Sunday, September 27, 2009

About that drug interaction thing.

So... remember how my doctor prescribed me both Savella and Ultracet? And remember how after looking it up I was all, nuh uh, no way that doesn't make sense? And how when I questioned him on it he was all, oh no really it's fine? And how when he said that I was all, uh, what are you talking about that's crazy I'm still not taking it?

Well. You're gonna love this.

Now, let's back up just a lil' bit. When I started on the Savella, I didn't have a prescription for it. Why? Because I needed to do a titration, gradually easing up to my full dose. For this, the drug company that makes Savella is kind enough (ha ha) to provide docs with sample packs. So after the visit where he prescribed both drugs, I filled an Rx of Ultracet, but *not* of Savella.

OK. So fast forward one month. I've been taking the Savella, have figured out I should NOT also be taking the Ultracet (and subsequently have not taken a single pill; still have the entirel bottle of SIXTY sitting in my nightstand drawer), and have had the second visit to the doc wherein I question him and get confusing answers. He has now written me an actually scrip for Savella so that I can continue taking it, because it seems to be working for me. I head to the drugstore.

Well, you know, drugstores do this thing, right? For people like me, who take lots of different medications. They check for drug interactions. And wouldn't you know? They see that they've already filled me up this bottle of 60 Ultracet, and then here I am waltzing in asking for Savella. RED ALERT! RED ALERT! MAJOR DRUG INTERACTION! Basically they tell me that unless they speak with my doc (or, given that of course it's Saturday, because when the hell else do I have time to go to the drugstore? at least the on-call guy) there is no way on god's green earth that they are giving me these pills.

How did I feel at that moment? Well. Unlike the SNAFU with my birth control pills the other month, where my rage was split between Walgreens and my health insurance company, I felt (feel) that this particular event sits squarely on the shoulders of one person. And that person is my doctor! Not only did he tell me to take these drugs together. But he continued to tell me it was alright after I questioned him for a good five minutes on it, explaining to him everything I'd found to the contrary! And fine, OK, the internets is not always the most valid source. But I think this little drugstore experience is proof enough that I was right and he was wrong. And fer serious, I don't want that to ever be the case between me and my doc when it comes to the medication he's prescribing me! It is, to say the least, unnerving.

You'll want to know how it worked out, eh? Well, it goes like this. At the Walgreens pharmacy, you basically have two kinds of people. There are the "pharmacy techs" who work the counter and essentially read the script. So when the kid I was talking to saw the interaction problem on his computer screen, the little light blinked on in his head, and he said "Oh there's a drug interaction we can't fill the prescription until we speak with your doctor." I explained to him that I'd figured it out for myself, that I hadn't taken even a single pill of the Ultracet, and that anyway clearly my doc wasn't in as it was Saturday. I got back: "There's a drug interaction we can't fill the prescription until we speak with your doctor." I asked if I could just have four pills to get me through till Monday, because if I stopped taking them suddenly it would make me sick. I got back: "There's a drug interaction we can't fill the prescription until we speak with your doctor." Ahh, corporations.

Don't get me wrong. He was a nice kid, and I'm sure he would have liked to help me. But assuming he had the mental ability to find a way to help me, company policy had done everything in its power to keep him from doing so.

Luckily, there is a second type of employee at the Walgreens pharmacy: actual pharmacists. When they choose to, they can think and make judgment calls. Front counter robot man started trying to get an on-call doctor on the phone, but by that time the pharmacist on staff was already on hold doing the exact same thing. She finally got one of the sort of operator people on the line and left a message, which was a bit of a trial - clearly these folks are used to taking restaurant reservations or something, because she had to say "serious drug interaction" about six times.

When she was done on the phone I sort of flagged her down. I told her what I'd told the kid at the counter, as he clearly had not done so: that I had figured out the problem for myself and hadn't taken any of the Ultracet. Her eyes sort of brightened. "You haven't taken any of it?" She filled the prescription.

She told me in no uncertain terms that I was NOT to take ANY of the Ultracet EVER while still taking the Savella. She even wrote it on on the bag: DO NOT TAKE WITH TRAMADOL!

