Hello Dazzle! Thanks for coming and hanging out with me today, I’m glad that you are here. Today I want to talk about the differences between Excuses and Explanations. Because, I think it really matters. Let’s start by looking at the definition of both words.Continue reading “Excuses vs Explanations”
Hello Dazzle! Thanks for coming and hanging out with me today, I’m glad that you are here. Today I want to talk about the idea of taking a medication holiday. This is an option that is often overlooked so I wanted to talk about it a little bit. First, let’s cover what the term “medication holiday” is talking about. Often times when a person has a chronic illness they are on medications for really long periods of time. A medication holiday is when a person takes a break from taking one or all of their medications for a planned period of time.
Pros of taking a break from medication
For the right people on the right meds, a drug holiday can help determine how well a medication is working. How the course of the illness is progressing can be better assessed by allowing you and your provider to monitor your symptoms without the medication. Sometimes conditions get better over time and it can be hard to tell if they have improved because of the medication alone or if the medication is no longer required.
It can also help limit side effects or help balance quality of life in context of the side effects. There are times that medication side effects get worse over time and in this context, taking a break from the medication can help reduce this cumulative effect. Taking holidays can also be a way to mitigate the effect of those side effects. If a medication is causing severe nausea or impairing your ability to eat, taking a break from the medication on a scheduled basis can be a way to get those much needed calories. But it can also be about balancing quality of life issues. You might consider taking a break from a nausea inducing medication over the holidays so that you can better enjoy all the feasting. This is often done with SSRI medications as a way to balance the sexual dysfunction they can cause. 
Sometimes you need to consider stopping a medication because of the cost. There are times that this isn’t a choice. If your medication is no longer covered or you no longer have insurance you may no longer be able to afford the medication and thus have to stop taking it so that you can afford other things like food and housing. Sometimes this is just a gap while you transition insurance and sometimes it means stopping for the foreseeable future. This is a crappy reality of having a chronic illness, but there are times that people have to choose between eating and taking their medications. And it might just be a case of the medication being really expensive and trying to determine if the cost is really worth the benefits that you are getting from the medication. 
Another reason for drug holidays is to permit a drug to regain effectiveness after a period of continuous use, and to reduce the tolerance effect that may require increased dosages. There are many medications that our bodies become tolerant to taking over time. This means that they will no longer have the same effect that they did when you first started taking the medication. Taking breaks from the medication can prevent this tolerance from happening in the first place and if tolerance has developed it can be reversed with a medication holiday. This is one way to reduce the risks that comes with higher doses of medication. 
If you are taking multiple medications, as many with chronic illness are, and are having serious side effects it can be difficult to determine which medication is causing the side effect since many medications share side effect risks. This can be a very useful approach when those side effects are serious and indicate the need for a medication change. Systematically trialing each medication into a holiday can determine which medication is causing the problem. It might also reveal that none of the medications are the cause of the problem but rather there is a new medical problem that has developed.
There are also times that you and your doctor are considering the merit of adding another medication to your regime but there is a medication that you are currently taking that is contraindicated to be taken with the new medication. Starting out with a medication holiday might be a way to better evaluate the pros and cons of stopping the one medication in favor of starting the other medication. It can be difficult to clearly assess how being off that medication will be tolerated while you are still on it, thus a period off that medication can offer the insight needed to make the decision about making the medication switch. 
And sometimes, it can offer those of with chronic illness a needed break. Taking medications every day is not easy. It means keeping track and making sure that everything is timed right. It can mean lugging bottles of medications and snacks around with you where ever you go. There are times that it can be of value to take a break from your medications just for the psychological benefit of being able to take a brief break from being the chronic illness patient in some small way.
As an important means to addressing the very real risks that come with polypharmacy. Unfortunately, the standards of practice do not include the regular review of the entire list of medications that a person is taking and the risks that they pose as a group. A medication holiday can be a means to achieving deprescribing goals or reducing the number of prescriptions that you are taking overall. This evaluation of polypharmacy risk is best performed by a pharmacist as they are the experts in medication. If you are taking more then 3 medications, you should consider having a pharmacy consultation appointment to review your medications as a group. Many medications interact with each other or augment the risks of each other. Since we often receive medications from different doctors and different pharmacies it becomes all too easy to have this kinds of risks in your medication profile.  
Cons of taking a break from medication
The first major con is that there isn’t much research on taking medication holidays. Most of the research done on taking medication holidays has been done in context of ADHD medications for children or for bisphosphonates. There is some research on other conditions, but it is limited. This means that it isn’t likely that there is any data regarding the medication you are looking to take holiday from. The first reason that the lack of research matters is that it means that there isn’t any data on the most beneficial or harmful ways of taking the holiday. It also means that there isn’t any data on how taking holidays impacts the overall outcomes in context of long term treatment goals.
