Every Drug Has Side Effects. Here’s the Truth About Them.

Side effects. Adverse reactions. That folded-up piece of paper in your medication box with the tiny type nobody can read. That laundry list of horrible things in every drug commercial. This week, co-hosts Erin Stein and Dr. Gillian Goddard break down what all of it really means.

We start with the definitions: all side effects are adverse reactions, but not all adverse reactions are side effects. We explain how clinical trials sort side effects from coincidences with terms like “common,” “rare,” and “incidence not known.” We break down the actual numbers behind these categories and walk through a real medication’s side effect lists.

There is no medication without side effects, but side effects shouldn’t be your only consideration. We cover how to weigh benefits against the risks of doing nothing, when to stop a medication and call your doctor, and practical pharmacy tips: similar-sounding drug names, brand vs. generic, expiration dates, and why your medicine doesn’t belong in a steamy bathroom or your checked luggage.

We take a moment to remind you that while this is a medical discussion, it is not providing a diagnosis or treatment or any medical advice. The only way to get a diagnosis, treatment or medical advice for your particular condition is through a discussion with your doctor.

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Visit www.thesavvypatient.com/podcast for episode transcripts.

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Get your copy of The Hormone Loop by Dr. Gillian Goddard wherever books are sold.

This episode was produced and edited by Erin Stein. Music: “All We Live For (instrumental)” by Wolfclub licensed through Audiio.com. Intro and outro edited, and video created, by Ian Mayer. The Savvy Patient logo by Amanda Spielman.

TRANSCRIPT

Gillian Goddard: Hello and welcome to The Savvy Patient.

Erin Stein: Welcome everyone!

Gillian Goddard: We're going to talk about side effects and adverse reactions.

Erin Stein: Side effects! You might as well start there.

Gillian Goddard: Yeah, good place to start. Definitions. So, an adverse reaction is anything that happens while you're taking a medication, whether it is related to the medication or not. And this becomes super important in clinical trials, and we'll talk about that. A side effect is something that occurs that could reasonably be attributed to a medication or an intervention, a treatment of some kind. So, all side effects are adverse reactions, but not all adverse reactions are side effects.

Erin Stein: Okay.

Gillian Goddard: Did that make sense?

Erin Stein: It's like a pumpkin and a gourd situation.

Gillian Goddard: Exactly. Exactly. How seasonally appropriate.

Erin Stein: Right? So, when you're getting a medication, you get a folded-up fat piece of paper, and it has tons of tiny type on it that probably none of us can actually read anymore.

Gillian Goddard: The package insert. The tiny type is called the complete prescribing information. And it's important to note that while it's included in the package, it is really written with physicians as the audience, not patients. 

Erin Stein: Yeah, so I feel like I get a medication, I get this piece of paper and I'm like, should I read this? I feel like I should be reading it, but then it's pretty dense and difficult to know if I can really use what it's telling me or not.

Gillian Goddard: Right. Right. Because you're not the intended audience. The intended audience is the person who prescribed the medication to you.

Erin Stein: I would rather have the information for myself to look at than not, but it seems like putting it in the package is not necessarily reaching the intended audience. Maybe.

Gillian Goddard: We know how to find that information as prescribers. And typically, if you're prescribing a new medication, you have been briefed or have read the research or have read the prescribing information, which is actually readily available on the internet these days too.

Erin Stein: Yes, to be fair, we didn't used to have it all on the internet.

Gillian Goddard: Correct.

Erin Stein: But we do now. We should also talk a little bit about what else is on that tiny folded up piece of paper because there are side effects, there are adverse effects or reactions, and one thing I do look at is contraindications.

Gillian Goddard: Yes.

Erin Stein: Sometimes doctors mention it and sometimes they don't, but there's usually a list of things you shouldn't take at the same time.

Gillian Goddard: Yes, either you shouldn't take them literally at the same time together, or you shouldn't take this medicine plus that medicine as part of your medication regimen as a whole. And those are two different things.

