conventional therapy and for the relief of symptoms associated with acute and recurrent diabetic gastroparesis (diabetic gastric stasis) in adults. Therapy should not exceed 12 weeks in duration. Take on an empty stomach up to four times daily, at least 30 minutes before eating and at bedtime.

METOZOLV ODT is contraindicated in patients with intestinal obstruction, hemorrhage, or perforation; pheochromocytoma; known sensitivity or intolerance to metoclopramide; epilepsy; or are receiving concomitant medications with extrapyramidal reactions.

Extrapyramidal symptoms (EPS), manifested primarily as acute dystonic reactions, occur in approximately 1 in 500 patients treated with the usual adult dosages of 30 to 40 mg/day of metoclopramide. These usually are seen during the first 24 to 48 hours of treatment with metoclopramide, occur more frequently in pediatric patients and adult patients less than 30 years of age and are even more frequent at higher doses.

Drug-induced Parkinsonism can occur during metoclopramide therapy, more commonly within the first 6 months after beginning treatment, but also after longer periods. Patients with a history of Parkinson’s disease should be given metoclopramide cautiously, if at all, since such patients can experience exacerbation of Parkinsonian symptoms when taking metoclopramide.

There have been rare reports of an uncommon but potentially fatal symptom complex sometimes referred to as Neuroleptic Malignant Syndrome (NMS) associated with metoclopramide. Clinical manifestations of NMS include hyperthermia, muscle rigidity, altered consciousness, and evidence of autonomic instability. The management of NMS should include immediate discontinuation of metoclopramide and other drugs not essential to concurrent therapy.

Depression associated with metoclopramide use has occurred in patients with and without a history of depression. For those patients with a prior history of depression, metoclopramide should only be given if the expected benefits outweigh the potential risks.

In one study in hypertensive patients, intravenously administered metoclopramide was shown to release catecholamines; hence, caution should be exercised when metoclopramide is used in patients with hypertension. Any rapid rise in blood pressure associated with METOZOLV ODT use should result in immediate cessation of metoclopramide use in those patients.

Since metoclopramide produces a transient increase in plasma aldosterone, patients with cirrhosis or congestive heart failure may be at risk of developing fluid retention and volume overload. If these side effects occur at any time in any patients during metoclopramide therapy, the drug should be discontinued.

Adverse reactions, especially those involving the nervous system, may occur after stopping the use of METOZOLV ODT.

In clinical studies, the most frequently reported adverse events (≥2% occurrence) were headache, nausea, fatigue, somnolence, and vomiting.

Complete Prescribing Information for METOZOLV ODT, including BOXED WARNING

Important Safety Information about OSMOPREP

WARNINGS

There have been rare, but serious reports of acute phosphate nephropathy in patients who received oral sodium phosphate products for colon cleansing prior to colonoscopy. Some cases have resulted in permanent impairment of renal function and some patients required long–term dialysis. While some cases have occurred in patients without identifiable risk factors, patients at increased risk of acute phosphate nephropathy may include those with increased age, hypovolemia, increased bowel transit time (such as bowel obstruction), active colitis, or baseline kidney disease, and those using medicines that affect renal perfusion or function (such as diuretics, angiotensin converting enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs], and possibly nonsteroidal anti–inflammatory drugs [NSAIDs]).

It is important to use the dose and dosing regimen as recommended (PM/AM split dose).

OSMOPREP® (sodium phosphate monobasic monohydrate, USP, and sodium phosphate dibasic anhydrous, USP) Tablets are indicated for cleansing of the colon as a preparation for colonoscopy in adults 18 years of age or older. Considerable caution should be advised before OSMOPREP is used in patients with severe renal insufficiency, congestive heart failure, ascites, unstable angina, gastric retention, ileus, severe chronic constipation, bowel perforation, toxic megacolon, gastric bypass or stapling surgery, or hypomotility syndrome. Use with caution in patients with impaired renal function, patients with a history of seizures or at higher risk of seizure, patients with higher risk of cardiac arrhythmias, known or suspected electrolyte disturbances (such as dehydration), or people taking drugs that affect electrolyte levels. Patients with electrolyte abnormalities such as hypernatremia, hyperphosphatemia, hypokalemia, or hypocalcemia should have their electrolytes corrected before treatment with OSMOPREP.

OSMOPREP is contraindicated in patients with a known allergy or hypersensitivity to sodium phosphate salts or any of its ingredients, and in patients with biopsy–proven acute phosphate nephropathy. In clinical trials, the most commonly reported adverse reactions (reporting frequency >3%) were abdominal bloating, nausea, abdominal pain, and vomiting. It is recommended that patients receiving OSMOPREP be advised to adequately hydrate before, during, and after the use of OsmoPrep.

For complete Prescribing Information for OSMOPREP including BOXED WARNING.

Important Safety Information about VISICOL

WARNINGS

There have been rare, but serious reports of acute phosphate nephropathy in patients who received oral sodium phosphate products for colon cleansing prior to colonoscopy. Some cases have resulted in permanent impairment of renal function and some patients required long-term dialysis. While some cases have occurred in patients without identifiable risk factors, patients at increased risk of acute phosphate nephropathy may include those with increased age, hypovolemia, increased bowel transit time (such as bowel obstruction), active colitis, or baseline kidney disease, and those using medicines that affect renal perfusion or function (such as diuretics, angiotensin converting enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs], and possibly nonsteroidal anti-inflammatory drugs [NSAIDs]).

It is important to use the dose and dosing regimen as recommended (PM/AM split dose).

VISICOL® (sodium phosphate monobasic monohydrate, USP, and sodium phosphate dibasic anhydrous, USP) Tablets are indicated for cleansing of the colon as a preparation for colonoscopy in adults 18 years of age or older. VISICOL is not to be used in patients with congestive heart failure, ascites, unstable angina pectoris, gastric retention, ileus or acute obstruction or pseudo-obstruction, severe chronic constipation, bowel perforation, acute colitis, toxic megacolon, or hypomotility syndrome. Use with caution in patients with impaired renal function, pre-existing electrolyte disturbances, or people taking drugs that affect electrolyte levels. VISICOL is contraindicated in patients with a known allergy or hypersensitivity to sodium phosphate salts or any of its ingredients. In clinical trials, the most commonly observed (≥1%) adverse reactions occurring with use of VISICOL were generally transient and self-limited and included nausea, vomiting, abdominal bloating, abdominal pain, dizziness and headache.

Consult with your physician to see if this product is right for you.

Complete Prescribing Information for VISICOL, including BOXED WARNING

The information contained on this page is intended for US patients, healthcare professionals, and pharmacists only.