Medication withdrawal is common and a serious challenge for those who have been on medications for a long period of time. When you take a medication, your body can become accustomed to that medication being present. The longer you have taken the medication the more likely this will happen. Clinically, this is called dependence and is not the same as addiction. Dependence can happen even when you are taking a medication as prescribed. There are numerous medications that can cause medication dependence including opiates, stimulants, antidepressants, antiepileptics (seizure medications), sedatives, proton pump inhibitors (PPIs), laxatives, antipsychotics and others. Basically, the odds are that which ever medication you are considering taking a holiday from is one that there is a risk of dependence and withdrawal symptoms for.
There is a risk of relapse of symptoms. There was a reason that you were put on this medication in the first place. Thus, whenever you stop taking a medication there is a risk that the symptoms that the medication was put in place to treat will return or get worse. This is an indication that the medication was doing the job that it was prescribed to do and depending on the reason that you are taking the holiday may be evidence that the medication needs to be continued.  Along this vein, having symptoms may lead to needing treatment depending on the severity and nature of the symptoms being experienced. This could mean medical expenses that far exceed what the medication would have cost to prevent the symptoms.
How to make the decision to take a break from your medication?
If you are struggling with the side effects of your medications, feel that your medications are impacting your quality of life or don’t feel that your medications are helping with your chronic illness symptoms it might be time to consider talking to your doctor and pharmacist about taking a medication holiday. Whenever possible, you should talk to the doctor that prescribed the medication when you are looking to talk about a medication holiday. The doctor that prescribe the medication to you is going to be the most informed as to why you are on that medication and the reasons you were advised to take it. Thus, they are best equipped to advise you regarding the risks and benefits of taking a medication holiday.
Additionally, pharmacists are the experts in medications. If you and your doctor have decided that a medication holiday is a good idea for you then I recommend that you also speak with you pharmacist regarding the best way to take that medication holiday. There are many medications that cannot be safely stopped or started suddenly and there are many medications that are not recommended for medication holidays. Your pharmacist is going to be the most knowledgeable and up to date on these medication recommendations. Contact your insurance to see if they cover pharmacy medication management consult appointments. If so, the best approach is to schedule an appointment with a pharmacist which can often be done right through your primary care office. If it is not covered by your insurance then go to the pharmacy that fills the medication you are considering taking a break from and request to speak with the pharmacist regarding that medication.
It is essential that you do not make the decision to go on a medication holiday without talking to your doctor and pharmacist because coming off medications improperly can lead to serious adverse events.  You have the right to take a medication holiday even if it is not recommended by your doctor or pharmacist. You need to tell them that you want to be educated on the safest way to do so with the understanding that it is against their medical advice. This is also true if you want to stop a medication completely. The standards of practice for safe medication prescribing include educating the patient on the medication which includes the discontinuing of the medication. If they refuse to provide you education on your medications, you have grounds for a formal complaint to the medical board. 
You are your doctor should create a plan for your medication holiday. That plan should include:
- how to safely stop taking the medication (all at once or a slow taper)
- symptoms to expect when coming off the medication (withdrawal)
- symptoms to monitor for that would indicate that you should restart the medication
- how you should restart the medication if you need to
- what you should do if you cannot restart the medication
- the follow up monitoring plan (appointments, lab work etc.)
How often should you check in with your doctor?
This varies greatly depending on the medication that you are taking the holiday from and the nature of the holiday. What is important is that you and your doctor have clearly defined how often you should be checking in. It should also be clear if these check ins will be by scheduled appointments or through the doctor office communication services such as a patient portal. Be sure that it is also clear what things the doctor will be looking to discuss at these check ins. Do they want you to be keeping a symptom tracker or journal?
When is the best time to take a break?
This will also vary depending on the reason you are considering the medication holiday. It is reasonable to expect that you are not going to feel well while you are first coming off of a medication. Because of this, it is best to take a medication holiday when you can afford to experience withdrawal symptoms or a reoccurrence of the symptoms that the medication was treating. This means that the best times are often when you are taking a break from school or work so your professional or academic performance won’t be adversely effected.
Well, that’s about it for my rambling today. Thanks for coming and spending some time with me. If you like what you read, click on that like button. It really does help! Until we talk again, you take care of yourselves!