Erin Stein: Do they have different names or are they both just contraindication?

Gillian Goddard: So contraindication usually suggests that you shouldn't take the medicines as part of the same regimen. Some of the details about when and how to take the medication is part of the administration section. How to administer the drug.

Erin Stein: Mm-hmm.

Gillian Goddard: And that also usually includes things that people don't always think about. But can be important things like, can you cut the pills for example? Yes.

Erin Stein: Can't say I've ever noticed that piece of information being on there.

Gillian Goddard: Yeah, some medicines can be cut, and some cannot.

Erin Stein: Okay.

Gillian Goddard: Mm-hmm.

Erin Stein: Anything else in that little packet?

Gillian Goddard: So, the very first thing at the very top is the indications for which the medication is approved.

Erin Stein: Hmm. Approved versus not approved. But maybe still used for.

Gillian Goddard: Right. So, the FDA approves medications for specific indications. And each time a pharmaceutical company or manufacturer, when they submit for FDA approval, they're not just submitting for approval. They're submitting for approval for a specific indication. So, the very first thing is the list of indications. Now, once a medication is approved by the FDA, a prescriber—whether that's a physician or a physician's assistant or nurse practitioner—a prescriber can prescribe it for any indication. And then the insurance company can choose whether or not to cover it for a non-indicated or what's called an off-label indication. So, the very first thing at the very top is actually the indication for the medication. And if it's a brand name medication, it will only contain the indication for which that specific brand name was approved. So, I think the most common situation where we see this now is if you have semaglutide, you either have Ozempic or Wegovy because that molecule is patent protected. So, if you have a package of Ozempic, it will say that the indication is for the treatment of Type 2 diabetes. And if you have Wegovy, which is the same medicine made in the same factory with a different brand name on it, will say that it's indicated for the management of overweight and obesity.

Erin Stein: Interesting. I also think it's interesting that it the term is “indication” instead of like treatment or disease or condition or symptom. Indication is not a word that patients use ever to describe what we're dealing with.

Gillian Goddard: Yes, the indication is the thing that the medication is indicated to treat. 

Erin Stein: It's weird. It's a stretch. I don't know. I don't know where it came from. 

Gillian Goddard: I know, it's weird language, what can I say? Doing my best here. I didn't make it up.

Erin Stein: Okay. Everyone, generally speaking, would like to know what are the side effects of medication? If I take this medication, what are the side effects?

Gillian Goddard: Actually, I'm going to interrupt you there. What everyone wants to know is, “does this medicine have side effects?”

Erin Stein: Mm-hmm, mm-hmm.

Gillian Goddard: I would say yes. There is no medication… There is no medication… I'm going to say this one more time… There is no medication that is free of side effects.

Erin Stein: Right.

Gillian Goddard: It doesn't mean you will have side effects.

Erin Stein: You might have side effects because all medication has the potential to give you side effects.

Gillian Goddard: Correct.

Erin Stein: But it also has the potential to not. You just don't know.

Gillian Goddard: Yes. Some of the language we use around this can be confusing too. Because we use colloquial language, but as with many things in medicine, we have very specific definitions of what those different things are.

Erin Stein: Yes, so just before this I was looking up a medication, and I was looking for a list of side effects and it's not that simple. There are some side effects, but then it's more common, less common, and then there's incidence not known, and then there's adverse effects. And then there's the list of things if you already have you shouldn't take it.

Gillian Goddard: And there may or may not be data for that.

Erin Stein: There are so many things.

Gillian Goddard: So why don't we start with adverse reactions? Cause I think they're the easiest thing to think about.

Erin Stein: Okay.

Gillian Goddard: When a drug company is doing clinical trials for a medication and they want to get the medication approved by the FDA, they have to do a randomized control trial where usually half the people are getting the medication with the active ingredient and usually half the people are getting placebo, although this is not an episode about clinical trial design, so there can be some differences there. But some people are getting placebo, some people are getting the actual medication. And over the course of the clinical trial, one of the things that the participants get asked about and asked to report is whether they experience like a whole laundry list of symptoms or problems. Nausea, vomiting, headache, fatigue, weight loss, weight gain, acid reflux, confusion, depression, anxiety. You can imagine that when someone is in a clinical trial, they might have a headache. Because people have headaches.

