Digestive Health Newsletter

Staying on Medication - Your Health Depends On It

Stephen B. Hanauer, MD

Volume 1, 
February 01, 2004

by Stephen B. Hanauer, MD

Stephen B. Hanauer Stephen B. Hanauer, MD is Professor of Medicine and Clinical Pharmacology at the Pritzker School of Medicine of the University of Chicago. He is also Director of Inflammatory Bowel Disease Research Center. Dr. Hanauer is internationally recognized for his research, teaching, and patient care in the inflammatory bowel diseases (IBD), including ulcerative colitis and Crohn's disease. Dr. Hanauer shares his thoughts here on the importance of patients taking their medications for IBD.

People being treated long-term with medications for chronic diseases, such as inflammatory bowel disease (IBD), often don't like taking their medicine. You may feel like it's a constant reminder that you have a disease. It can be hard to remember to take medicine, especially when it is inconvenient. You may feel like there are too many pills and worry about side effects or the long-term consequences of taking medicine all of the time. You may not understand why you have to take medicine when you feel just fine, and you may want to take medicine only when you have symptoms. Other people share these same concerns. You're not alone. Approximately one million people in America have IBD. Many take daily medication to control symptoms. Millions of people need to take medicine everyday for other conditions too, sometimes several times a day. You probably have family members taking daily medication for high blood pressure, arthritis, or other conditions.

It's certainly understand-able to feel unhappy about taking medicine when you feel well, but continuing to take your medicine is one of the most important steps you can take to stay well. When I ask my patients who are successful taking their medicine long-term how they do it, they tell me that they remind themselves daily that they are taking necessary steps to remain healthy and in control of their future.

Currently, there's no cure for IBD (ulcerative colitis and Crohn's disease) other than removing the colon for ulcerative colitis. Fortunately, we have medicines that do a good job treating the symptoms of IBD for most people. These medicines can improve the quality of your life. They can help you stay in school or go to work feeling well. They can help you maintain an active lifestyle and do the things you enjoy whether it's going to the movies or playing your favorite sport. These medicines not only treat active symptoms, they can also help prevent relapses. Without consistent treatment, relapses can occur more frequently and increase in severity. It's very important, however, to take the medicines just as your doctor has prescribed.

A recent study of IBD patients showed that people who did not take their medication properly were about 3 times more likely to suffer a relapse than those who took their medications regularly as prescribed. In another study, 12 patients experienced a relapse, but all 12 did not take their medicine properly.

IBD is a disease in which every patient may not experience the same symptoms. Not everyone needs the same dosage of medication, so don't change how you take your medicine because someone you know takes their medication differently. Medication is prescribed based on the symptoms you are experiencing. If you feel that you are taking more pills than you can handle or if you are having unpleasant symptoms, be honest with your doctor and ask if there's another way to take your medicine. Do not change how you take your medicine without talking to your doctor.

If you have questions about how to take your medicine, be sure to call your doctor. Your pharmacist may also be able to explain how to use the specific medicine your doctor has prescribed.

Sometimes it can be hard to tell the difference between a side effect and a symptom. It's important to keep your appointments and to honestly discuss your symptoms and the way you have been using your medicine with your doctor. Taking charge of your health by taking your medicine responsibly and communicating any concerns you have with your doctor before making any changes is essential to maintaining progress and preventing relapse.

If you have IBD, whether it's ulcerative colitis or Crohn's disease, it's likely that you are taking medication for treatment. Some medicines are used only when you have active symptoms and other may be used when you have active symptoms and when you are in remission (that is, you no longer have symptoms) but still need medicine to prevent a relapse.

Steroid compounds (such as Celestone®, Cortenema®, Cortifoam®, Cortrosyn®, Deltasone®, Entocort™, Medrol® and Pediapred®) and antibiotics (such as Cipro® and Flagyl®) are sometimes used when people have active symptoms. These are very potent medications and can have unpleasant side effects for some people.

Even though they are very effective, they can be harmful if not taken as prescribed. Steroids are not drugs that can be stopped "cold turkey." They must be tapered slowly. Just stopping them could cause very low blood pressure, irregular heart beats, and even shock. It could even be fatal. If you taper them too quickly you could experience very unpleasant withdrawal symptoms and your IBD could flare up. Don't attempt to taper yourself off of steroids without the assistance of your doctor. You may also have heard before how important it is to take all of an antibiotic prescription to prevent germs from becoming resistant to the medicine. It's true. If your doctor has prescribed an antibiotic, take all of it as prescribed.

The group of drugs called 5-ASAs (such as Asacol®, Azulfidine®, COLAZAL®, Dipentum®, Pentasa®, and Rowasa®) are very effective for people with mild to moderate ulcerative colitis. Some 5-ASAs are indicated by the Food and Drug Administration (FDA) for the treatment of mild to moderate ulcerative colitis with active disease only and others are indicated for active disease and in remission to prevent relapse. Relapse can occur sooner if you take your 5-ASA intermittently or discontinue it too soon. Keep in mind that it's easier to prevent a flare up than it is to stop one once it has begun. Of the 5-ASAs, Azulfidine is the oldest and has more side effects. If you've been taking Azulfidine and are experiencing unpleasant side effects, ask your doctor if you can try one of the others. The newer drugs in this class have fewer side effects and are generally well tolerated by most people.

If you are having trouble remembering to take your medicine, try to think of strategies that will help you remember. Here are some strategies my patients have used to help them remember:

It's also important to develop a system to make sure you do not run out of medicine.

Working closely with your physician to take charge of your wellness is vital to maintaining your health and reducing the likelihood of relapse. Faithful adherence to your medication plan can make a huge difference in your success. It can be the difference between repeated relapses and progression of the disease and feeling good most of the time. Your commitment to yourself is the key.

CCFAThis information has been reviewed and approved by CCFA's National Scientific Advisory Committee.

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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 WARNINGpdf

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 pdf

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.pdf

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 pdf

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