Fun with Drug Interactions

 First of all, for no particular reason, here's a video of my happy feet.

Secondly, here's a video of one of my finish line dances.  Whenever I swim 1600 meters or more at a swim practice, I post one of these, though it's happening so often now I'm probably gonna need to up it to 1700.  So if you like fat chicks dancing or you wanna see updates. follow me on Threads @J3ninDallas. 

Thirdly, let's consider for a minute our nation's pharmaceutical companies.  These bold pioneers make wonder drugs so that their shareholders can make lots and lots of money.  Oh, and to cure diseases and treat conditions and whatnot.  This is a cautionary tale of what can happen when two prescription drugs collide with each other and make a big mess.

I think I told you guys I was diagnosed with Type 2 diabetes and a rare neurological condition the same week.  Which doesn't take into account that I already had ADHD and bipolar disorder and was being treated for those. Four conditions to monitor at the same time is a little flipping ridiculous, especially considering that two of them require testing and worksheets and, in one case, drops of blood.  Eesh.  Sure, years from now I'll probably also have heart disease and need three surgeries, but anyway, It's A Lot.  And finding a combination of medications that treat diabetes without also killing you is kind of like finding a combination of medications to treat bipolar disorder without killing you, only with some luck it only takes like six months instead of (in my case) three years, not counting lots of adjustments since.

Anyway, the first drug we tried is like the standard drug for diabetes, Metformin.  500 mg of this was fine, but it Did Not Do The Job; my numbers were still too high.  So my doc upped the dose to 1000 milligrams.  This was a mistake.  I had crippling nausea, not like minor stomach pain but as in I stopped being functional and had to go lie down on my side for half an hour.  A couple of times this happened in traffic and after the second time I called my doc back and said, "This is not safe."  I was being stubborn and trying to make it to three weeks, after which it (usually) gets better on its own. 

So back down to 500 we went.  Again, fine but not effective.  The next likely culprit in the arsenal is one of the semaglutide drugs, made somewhat famous (and infamous) for being prescribed off label for celebrity weight loss.  We're talking Ozempic, only I wouldn't take Ozempic because I didn't want an injectible that lasted for two weeks after my Metformin experience.  No, if it was gonna upset my stomach (which happens to me with basically every prescription drug made, never mind those that are  particularly known for that sort of thing) I wanted to be able to stop taking it Right Then.

Fortunately there is a pill version of one of these, which is called Rybelsus, and it starts out at a very low dose, just 3mg.  So we tried that and it worked great.  That plus the 500 mg of Metformin brought my numbers down where they should be.  There was, of course, some nausea, but nothing like Metformin.  It was a little like morning sickness.  It usually wore off by around 11:00, sometimes flaring up briefly later in the day. So I hit up all my friends who had ever been pregnant to find out what their go-to nausea treatments were. The surprising answer: Ginger.  Ginger tea in particular but also ginger candy and dried crystallized ginger (a little bitter but you get used to it, and Grayson likes it, too.)  So I lived on ginger and saltine crackers for a while, and the morning sickness gradually went away.  

Unfortunately, something else went away at the same time:  My ability to do my job.  I began falling asleep at my desk.  Like, routinely.  I can fall asleep just about anywhere, and in just about any position, but concentrating deeply on something and then suddenly startling awake and realizing that 20 minutes had gone by and I didn't know where I was or what was going on because I had, uh, been asleep was kind of a new thing.  Also, that deep concentration?  Disappeared. Kind of gradually but once it was gone, it was gone.  After two weeks I was going in to work and just kind of taking up space until I could go home.  Which is, you know, kind of bad when you manage a large number of complex things that keep the revenue generating machines chugging along.  

Right about this time, my doc was going to up my dose of the new diabetes med to 7 mg, but fortunately we had a problem with my health insurance. 🙄 The Ozempic class meds, in addition to being known for weight loss, are also expensive. The problem, apparently, is that I don't have T2D and you have to have T2D to take Rybelsus.  I of course have T2D, and we've sent them records showing this a couple of times, but I don't think an actual human being has looked at them.  So I have to appeal and so on, which should prompt an actual human being to look at them.  But I haven't done that yet because I got this text from a good friend.  I paraphrase:  "Hey, have you heard that those new diabetes meds can interfere with medications for ADHD and bipolar disorder?  Something about dopamine receptors and poor absorption?  You might want to check that out."  