Erin Stein: Mm-hmm. Yeah.

Gillian Goddard: And that headache may or may not be due to the study drug, the drug that the company wants to get approved. And so, the way you decide whether something's an adverse event or a side effect, right, is you see how many people in the placebo group had a headache and how many people in the treatment group had a headache. And if it's the same, we assume it's not because of the drug and that's an adverse event.

Erin Stein: Okay.

Gillian Goddard: Yeah. Because people have headaches all the time and just because you have a headache doesn't mean that it's because of the medication that you're taking. Could be for all kinds of things.

Erin Stein: Well right. And I also think there's a difference if you simply ask people, are you experiencing anything? Versus giving them a laundry list to choose from.

Gillian Goddard: Right, right. And they will ask about anything else, and they'll ask about things like have you been in the emergency room? And they're instructed to then report that back to the researchers, for example. And so, as part of the clinical trial process there's this gathering of all kinds of different adverse reactions, and then they use the data from placebo versus treatment group to decide whether they want to attribute that adverse reaction to the study medication and call it a side effect.

Erin Stein: Okay. But then they still list all those things.

Gillian Goddard: Mm-hmm. They do. And they list them in a very specific order. They start with the most common and they move to the not known. So, they go from the “most common” to the “least common” to the “not known.” And each one of those terms has a specific numerical meaning. So, a very common side effect or adverse event occurred in more than ten percent of the study participants.

Erin Stein: Okay.

Gillian Goddard: Common side effect is one that occurs in between 1% and 10%. So more than 1%, but less than 10%. Now, when I think of common, 1% doesn't sound that common. That means 99% of people didn't have it, right? But in sort of medical language in this rubric, common is something that occurs between 1% and 10% of the time. And then most of the time, the rest of the events get lumped into uncommon, which means it occurs less than 1% of the time. But there are delineations of what is uncommon, rare, very rare, and not known.

Erin Stein: I'm looking at a medication on mayoclinic.org and this particular one has a more common list, but then a less common or rare list, and then the incidence not known list, which is quite lengthy.

Gillian Goddard: So, incidence not known, it means that they don't have enough info. It was probably something that was actually so rare that they can't decide… like one person had it.

Erin Stein: Well, does that mean literally probably one person had it?

Gillian Goddard: Or so few that in a trial of, you know, 3,000 people—I mean, some of these trials for some of these medications for things like cholesterol and diabetes and heart disease, oftentimes those clinical trials have thousands and thousands of participants. And so, if you have a couple of people, a small handful of people, it's a little hard to know. Is that real? Is it artifact? So that's why it gets recorded. Then after these drugs get approved, the FDA continues to keep records on side effects and adverse reactions. Then there's like this continued accumulation of data.

Erin Stein: I think it's worthwhile going through an example. Because this actually is really informative and the average person does not know this, that there are actually numbers assigned to these things. So, I looked up sertraline.

Gillian Goddard: Okay. Sertraline is Zoloft. It's an antidepressant selective serotonin reuptake inhibitor [SSRI].

Erin Stein: Good job. And it has a short very short list actually of more common side effects.

Gillian Goddard: Mm-hmm. What are they?

Erin Stein: They include decreased interest in sexual intercourse. Also, it says check with your doctor immediately if any of the following side effects occur. And I'm like, decreased interest in sexual intercourse is not something I would immediately contact a doctor about.

Gillian Goddard: It's a medical emergency? [laughs]

Erin Stein: The next one perhaps. Failure to discharge semen. And I think if you have a penis and you can't discharge semen; that's probably a cause for concern. Inability to have or keep an erection, loss in sexual ability, desire, drive, or performance.

Gillian Goddard: Mm-hmm.