Additional Reading and References
- Appropriate Prescribing of Medications: An Eight-Step Approach
- Selective serotonin reuptake inhibitor-induced sexual dysfunction: efficacy of a drug holiday
- Withdrawal from pharmacological treatment and drug holidays
- Understanding Drug Tolerance
- Discontinuing Medications: A Novel Approach for Revising the Prescribing Stage of the Medication-Use Process
- Millions of adults skip medications due to their high cost
- Effects of discontinuation of chronic medication in primary care: a systematic review of deprescribing trials
- Stopping long-term drug therapy in general practice. How well do physicians and patients agree?
Hello Dazzle! Thanks for coming and hanging out with me today, I’m glad that you are here. Today I just wanted to touch base and give a little update as to how things have been going in my life. Most of you already know that the last few years have been rather difficult for me. If I was to use one word to describe 2022, I would use tumultuous. It was a year that was filled with confusion and uncertainty. A year that has brought a great deal of change into my life. Some of that change has been really good and some has been really difficult. At the end of the year, in December, I took a leap of faith and I left bedside nursing to work full time as Zebra Pig. It has been about a month now. So, what has a month of full time as Zebra Pig been like?Continue reading “010223 Update”
Hello Dazzle! Thanks for coming and hanging out with me today, I’m glad that you are here. Today I am going to talk some more about poop. Specifically, I am going to be talking more about constipation. In the first part, I talked about what constipation is and why it is important to prevent it or to treat it when prevention is unsuccessful. In the second part, I talked about chronic constipation. And in this last part I want to talk about treating constipation.
The first thing to consider for the treatment is what is causing the constipation. Addressing the cause is going to lead to greater success rather then focusing on treating the constipation itself. There are times, however, that the cause cannot be removed such as when the cause is a medication side effect that cannot be removed from the care plan. There are also occasions that the cause isn’t known or there are numerous causes that are contributing to the constipation. In all of those cases, it likely be necessary to treat the constipation itself rather then the cause or in addition to the cause. It is also important to note that in many cases it is impossible to determine the cause of the constipation.
One cause of constipation that is often overlooked is the removal of the gallbladder. This small organ was once under valued and frequently removed when a person developed gall stones. Now surgeons try to avoid the removal of the gall bladder because we have a greater understanding of its importance. When the liver makes bile, about half of it goes directly into the duodenum while the other half is stored in the gall bladder for future use. When the gall bladder is removed it makes it so the body can no longer control the release of the bile into the duodenum. This means that our bodies can no longer release the bile from the gall bladder in response to the substances that are present in the duodenum. How does that relate to constipation? The bile salts that are the main component of bile have a significant impact on the motility of the gut. Thus, if you have had your gall bladder removed you might want to consider talking to your doctor about adding bile salts to your treatment plan.
While bile salts are available as an over the counter supplement, I would still recommend that you discuss the specifics of your case with your gastroenterologist before starting them. This is partly because there are conditions in which bile salts are not recommended to be taken such as with liver disease. It is also because there are multiple types of bile salts on the market that the FDA has approved for various different uses. Those being sold over the counter are not the types of bile salts that have been studied and approved by the FDA. The kinds of bile salts that have been approved by the FDA are those that require a prescription.
Occasional constipation can usually be treated with self care. Generally, if you are having hard stools or have not had a bowel movement in 3 days you can start by trying dietary modifications. Drink additional water and eat high fiber foods. If this doesn’t work for you, consider trying an over the counter fiber supplement, stool softener or laxative. If you are not sure which to try, consult with your pharmacist or doctor. If you have any bleeding with your stool you should talk to your doctor. You should also talk to your doctor if you go more then 7 days without having a bowel movement.
If you have recurrent constipation, you should see your doctor for recommendations on how best to prevent the constipation and how to treat it during the episodes. Recurrent constipation is generally treated with diet changes that include increased water intake and a high fiber diet. It also usually includes a fiber supplement. Sometimes, you will need to see a dietician or nutritionist to help you find your best dietary approach. This is more likely to be the case if you have other medical problems. A medical journal can be an excellent tool in helping you establish an effective diet plan.
Functional constipation requires medical management for successful treatment outcomes. Each type of constipation has different treatment approaches that are more likely to be effective. IBS-C will also have a distinct treatment approach. However, there are some things that have been shown to be helpful in all types. In general, dietary changes are helpful in all types of constipation. Increasing water and fiber intake being the dietary changes given primary focus. Using a medical journal can reveal foods that are constipating to the individual rather then eliminating foods based on averages or generalizations.
