Friday, October 12, 2012

(How to Avoid) Poisonings in Lupus Patients

Please excuse my having been AWOL from the blogosphere recently. My current Master's program is rather intense. By "rather intense" I mean "new classes start every eight weeks." Yikes. That being said, this term I've been taking an injury-prevention class. "Injury" as a public health term includes poisonings, as well as more traditional injuries, and the class has made me realize how easy it would be to accidentally poison a lupus patient like yours truly. We are on so many different medications, some of which can interact with each other, that it seems a miracle that more of us are not going the way of Anna Nicole Smith, Heath Ledger and Amy Winehouse.

In order to prevent lupus patients from becoming the newest "accidental poisoning" victims, I've compiled a list of some of the more obvious dangers, and how we can avoid them. This is by no means a comprehensive list, by the way. If you're ever unsure about medications, ask your pharmacist! That's what (s)he is there for, and I always enjoy a good round of "Stump the Pharmacist."

Tylenol/Paracetamol/Acetaminophen (depends where you live):
   As odd as it is to think of this common over-the-counter drug as dangerous, it can actually be a potent liver toxin. You only need to exceed the recommended dose by a relatively small amount to put yourself in real danger of liver failure. Why do I pick on this drug for lupus patients? I mean, we all know that it's just a sugar pill when it comes to pain control. Yes, but at least for me it's a dietary staple when I'm running my weeks-long fevers. I count the hours until I can take it again, as the fever normally returns an hour before the next dose is due. Also, there are a few things that some people may not be aware of that make it easy to overdose on this drug.
  1. Tylenol comes in many different doses. Normal Tylenol is generally 325 mg. Extra-Strength is 500 mg. Extended-Release Arthritis pills (my personal favorite) are 625 mg. What does this mean in non-geek? Taking two ordinary Tylenol will give you roughly half the dose of two Arthritis Tylenol pills. So if you're used to taking one variety, it's easy to accidentally take a very different amount of another.
  2. Tylenol is hidden in some prescription painkillers. Vicodon 5/500, for example, has 500 mg of Tylenol. So if you take two vicodon as prescribed, and then take a couple tylenol, you've probably just given yourself an overdose.
  3. Tylenol + alcohol = bad idea. Tylenol and alcohol both end up in your liver. Your liver, fine organ that it is, can generally deal with either one, assuming you don't overdose. However, if you throw both drugs at it at the same time, it can become overwhelmed and start to fail. Take the warnings on the box seriously: do not mix tylenol and alcohol.
  Most of us know this drug. It is a chemo drug often used to treat lupus. And, as anybody who has ever taken this medication knows, it is innately poisonous. That's the point, really. It is supposed to poison enough of your immune system to keep the system from killing your body, but not poison the rest of the body. Of course it does poison other parts of the body, but most doctors (who aren't taking mtx) feel that a little bit of systemic poisoning is worth knocking down our kamakazi immune systems. And they're probably right, although it's hard to agree with them the day after the weekly dose. There are some ways to either increase or decrease your risk of poisoning with methotrexate, though:
  1. This is a once a week drug, NOT a daily drug. Lupus patients have died because they failed to understand this. When your doctor tells you to take, for example, 8 pills, (s)he means to take 8 pills once a week. Take 8 pills once a day and you may end up dead.
  2. To help with the side-effects of methotrexate, your doctor should give you a prescription for folate/folic acid. If you still have a lot of trouble, than (s)he should give you a prescription for leucovorin, which is a stronger form of folic acid. This helps protect the rest of the body, and allows the methotrexate to attack only the immune system. If you're having side-effects that won't go away and you're not on leucovorin, I highly recommend pestering your doctor until you get a prescription. For me it makes the difference between being uncomfortable and having dry heaves for two days. 
  3. You absolutely must not mix methotrexate and alcohol for the same reasons listed under tylenol. Unfortunately, methotrexate is a stronger poison than tylenol, so the consequences are even more severe if you mix the two. Drinking while on methotrexate is a good way to lose your liver and/or die.
  4. Women taking methotrexate must not become pregnant. I know, it sucks. Lupus tends to hit women who are of childbearing age, and a lot of us would like children. But methotrexate is highly dangerous to a developing infant. It WILL cause either severe birth defects or miscarriage.  There is no way to safely have children while taking this drug. None.
NSAIDS (Non-Steroidal Anti-inflammatory Drugs)
  Whether they are over-the-counter (Aspirin, Aleve, Advil, etc.) or prescription (Celebrex, Meloxicam, etc.), any lupus patient has had to take NSAIDs at some point. They are the physician's first response to arthritic pain. I've taken eight separate NSAIDs that I can think of off the top of my head. None of them worked for me, but they were worth a try. That being said, there is one danger to be aware of. All of these drugs are related, so it is dangerous to take multiple varieties at once. This is especially true of the over-the-counter NSAIDs; they are all derivatives of aspirin. One of the side-effects of all such drugs is that they reduce your blood's ability to clot. This can be beneficial in small doses, and doctors routinely prescribe baby aspirin to people at high risk for a stroke. However, if you combine, for example, aspirin and advil, your body may not be able to stop bleeding if you have even the slightest cut or bruise. Add that to the fact that traditional NSAIDs really mess up your intestines, and you have the potential for serious danger. So choose one NSAID, and do not take another until after the dosing period of the first one is over.