Erin Stein: I'm a little bit like, ability? [laughs] 

Gillian Goddard: Well, that applies more to people with a penis, typically.

Erin Stein: Yeah, I think so. I think clearly that's what was being considered. So that's it. Those are the four more common side effects. 

Gillian Goddard: And if you actually think about it, they are all part and parcel of one thing.

Erin Stein: Yes. And how many times have you heard about the side effects of antidepressants and SSRIs and how dangerous they can be? 

Gillian Goddard: So very, very many times.

Erin Stein: So many times, and I'm looking at this and I'm kind of shocked that that's it. Now then we move on. There's a less common or rare list.

Gillian Goddard: Mm. That would be less than one percent.

Erin Stein: So less than 1% of people who take it listed the following. It's not a huge list; I'm going to read it. Aggressive reaction, breast tenderness or enlargement, confusion, diarrhea, drowsiness, dryness of the mouth, fast talking and excited feelings or actions that are out of control, fever, inability to sit still. Increase in body movements, increased sweating, increased thirst. [meow in background] Did you hear my cat?

Gillian Goddard: Mm-hmm.

Erin Stein: Lack of energy, loss of bladder control, mood or behavior changes. Again, you're taking an antidepressant! 

Gillian Goddard: Isn't that sort of the point? Yes.

Erin Stein: Okay. Muscle spasm or jerking of all extremities. There are a lot of movement related things. 

Gillian Goddard: Yes.

Erin Stein: Nosebleeds, overactive reflexes, racing heartbeat, red or purple spots on the skin. Restlessness seizures, shivering, skin rash hives or itching, sudden loss of consciousness, which would be alarming…

Gillian Goddard: Indeed.

Erin Stein: Unusual or sudden body or facial movements or postures, and unusual secretion of milk in females.

Gillian Goddard: Mm-hmm. Yes. Can happen in males too but is less common.

Erin Stein: So that is the list of less common or rare [side effects]. 

Gillian Goddard: I see a lot of people, and I see a lot of people who are taking SSRIs, sort of the class of medicine in general. And typically, not always, but typically the side effect profile kind of goes with the class because the medications in a class are all working in the same way. And so, I see people taking SSRIs all the time. And some of these things I've never seen in someone taking an SSRI, in twenty years of medical practice.

Erin Stein: Everyone's going to want to know what you have seen.

Gillian Goddard: Well, so one of the things that can cause a lot of those side effects is something called serotonin syndrome. It is what happens if your body has too much serotonin. And that's an endocrine emergency. So, if it's happening in the hospital, the endocrinologist gets called. And so, working in a New York large New York City hospital as a fellow, that was something that I saw. Not often, but from time to time.

Erin Stein: Okay. Then there's a huge list. This is the incidence not known.

Gillian Goddard: Right.

Erin Stein: And I'm not going to read this entire list because it's way too long. But it goes from blindness to your skin loosening, there's a lot about your urine and your stools, breathing, fainting, blood pressure, clotting, everything from indigestion to muscle twitching to rapid weight gain to severe mood or mental changes, shuffling walk.

Gillian Goddard: Mm-hmm.

Erin Stein: Weirdly specific.

Gillian Goddard: Dopamine related.

Erin Stein: Okay, twitching, twisting movements of the body, a lot of again, more movement things, unpleasant breath odor, vomiting of blood. Again, that would be very concerning.

Gillian Goddard: It is very concerning. It is a medical emergency, but how we could say that it was related to your SSRI, I'm not quite sure. Which is again why it's in this category. Like, are these things related to the SSRI or are these just things that happen to people not all that often? And so, we can't really tell.

Erin Stein: So, there's those lists, then there's more common, less common, and incidence not known again, but these are all shorter lists. So, I guess the lists I read were ones where you should contact your doctor if you have them. And these are the ones where you don't necessarily need to contact your doctor unless they are bothering you.

Gillian Goddard: Mm-hmm. Mm-hmm. So, these are side effects, but if they're tolerable, no need to worry.