So people, if you're reading this and have been taking these drugs together and having nasty side effects, please please please call your doctor right now. This is nothing to mess around with. This can cause Serotonin Syndrome, which always makes you quite ill and in its most severe instances can actually kill you. Medications are serious stuff and should always be approached carefully. Doctors, clearly, do NOT always know what they're doing. They have drug representatives shoving things down their throats, and in turn they shove things down ours. There is so much on the market these days - I imagine that even for the most conciencious docs it's very difficult to keep up with, and most of us real sickies have more than one doc anyway. Which is precisely why drug stores check for interactions in the first place.

Take care. And always look up your medications before you take them.


Sunday, September 20, 2009

How am I doing on Savella? An update.

It was pointed out to me that I left y'all hanging as to how it's going now that I've reached the full 100mg dose of Savella. I've been on it full fledged for almost two weeks now, and I seem to be doing... pretty well. The terrible fatigue I was having seems to have petered out, despite the fact that I working like a madwoman. In fact, yesterday after (9 hours of) work I went out! Like, into the city, with people, to be social! Can you believe it? I kind of can't.

As far as pain goes, well, I'm not running any marathons or anything. I'm not a whole new person. Last weekend I was having some pretty terrible sciatica - possibly backlash from having stretched for many days in a row like a good little girl and then abruptly stopping the stretching because work overwhelmed me? Hard to say. I actually didn't leave the house the whole weekend, because that particular type of pain makes walking, well, a real pain. :P BUT. I seem to be back to a manageable baseline, which is always and forever the goal. I have been back to work for three weeks now and haven't had to call in, have barely even been late. Is that because of the Savella? Who knows. Maybe. It's not making things worse, though, which is a relief, and it might be helping.

I'm actually sort of excited about something that I noticed happening on Saturday. I woke up (early - about 8 - that's been happening lately) and wanted to get up and do things. I cooked an apple cinnamon oatmeal breakfast from scratch. Simple but very yummy. Then I spent a few hours blogging. Then I dragged Jonathan into the city, and kept him out all day: we checked my P.O. box on 14th street, had lunch and mid-day dessert in Brooklyn, stopped by Union Square, and went to Bed Bath and Beyond and got a crock pot which I'm super excited about! But really. We were out all day. That's something we haven't been able to do in quite a while; a huge change for me, and a change for the better in a big way. And I can't help but feel that it has something to do with having a more appropriate level of serotonin in my brain...

I have some updates for you about taking Savella (milnacipran) and Ultracet (tramadol) together, but that can wait for a minute. Suffice it for now to say, please don't do it!


Saturday, September 19, 2009

Umm... OK... Umm...

Alright. So back in mid August, my doc put me on Savella. As we know, Savella is an SNRI - Serotonin and Norepinephrine reuptake inhibitor. During the same visit he prescribed a drug called Ultracet for pain. I'd not heard of it before. I did not start taking it immediately, because I never start two drugs at one time: if something is messing with me, I want to know which one it is.

Well, a few weeks went by, and I got curious about the Ultracet. Now, before I take anything these days I generally look it up on tha internets. Well, I looked up good ol' Ultracet and what did I find?

GENERIC NAME: tramadol and acetaminophen

BRAND NAME: Ultracet

DRUG CLASS AND MECHANISM: Ultracet is a combination of two drugs, tramadol (Ultram) and acetaminophen (Tylenol), that is used to relieve moderate, acute pain such as pain following dental or surgical procedures. Tramadol and acetaminophen each relieve pain, but they do so by different mechanisms. Tramadol achieves pain relief in two ways. It binds to the ยต-opioid receptor on nerves (the same mechanism that is responsible for the effectives of narcotics, such as morphine), and it also inhibits the reuptake of serotonin and norepinephrine by nerves. This inhibition may lead to reduced transmission of pain signals through the spinal cord to the brain. Acetaminophen achieves pain relief in the spinal cord and brain by increasing the threshold to pain, that is, by increasing the strength of the painful stimulus that is necessary in order to give rise to the sensation of pain. It does this by inhibiting an enzyme that makes prostaglandins. Ultracet was approved by the FDA in 2001.