  I don't know about you, but I know I take at least two drugs that may potentially interact. However, my doctors are a) aware of that fact and b) have decided it's worth the risk. Let's hope they're right. They can only make this decision because I tell every doctor every single drug I take. This is why it's absolutely imperative that you tell your doctors about every drug, supplement, alternative medicine, etc. you take. Even alternative treatments can interact with medications, and it's important that your doctor and pharmacist know exactly what you are taking so that they can make informed decisions about your medications.

I'm not trying to tell anyone what they have to do, nor can I say that I have never, for example, taken more tylenol than was strictly wise. But many people are unaware of how easy it is to poison yourself when you have lupus. When you think about it intuitively, it's not that surprising, really. I think I'm on about 15 prescriptions or so (I stopped counting after I passed a dozen; it was too depressing), and it makes sense that at least some of those might interact with anything else I might take. So I can only urge caution, and suggest that you play "Stump the Pharmacist" if you have any questions. It's a lot of fun to see them have to go look up things, actually. Also, it's worth doing your own research. I generally look up any new drug I'm given to see if it will interact with something I already take. I also check to make sure that what the pharmacist gives me is what has been prescribed. I've had pharmacists try to give me the wrong drug before. Do not hesitate to tell a pharmacist that (s)he has screwed up. It could save your life.

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Usual Disclaimer: I am not a clinician, and cannot offer medical advice. All opinions or information offered is from my own research, and reflects only my opinions or conclusions. I am not representing any institution; all articles are strictly my own.


  1. Well written. Are there other common combination problems out there? I know Tylenol needs to be carefully respected, but I wonder if there are other OTCs that commonly mess people up in a serious way.

    1. Thank you, and yes, now that you mention it, my wise father taught me not to mix NSAIDS. I'll edit the article accordingly.

    2. No need to do any edits, I was just wondering if there are other OTC drugs or supplements that also have such serious consequences that they too deserve to be called out? I know there are dangerous ones out there, but are any of them a frequent source of overdose poisoning?

  2. I'm a Cub Scout leader of a child with severe food allergies, so not poisoning Henry has been an ongoing concern for several years. Fortunately he is becoming less allergic. Do you have dietary interactions to think about as well as drugs? I know you mentioned alfalfa sprouts as a problem. I have a goal of getting through life without poisoning anybody . . .

    How are things looking for your Lupus walk next week?

    1. Unfortunately, I seem to have re-developed my childhood allergy to wheat/gluten. It's a major pain, as I'm sure you can imagine. The walk is looking alright so far. My roommate's friend has also offered to let us crash at her place in the district if we don't want to travel the day of the walk, so I think that I'm set. Thank you for your kind offer, though!

    2. Have you looked at the possibility of going gluten free? There is possible link between lupus and gluten sensitivity

    3. Yes. I eat a gluten free diet.

  3. My brother had celiac disease. Fortunately for him, the doctor caught it quickly. I do not remember "Billy Bread" fondly. Ick. He has largely grown out of it now, although I understand that he still considers whole wheat bread to be a weight loss aide. Don't you just want to tell your body to "get with the program"? Good luck with your walk.