Erin Stein: Okay. I guess I haven't noticed that before. That there's two separate lists.

Gillian Goddard: Yeah, that's not typical on a package insert.

Erin Stein: I don't think you see that on the package, but this is on the Mayo Clinic [website], and I feel like this may be where other reference websites are going. Like, here's a list to worry about and here's a list to not worry about as much.

Gillian Goddard: Mm-hmm. Mm-hmm.

Erin Stein: Although I think maybe you would want deal with some of these. I mean, the more common in this category is all sort of like gastrointestinal.

Gillian Goddard: Yeah.

Erin Stein: Diarrhea, heartburn, stomach cramps, trouble sleeping, or sleepiness.

Gillian Goddard: That is because serotonin affects your gut.

Erin Stein: Unusual drowsiness but also trouble sleeping are both listed.

Gillian Goddard: Right? Isn't that fun?

Erin Stein: Yeah. It is fun. And then less common anxiety, nervousness, bladder pain, pins and needles, constipation, frequent urge to urinate, increased appetite, stuffier runny nose,

Gillian Goddard: Mm. Mm-hmm.

Erin Stein: And then incidence not known, decrease in smell, flushed dry skin. Fruit like breath odor.

Gillian Goddard: Yeah. That's ketosis.

Erin Stein: How would you even know that?

Gillian Goddard: I don't know.

Erin Stein: So, they listed the swelling of the breast and the unusual secretion of milk, both in the list of things to worry about and also in the list of things to not worry about. So, if you are a person reading these things, what the hell are you supposed to do with this?

Gillian Goddard: I know, I know. To some degree, unfortunately, there's an expectation that you are applying common sense.

Erin Stein: Ha ha ha.

Gillian Goddard: It's hard to know how to apply common sense. I mean, I know that the reason people can see an increase in breast size and experience breast discharge with these medicines, if rarely, is because in theory they can affect dopamine levels and dopamine levels can affect your secretion of the hormone prolactin. But I will tell you that I'm an endocrinologist. I would say even your run of the mill internist and certainly more surgical specialties like those doctors probably never learned that.

Erin Stein: Yeah.

Gillian Goddard: In general, if you're experiencing something, it's always worth reaching out to your doctor and asking. What I often end up saying to people is it's not a typical side effect, but that doesn't mean that it's not a side effect that you're having because not everybody's body reads the textbook. Not everybody's body reads the package insert. And so sometimes people will have unusual or unique side effects.

Erin Stein: If you are a person looking up a medication, trying to navigate these different kinds of information. I would think the list of pre-existing conditions, which it's not going to be what it says, but that's how I think about it. Like if you already have often heart issues or some other already occurring medical thing. And if you do, you should then not take this medication. To me, that's the most important info.

Gillian Goddard: It is, although I will tell you a lot of times it's very broad. So, for example, there are all kinds of medicines even over the counter medicines, Sudafed comes to mind, where it tells you not to take it if you have a thyroid problem. However, what that technically means, is that you shouldn't take it if you have poorly controlled overactive thyroid because both can raise your heart rate. Not if you have the much more common underactive thyroid. And so, what that means is that, you know, come cold and flu season, a lot of endocrinologists and primary care doctors have people asking them whether it's okay for them to take these medications or worse—I'd rather have you ask the question—just avoiding treating their cold and flu symptoms and feeling cruddy because they are afraid to take them and they don't want to bother their doctor. You're not bothering your doctor.

Erin Stein: That is, generally speaking, key information and something to go over with your doctor if you're discussing new medication. And then really, you're looking at more common side effects as something to consider that might happen. We get really hung up on them. 

Gillian Goddard: Yeah, I agree.

Erin Stein: Like we get really hung up on side effects and what are the side effects? What are the potential side effects? And part of it I think is that when you see all these drug commercials, they legally have to have some speed reader run through all these horrible things that this drug might cause.

Gillian Goddard: Yes.