Mmm. OK. Color me concerned. So explain to me exactly how it is that it's OK for me to be taking this with Savella? It's in the same drug class! The tiniest amount of research into these drugs will tell you that you have to be careful to avoid what's called Serotonin Syndrome - wherein you effectively achieve overkill and end up with too much serotonin, making you quite ill and in rare instances causing death. Well, a little more poking showed that somebody (or somebodies) doesn't think it's OK at all to be taking these two drugs together.

tramadol ⇔ milnacipran

Major Drug Interaction

Applies to: Ultram (tramadol) and Savella (milnacipran)
GENERALLY AVOID: Due to its serotonergic activity, coadministration of tramadol with serotonin-enhancing drugs such as SSRIs, SNRIs, nefazodone, trazodone, and mirtazapine may potentiate the risk of serotonin syndrome, which is a rare but serious and potentially fatal condition thought to result from hyperstimulation of brainstem 5-HT1A and 2A receptors. Symptoms of the serotonin syndrome may include mental status changes such as irritability, altered consciousness, confusion, hallucinations, and coma; autonomic dysfunction such as tachycardia, hyperthermia, diaphoresis, shivering, blood pressure lability, and mydriasis; neuromuscular abnormalities such as hyperreflexia, myoclonus, tremor, rigidity, and ataxia; and gastrointestinal symptoms such as abdominal cramping, nausea, vomiting, and diarrhea. Patients receiving tramadol with serotonin-enhancing drugs may also have an increased risk of seizures due to additive epileptogenic effects of these agents. MANAGEMENT: In general, the use of tramadol in combination with highly serotonergic agents should be avoided if possible, or otherwise approached with caution if potential benefit is deemed to outweigh the risk. Patients should be closely monitored for symptoms of the serotonin syndrome during treatment. Particular caution is advised when increasing the dosages of these agents. The potential risk for serotonin syndrome should be considered even when administering serotonergic agents sequentially, as some agents may demonstrate a prolonged elimination half-life.

Eyeah. OK, so in the span of three minutes my doc prescribed me two drugs that I'm clearly not supposed to be taking together, and told me to take both twice a day! This, to say the least, makes me uncomfortable. And given how slowly I had to ease onto a full dose of the Savella (and that even that made me ill every time I went up a few mg's), I can't imagine how sick it would make me to just start popping these pain pills. I've found several boards with many people discussing how taking these two drugs together made them ill enough to miss work, with all the symptoms I'm familiar with - nausea, dizziness, shivers...

Well, I saw my doc this Thursday for a follow-up on the Savella. I told him what my experiences have been with it. And then I mentioned what is clearly this drug interaction problem.

And he said that it's fine! That there's really no problem with taking both of them! What? I'm sorry but that just doesn't make any sense. On this drug I'm not even supposed to take herbal supplements that affect my serotonin level, and here he's saying that a prescription drug that does so is just peachy? I told him it makes me uncomfortable to take it and asked if there's anything else he can give me for pain, but we've basically run out of things that aren't narcotics or anti-inflammatories that destroy my stomach.

So, yeah, I'm frustrated, and confused, and my faith in my doc has slipped a further notch. Kinda sucks. A lot.

Any words of wisdom would be appreciated.

Sunday, September 13, 2009

A marathon, not a sprint.

It's been a long week. When I went back to work after a short hiatus, I went with a conviction that I would work a normal, 7 hour work day (9 to 5 minus an hour lunch). Well, two hours into my first day back I could see that doing such a thing would be far more stressful than just working a bit extra each day, getting a little more done, and having less to come into each morning. So I (mentally) capped it at 9 hours - of actual work, that is.

Well, I've mostly stuck to that. It's largely been without a lunch of any sort, which is fine with me because my appetite has been funny, and Midtown Manhattan is the most boring place ever anyway. Plus it makes the day shorter overall. Friday was a ten hour day - just wanted to wrap things up so I could not worry about them over the weekend, you know?

The main problem with working this way is that it takes such a bite from my life. I get home at six, seven, eight with nothing left. But I still have to deal with the aches and pains of the day, with figuring out what to do for dinner, with the rest of, well, life. And still, the temptation is there - because I'm an effing workaholic - to work even more.

So I have to keep reminding myself that it's a marathon, not a sprint. I actually can't get to the end of it. I could work 12 hours a day for a month, and I sure would land myself in bed for a week, but I wouldn't get to the bottom of the pile on my desk. Because there is no bottom. It's an endless stream. Like dust - no matter what I do there will always be more.