WELL, HOLY CRAP.  

That was exactly what was happening.  It was like not being on meds at all.  Apparently the problem is particularly acute with extended-release meds, which my most important one is.  It's called Vyvanse and it's the one that keeps me awake in the face of the two or maybe three other meds (I lose track) that want to put me to sleep.  I went without Vyvanse for a month last summer during a national shortage and it was kind of like trying to rouse myself from a coma.  My psychiatrist ended up prescribing Adderall temporarily, which did the job, but it was like using a bulldozer to find a china cup, if I can quote Rene Belloq.  I mean it was harsh. I still take Adderall once in a while but it's a desperate times/desperate measures sort of thing.

Anyway.  The problem is that semaglutide disrupts absorption of certain substances by the stomach and intestines.  If you're not taking any other meds, this isn't a big deal, but if you are, it can be a real problem.  You're supposed to take the diabetes med right when you wake up and then not eat for 30 minutes so it can get going.  (This delay in my morning coffee has only been mildly dangerous for the population at large, though Joan has the Joint Chiefs of Staff on speed dial just in case.)  So I was doing that and then taking everything else when I got to work.  Which meant I was taking everything else right when Rybelsus was at its strongest.  No wonder nothing else was getting through.  There's also some problem with disruption of dopamine receptors in the brain that I'm not quite sure I understand, but that didn't seem to be my biggest issue.  My biggest issue was that the stuff couldn't get in. 

So I notified my Regular Doc about this and called my psychiatrist.  He called me right back (he usually does; he's a rare specimen of the breed) and said that he had an idea.  Try taking the Vyvanse about an hour before the Rybelsus and -- you'll love this -- take the capsule apart and pour the contents into a glass of water.  Then drink the water.  I bet you always wanted to know what the inside of a capsule looks like, right?  Well, sorry to disappoint, but it's just kind of this plain white powder.  

So that's what I've been doing.  My Regular Doc is holding off on increased doses and fighting with my insurance company before we find out if it works, but so far it seems to be.  I was going to take a whole week off work but instead I took half-days, and I was able to work the half-days (though I seem to be crashing and burning about 2:00 -- not surprising if I'm taking the Vyvanse three hours earlier.)  And the other meds seem to be working better, too.  I'm taking them all at the same time, before the Rybelsus.  This would not work with Ozempic or any of the other injectables, so I dodged a bullet there. 

There are, of course, some wrinkles in the plan.  Firstly there's the crashing and burning early part.  That might be solvable with a suitable application of Adderall; again, desperate times desperate measures.  Then there's the problem of waking up basically in the middle of the night, slamming down the powder for a strong stimulant that's supposed to be in a time release capsule, and then trying to go back to sleep.  Yeah, that's not working very well. And probably contributes to the 2:00 crash and burn.  There is a chewable version of Vyvanse, for little kids, that might also work.  It's absorbed in your mouth and bypasses your stomach entirely.  But it's kind of not as strong, so my psych doesn't want to do that unless the drinking the powder doesn't work.  And then there are the empty capsules themselves, left on the night stand after I swallow the powder and try to go back to sleep.  Guess what makes a great, rattly cat toy and makes a bunch of noise at 5 am? 

By the way, how cool is drinking powder?  Think Maria de Medici tipping her poison ring into your glass of water.  Sometimes it tastes bitter and sometimes it's kind of mildly sweet, so there must be two different components in there, at least.  Of course, it tickles my throat and makes me cough, too.  Nothing is ever perfect.  

I've reported this whole mess to the drug companies involved and I told my psychiatrist that he needs to Tell People.  Neither he nor my Regular Doc saw this coming.  I mean, there is one tiny line on the Rybelsus warning label that says something about malabsorption.  But it's awfully arrogant of Rybelsus, really, to act like it's the only important medication anybody out there is taking. This could be a big problem.  What if you're being medicated for schizophrenia and you start hallucinating because you also have T2D?  What if you're depressed and you go from mildly unhappy to actively suicidal?  I mean, people should know about this. I'm sure all of you know at least one person with ADHD and/or bipolar disorder and/or schizophrenia who also has T2D.  (If you don't, you're probably not hanging around with the fun crowd.)  So, like, tell people.  Thank you for coming to my TED talk.