Erin Stein: Every single commercial it's like something horrible happening and then death. 

Gillian Goddard: May cause death. Yeah.

Erin Stein: Okay, why would I want to take that medication? Right?

Gillian Goddard: Right. I mean, you will not be surprised to hear that while people are enrolled in a clinical trial for a medication, sometimes they die. And that doesn't mean it was the medication that caused it.

Erin Stein: Also, I looked up a birth control pill to look at side effects and death is contemplated in that list as well, but the risk of death from childbirth is much higher than from taking a birth control pill.

Gillian Goddard: Yes, yes yes yes, a hundred percent. You cannot consider side effects in isolation. You have to think about what you're taking the medication for and the potential quote unquote side effects or adverse reactions of doing nothing.

Erin Stein: Right. And side effects get talked about and treated like a primary consideration. And I'm not sure that it should be the primary consideration. I think what you might be taking the medicine for; the potential benefit of the medication is probably your primary consideration.

Gillian Goddard: Mm-hmm.

Erin Stein: And it's definitely something you should talk to your doctor about whether the side effects are actually common. Which ones do they know? Like you were saying, do they have patients who've had these side effects, or have most of their patients been just fine and not had any of these things happen? And one very specific example of that is tamoxifen, a medication that I am on that does have side effects. A lot of them for a lot of women, and then a lot of women have zero.

Gillian Goddard: Mm-hmm.

Erin Stein: So, my doctor talked to me about it. The benefit is reducing my cancer risk by a significant percentage that is definitely worth it to me to try it and see what happens and see if I'm one of those people who has a lot of side effects or if I'm one of those people who doesn't. And thankfully I don't have many side effects. But it was still worth it to me to give it a shot, even if I was going to end up being one of those people.

Gillian Goddard: Well, you know where this comes up all the time is when we talk about medicines for osteoporosis. So, osteoporosis is a funny disease because it is completely asymptomatic, completely asymptomatic, until your hip snaps or your vertebra collapses like a pancake. And yet people hear about all these scary, scary side effects of the medications. But by the time we recommend medications, your fracture risk, your risk of having a fracture without medication is so much higher than your risk of the adverse reactions that people worry about, which are, uncommon, they incur in less than one percent of women. And typically, we're talking about reducing your risk of a fracture that you're already at very high risk for, sometimes by as much as 70%, depending on your age and risk. And so, we have to put these things in perspective. This less than one percent risk of a scary side effect versus the opportunity to reduce your risk of something like a hip fracture, maybe by upwards of 70%. And maybe you had more than a 20% risk of a fracture to begin with. If you're at a high risk of having a fracture and we can get that down into the single digits, and the downside is that you have this, less than 1% chance of this complication. I don't know. The math seems pretty straightforward to me. But I think a lot of times when people are feeling just fine, it's hard to think about that.

Erin Stein: Yes. And I do want to say, you may be one of those people. You may try the medication, and you may have some horrible reaction or side effect. That does happen. It's not like it never happens. And I don't want to gaslight people into being like, you'll be totally fine, take this medicine. 

Gillian Goddard: No, absolutely not. Absolutely not.

Erin Stein: But I think it's worth trying it. If you are having something happen, you know, and then you should stop the medication and talk to your doctor about something else.

Gillian Goddard: And sometimes we can manage side effects. And sometimes it's worth having a conversation about how we do that, going into it, especially if side effects are very common. So, metformin is a medication that I prescribe very, very, very, very frequently. It is an old generic medication that's indicated for the treatment of Type 2 diabetes. But has been studied for all kinds of other things. And we use it often in women who have polycystic ovary syndrome or PCOS, now we call it PMOS. And it has a lot of common side effects that are gastrointestinal. But when I talk to patients about what those side effects are, I also tell them all the things that they can do to reduce their risk of having those side effects. And I let them know that typically those side effects get better over the course of just a couple of weeks if they stick with the medication. And so, understanding that, yes, in that case, gastrointestinal side effects occur in as many as 30% of people, but not for forever. So, understanding how the side effects occur and what to expect is a helpful conversation to have, especially when a medicine has common side effects like that.