I don't know why this is such a hard thing for me to absorb. I know I'm not alone - many of us have this disease of "it must be done NOW!" And we would all do well to get the hell over it. Anyone who wants to tell me that my 45 hour work week isn't good enough can bite me. I produce plenty of work product in 45 hours, and I'm quite good at my job: these are the facts I must remember.

Still. Am I working this weekend? Yes, yes I am. But from home, and only a little...

Friday, September 4, 2009

Adjusting to Savella... well, hopefully I will.

I've been on this new medication for almost two full weeks now. Based on the setup of the titration pack, I should have been up to 100 mg after the first week. To that I say, hell no. I'm sensitive to new drugs, particularly to those that act on neurotransmitters. (For those of you just joining in, Savella is an SNRI.) My doc gave me two packs, to get me through a month, and I'm using them as gradually as I can calculate. Here's my schedule:

Day 1: one 12.5 mg pill in the evening
Days 2 and 3: 12.5 mg pills morning and evening
Days 4 through 6: 12.5 mg pill morning, 25 mg pill evening
Days 7 through 9: 25 mg pills morning and evening
Days 10 through 14: 25 mg pill morning, 50 mg pill evening
Days 15 and 16: 37.5 mgs in morning, 50 mg pill in evening
then to 50/50, which should be the top dosage.

A little crazy you say? Well maybe. But I'll tell you, if I was doing it any other way I don't know that I'd still be functioning. As it is I'm feeling the drug acutely. How do I know it's the pills and not just my normal crap? Well, because this isn't my first trip down the neurotransmitter brick road. The hot-but-cold, the crawling scalp, the I need to close my eyes RIGHT NOW fatigue - I know these feelings. They appeared the day after my first dose, and they've increased with each increased dose but then subsided, like a tide. So while I'm confident of their provenance, I'm also hopeful that my body will adjust - that they are not a permanent feature of my heavily medicated life.

I'm currently on day 12 - for the past two nights I've taken a full fledged pill. And oh my. Last night after work and then therapy, I fell asleep at 10pm on the couch. There was no more awake to be had. Today, my office closed early, and my god was I thrilled. Sweet relief for my aching brain. I've been home for a bit over an hour, and bed is calling my name for a late afternoon nap.

I knew that this would be a difficult adjustment. And really it hasn't been as bad as it could be. I'm anxious of what a full 100 mg dose will bring, but I can only hope that my slow approach will cushion the blow. I keep trying to remind myself that these side effects are still nowhere as debilitating as the pain that keeps me tethered to bed, and that this is all for the greater (long term) good. So here's hoping it does some.

Wednesday, September 2, 2009

Back to work OMG.

So, I started back to work on Monday. And it's been freakin' insane. I still have 70 emails in my inbox that I haven't gotten to look at, because all day long for the past three days all I've done (for nine hours each of those days, mind you) is put out the immediate fires. It's completely exhausting. But the surprising part is, it's alright.

I was extremely nervous about going back - to the extent that on Sunday night I had a few little breakouts of hives. But there doesn't seem to be any resentment that I took the time. Everyone just seems thrilled to have me back... and more than happy to pile on the work.

I had planned to only work a standard workday, which at my firm is a typical 9 to 5 minus an hour lunch. But a couple of hours into Monday it was obvious that that wasn't going to work. So I'm not jumping back into my ten to eleven hours, but I am capping it at nine. So far I haven't had to butt heads about it, thankfully. Stress-inducingly enough, there's a small chance that one of my cases might go to trial next week. Keep your fingers crossed that everyone settles - I do *not* have it in me to keep a trial schedule right now.

So yeah, I'm totally exhausted. Monday and today involved evening napping. But the part I'm excited about is that I'm getting through the days, and I feel alright! I don't feel fabulous or anything, but it also doesn't feel like I'm pushing on the verge of breaking, like it did before I took the break. I'm hoping that maybe tomorrow or Friday can be semi-normal, instead of an endless stream of emergencies. That's probably just a pipe dream, but you can't keep a girl from wishing. Either way, a three day weekend waits at the other end, and I'm through the better part of my first week back to work.