This week we will continue our drug survey by looking at over-the-counter allergy medicines and prescription sleeping pills. As noted in my first drug survey post, these posts are meant to be descriptive, not prescriptive. They are meant to help you ask your doctor the right questions, and let him know the right information. Adverse drug interactions can be an issue, particularly in the drugs that we are looking at today, but many patients don’t know what information can help a doctor determine if your symptoms are due to a drug interaction or not.
Both allergy medicines, such as Zyrtec-D and Claritin-D, and sleeping pills, such as Ambien, are medicines that control symptoms. They do not cure the underlying problem. In the case of allergies, there usually is not a cure. In the case of insomnia, there is usually an underlying cause that needs to be addressed, particularly if it is an indicator of another medical issue. Recall from Part 1 that when it comes to weighing out the risks and benefits of a particular medical treatment or medication, the standards are different when considering a drug that cures a potentially life-threatening disease versus a drug that manages pain or symptoms versus a drug that is taken by an otherwise healthy individual for lifestyle or cosmetic reasons. As a note, antihistamines, which are the primary ingredients in allergy medicines, do not cure the patient of the allergy, but in cases of a severe allergic reaction, controlling the symptoms can be a matter of life or death and should be prioritized accordingly.
Zyrtec-D, Clartin- D (antihistamines with pseudoephedrine)
Allergies occur when the immune system wrongly responds to a normally harmless substance, causing a range of symptoms from cold-like reactions, such as congestion, to an anaphylactic response. Zyrtec-D contains the antihistamine, cetirizine. Claritin-D contains loratadine. There are several other name-brand allergy medicines, but Claritin and Zyrtec tend to be widely used, particularly in their pseudoephedrine-containing forms. Both of these drugs also contain pseudoephedrine which is a decongestant.
Researchers have done some fairly extensive clinical trials with allergy medicines. Antihistamines have a few side effects including dry throat and drowsiness. Their function is to tell a particular part of the immune system to stop reacting. Histamines are part of the immune system and help the body fight foreign invaders. There are several histamines in the body. The Asthma and Allergy Foundation of America defines allergies as an overreaction by the immune system to substances that usually cause no reaction in most individuals. The antihistamine does not target the entire immune system or even all of the different types of histamines. It targets H1, which is the histamine associated with allergy symptoms such as bug bites and pollen-related reactions.
The pseudoephedrine portion of Claritin-D and Zyrtec-D, however, has quite a few side effects, and if taken in larger dosages can be addictive and habit-forming. See here for a complete list of side effects. The pseudoephedrine works to alleviate congestion by constricting blood vessels predominantly in the nasal passageway, although it may constrict other blood vessels in the head as well. Pseudoephedrine is a class of ephedrine drug, so it is a central nervous system stimulant, which carries some risks, including risk of abuse. In larger dosages it can cause a sense of euphoria, increased energy, anxiety, and alertness. Even if taken properly, pseudoephedrine can elevate blood pressure and can affect the heart.
Two issues are noteworthy with pseudoephedrine drugs: 1) There have not been sufficient clinical trials done on people over the age of sixty, 2) Dosage is important, so one must make sure not to accidentally take two cold medicines containing pseudoephedrine.
Overall, the ethical issues with allergy medicines stem from the potential abuse of pseudoephedrine more so than the histamine blocker. The risk of abuse is a known risk and measures, such as not having these drugs on the pharmacy shelves, and providing an ID to purchase them, are good ways to ensure someone is not stocking up on pseudoephedrine-based products. I do think people who have heart issues, are over 60, or on blood pressure medicine should keep in contact with their doctor before and while taking these drugs. Finally, pseudoephedrine is on the World Anti-Doping Agency’s list of banned substances. Athletes are not permitted to have more than 150 mg in their urine at the time of competition. Typical allergy medicines have 120 mg per capsule.
Ambien (sleeping pills)
Ambien, or sleeping pills, is not nearly as straight-forward as allergy medicines. Antihistamines seem to target the particular histamine that causes symptoms and pseudoephedrine, while a risky drug, is highly regulated and generally targets the nasal passageway and sinuses. Sleeping pills, on the other hand, work on everyone whether you are having problems sleeping or not. They do not target a specific issue in the body. They target the signals that tell your body to sleep. Sleeping pills only deal with an inability to sleep; they do nothing to address whatever is causing insomnia. The actual causes of insomnia, whether physical or psychological, must be addressed in order to cure insomnia. Therefore, sleeping pills are not a cure; they are for symptom control. Additionally, sleeping pills have a number of side effects, some of which are more pronounced in some people than in others, and drug interactions are a major concern when using these drugs. High enough dosages of stronger prescription sleeping pills, combined with other drugs or alcohol can lead to unconsciousness, or even death.
Ambien’s generic name is zolpidem and is considered a sedative or hypnotic drug. Quick release pills help people fall asleep, and extended release pills (Ambien CR) help people stay asleep. Something that was emphasized in every report I read on sleeping pills was they are meant for temporary use only. Long term studies have not been done, although severe ‘withdrawl’ symptoms after taking Ambien for more than three weeks have been reported. Aside from the potential for addiction, probably the most dangerous side effect of Ambien (and Lunestra) is short-term memory loss or sleep-walking. It is difficult to know how common sleep walking and long-term memory loss occurs since information requires a spouse’s report or the person finding evidence of this occurring. For example, one woman found a half-eaten tub of butter on her kitchen counter, and realized that she had eaten it in her sleep. On rare occasions, police have pulled over people who were driving while sleeping after taking Ambien.
From an ethics standpoint, Ambien has several potential physical and psychological side effects, but is not necessarily a cure for the underlying cause, so the issue of weighing out the risks and benefits of a drug comes into play. One issue that raises a red flag for me is a drug that can cause short-term memory loss, possible sleep walking and sleep eating, and is also a highly regulated substance with exact indications of proper dosage. Overdoses can cause loss of consciousness and slowed heartbeat. This just doesn’t seem to be a very safe combination. It may be prudent for those taking Ambien to have some precautions in place, such as a spouse keeping the pills in a safe place.
The second issue that raises some red flags is that sleeplessness can often be overcome by changing certain lifestyle habits that are not conducive to sleeping. Furthermore, the Journal of Family Practice says that physicians report a similar success rate using cognitive behavior therapy as using prescription sleeping pills. This raises the “quick-fix-pill-for-everything” red flag. If we were honest with ourselves, many of us would rather take a quick-fix for the symptoms in a convenient pill form rather than change our habits or address the real cause of insomnia. For example, watching a bright screen before you go to bed can cause sleeplessness, yet how many people read with a back-lit laptop, ipad, e-reader or watch television in bed? Other causes of sleeplessness are drinking alcohol late at night, being overweight, eating dinner too late, not going to bed and getting up at the same time every day, not exercising (although exercising before going to bed can cause restlessness), and regularly getting eight hours of sleep.
The most common cause of insomnia is stress or anxiety. Sometimes it is caused by chronic pain or sleep apnea. If this is the case, then insomnia might be a blessing rather than a curse because it serves as a signal that you need to deal with some stress and anxiety or it is a signal that you need to be evaluated for apnea. I believe Americans are very productive people, but sometimes we get so caught up in our busy schedule and productivity while also balancing the tough trials of life that we rarely take time to deal with stress and anxiety. Sometimes just incorporating a little time for reading, reflection, exercise, prayer, or even just acknowledging that you are struggling with stress and anxiety can do wonders for insomnia issues.