Erin Stein: And I'm going to not being a doctor go out on a limb and say a lot of medications can cause gastrointestinal things. 

Gillian Goddard: Yes.

Erin Stein: It seems to me like most of them can, so it's always worth talking to your doctor, like, should I expect this?

Gillian Goddard: Mm-hmm.

Erin Stein: How long should I give it a week or two and it should clear up and give it a chance? Or can I gradually increase the dose to manage that, you know, all that stuff is worth talking to the doctor about. A lot of times we don't. This is part of how to be a savvy patient. Ask these questions when you're getting a medication because so often you go in, you're like, I have this going on. The doctor's like, here's this medication. You're like, okay, great. And then later you're like, wait, what do I need to know about this medication? 

Gillian Goddard: Yeah.

Erin Stein: Be prepared to ask these questions. But don't be so afraid to take something just because it might have side effects. As we said, everything might have side effects. And it's really, what are those side effects? What's the potential benefit? Talk to your doctor about what you should be looking for. But if you have a sudden, more drastic reaction, stop the medication. A lot of us defer to the doctor, there's an authority figure, they've told us we need to take this and we start taking it and we might push ourselves to keep taking it, even if we are having a side effect or an adverse reaction, that's pretty drastic and like we talk about it with perimenopause symptoms. If it's affecting whether you leave the house or not, that’s a dramatic symptom and you should probably stop and call your doctor.

Gillian Goddard: Yes, the call your doctor is super important though. So yes, it's a hundred percent reasonable to stop a medicine causing a side effect, but don't just stop it and not let your doctor know. It might be that you need a different treatment or a different version of the medicine. And it might be that it's treating something really important. And so, the call your doctor is a key step.

Erin Stein: Yes. Or send a message in the portal.

Gillian Goddard: Yes, if it's not emergent. Don't send portal messages that are emergent.

Erin Stein: Call a hotline. It's always good to talk to the doctor about that potential scenario when you're getting the medication, say, what if this happens? What if that happens? Should I stop it and call you? And they will probably have some thoughts on that. But yes, I'm not suggesting just stop taking it and walk away and never talk to your doctor again.

Gillian Goddard: You're not suggesting that, but you would be amazed. They come into the doctor many months later and you find out that they stopped taking something because they had a side effect. So

Erin Stein: Yes, it's true, it's true. And it's because it seems inconvenient and like a chore.

Gillian Goddard: And people don't want to complain.

Erin Stein: The message is you don't have to wait to have an appointment. You can send the doctor a message to let them know. So that if it is something you really need to be addressing, you can address it sooner.

Gillian Goddard: A hundred percent. And sometimes the doctor will be like, try taking the medication with food instead of on an empty stomach or try taking it at a different time of day. We often have tips and tricks and workarounds that can be helpful too.

Erin Stein: I know it's so annoying sometimes to try and remember take this one with food, take this one without food, take this one with a gallon of water…

Gillian Goddard: I know. Take this one with two sips. There are medicines that require all different types of administration. I wish that wasn't the case, but there are real and valid reasons that we make those recommendations. And so, it is important to do your best to take each individual medication the way you're instructed to take it. I appreciate that it can be challenging and inconvenient. But there are real biochemical reasons in many cases. And so, it is important to do your best. Nobody's perfect. Just do your best.

Erin Stein: Yes. So that is other key information that is usually on that little insert is things like that.

Gillian Goddard: It is and if it's really important, if it's really critical, typically it will be A, written in the instructions, and B, oftentimes it'll have those extra stickers on the outside of the bottle that the pharmacist on to say take this with food, take this on an empty stomach.

Erin Stein: You're right, I forgot they have fun stickers they can add.

Gillian Goddard: They're all different colors. They add those when it's extra important. When it is really part of the administration that is critical.

Erin Stein: So, pay attention to that, people. If you get a sticker, they're not just for funsies.