Fiber supplements are generally considered helpful in all types of constipation. However, it is important to consider the possibility of gastroparesis for those patients with slow transit constipation as this common comorbidity would preclude fiber supplements as well as a high fiber diet as they would exacerbate the gastroparesis. If the person has been diagnosed with slow transit constipation they should be screened for gastroparesis as well, especially if they have historically not noted an improvement in symptoms with increased fiber.
There is a lack of research to support that stool softeners improve any kind of constipation despite them frequently being used to treat all forms of constipation. This is in part due to stool softeners having a low risk profile. If a stool softener is tried and not found to be effective it is important that it isn’t continued simply as a matter of course which is a common practice. While the risk profile is low, it is not fully without risk and those risks can never be justified when there is no benefit being gained.
When considering osmotic laxatives, miralax and lactulose where shown to have an equal efficacy. However, miralax is now over the counter while lactulose still requires a prescription. Additionally, miralax was associated with less gas as a side effect then lactulose. Insurance coverage may play a factor in which medication would be ideal as most health insurance does not cover over the counter medications. However, it being covered by the insurance does not mean that it will cost the patient less than the over the cover option.
Slow transit constipation generally responds better to stimulant laxatives such as dulcolax or senna which are both available over the counter. It also responds better to prokinetic medications which increase bowel motility such as metoclopramide or erythromycin. The prokinetic medications are good choices in the cases where gastroparesis is a comorbidity as these medications are also used to treat the decreased motility of the stomach.
Normal transit constipation does not show any difference in efficacy between the stimulant or osmotic laxative. If the person has problems with electrolyte imbalance an osmotic laxative should be avoided if possible. An osmotic laxative works by drawing water into the bowel which can also lead to electrolytes being drawn into the bowel along with the water. Additionally, osmotic laxatives should be avoided for those who have issues with dehydration or a diagnosis of postural orthostatic tachycardia syndrome.
Probiotics, specifically in the genera Bifidobacterium and Lactobacillus, have been used to treat all types of constipation. The research results on probiotics is unclear due to there being a lack of good data available to fully evaluate the effect they have on the gut in context to constipation. It is unclear whether any one particular strain of probiotic is more effective than another. Due to the paucity and quality of the existing data, and until further evidence becomes available, the use of probiotics in the management of chronic constipation remains experimental. Because microbes used as probiotics already exist naturally in your body, probiotic foods and supplements are generally considered safe. They may trigger allergic reactions and can present an infection risk to immune compromised individuals.
When treating defecation disorders, surgery is often needed when the cause is an anatomical problem such as a prolapse. However, having surgery to correct the anatomical problem does not guarantee the resolution of the defecation disorder but the reason for this is unclear. Subtotal colectomy (removal of part of the colon) can be considered for slow transit constipation, but this procedure does not have good long term outcomes. Generally speaking, surgery is not a recommended treatment for constipation.
When treating defecation disorders it is often necessary to use suppositories and enemas to cleanse the rectum of stool. However, there are other treatments available such as bio feed back, pelvic floor exercises (Kegels), pelvic floor physical therapy or botox.
In conclusion to all of this, I just want to make note that constipation is a complex medical problem that requires complex and dynamic treatment to reach optimal outcomes. However, it is a diagnosis that is all too often not taken seriously resulting in inadequate evaluation and treatment which leaves many suffering when numerous treatment options have never been explored. So, if you are one of the many people who suffer with chronic constipation, know that it is important to advocate for yourself and to seek care from a gastroenterologist rather then a primary doctor.
Well, that’s about it for my rambling today. Thanks for coming and spending some time with me. If you like what you read, click on that like button. It really does help! Until we talk again, you take care of yourselves!
Hello Dazzle! Thanks for coming and hanging out with me today, I’m glad that you are here. Today I am going to talk some more about poop. Specifically, I am going to be talking more about constipation. In the first part, I talked about what constipation is and why it is important to prevent it or to treat it when prevention is unsuccessful. In this, second part, I want to talk about chronic constipation..Continue reading “Constipation (Part 2)”
Hello Dazzle! Thanks for coming and hanging out with me today, I’m glad that you are here. Today, I want to give you a bit of a life update as well as talk about some of the bigger things that have been going on. Let’s start with the fact that I am not ok and my solution is that I am going to take a leap of faith. It is terrifying, but I know that things are not sustainable as they are. Which means that now must become a time of change, whether I want it or not.Continue reading “I’m Taking It On Faith”
Hello Dazzle! Thanks for coming and hanging out with me today, I’m glad that you are here. Today I want to talk about the myth of happiness. This is a topic that is really dear to my heart because I wasted a lot of years trying to be happy. And the truth is that I never found any kind of semblance of peace in my life until I gave on the myth of happiness.Continue reading “The Myth of Happiness”