Gillian Goddard: Yes. They're not just decoration. No, they're not. They're not. They serve a purpose.

Erin Stein: Any other things from the pharmacist giving you your medication?

Gillian Goddard: Well, first of all there are so many different medication names.

Erin Stein: Mm.

Gillian Goddard: They can start to sound very similar to one another, especially when we're talking about generic medications. So, like pantoprazole versus propranolol, you might not notice that difference.

Erin Stein: Mm-hmm.

Gillian Goddard: But one of those medicines is for stomach acid and one lowers your heart rate. And so, you really want to know that you have the right medication. In most cases, a generic medicine is completely fine and there's no reason to pay more and take the brand, but there are situations in which taking the brand instead of the generic might be important for you. And if that's a conversation that you've had with your doctor, you do want to make sure that when you go to the pharmacy that they have given you the brand medication and not the generic in those specific cases. Pharmacists are people; they can make mistakes. A lot of pharmacies, especially chain pharmacies, they're really, really busy. And so just making sure before you leave the pharmacy that you're getting the right medication.

Erin Stein: Make sure it's yours and then make sure it's the right one.

Gillian Goddard: Storage would be the other thing. There are two types of medicines where this is especially important. Pills and capsules tend to be pretty resilient. But liquids and injectable medications, which are also liquids, of course, but oral liquids and injectable liquids often need appropriate storage, oftentimes refrigeration. So GLP-1s, for example, you're supposed to refrigerate them, but many times they can be out of the refrigerator for many days. And so, you just want to be clear on how long you can have a medication out. That becomes important when people travel.

Erin Stein: Mm mm. I was just going to say for travelling.

Gillian Goddard: I have people packing their GLP-1s with an ice pack and that's not necessary in most cases.

Erin Stein: Now I have another secret question.

Gillian Goddard: Uh-huh.

Erin Stein: When you have medication and it's old.

Gillian Goddard: Yes. The expired medication.

Erin Stein: And it's been sitting in the cupboard for a couple of years, but it's the same medication that you've always taken.

Gillian Goddard: Mm. Mm-hmm.

Erin Stein: Does it still work or does it stop working if it's been sitting around?

Gillian Goddard: So, the FDA requires that all medicines have expiration dates and the way the expiration date is set is based on the stability of the medication when it's being stored properly,

Erin Stein: Mm-hmm.

Gillian Goddard: When it stays within a certain window of efficacy. If something's a hundred percent effective the day you get it, over time it's losing efficacy, probably very, very, very slowly in many cases, but it's losing efficacy even if you're storing it properly. And so, there's a threshold below which, like once it becomes 90% effective, that's when the expiration date is. And so, to some degree, it depends on how long past the expiration date. It's not like it suddenly turns to poison.

Erin Stein: Right.

Gillian Goddard: It just may not be doing what you think it is doing. It might be a placebo at that point.

Erin Stein: Ha ha ha.

Gillian Goddard: And that can be very important for certain types of medicines. If you're taking an old, expired bottle of pills for your blood pressure medicine and they're not adequately controlling your blood pressure, that could be problematic. If you found an old packet of birth control pills floating around in the bottom of an overnight bag, do you want to rely on that as contraception? I think it really depends on what you're taking the birth control pills for and how catastrophic an accidental pregnancy would be.

Erin Stein: Fair.

Gillian Goddard: It depends on the medication, right? If there's Benadryl in the medicine cabinet and you're having trouble falling asleep and you're going to take a little pink Benadryl, the placebo effect might be just fine in that situation.

Erin Stein: Ha ha.

Gillian Goddard: So yeah.

Erin Stein: On the topic of storage, it's probably not a great idea to keep your medications in the kitchen anywhere near the stove. Just thinking about temperature.

Gillian Goddard: So, it depends on your kitchen a little. So, the big issue with most medicines is temperature. It's because those are the conditions under which they've been studied. It doesn't mean that the minute the cabinet goes above eighty degrees that all the medicines in your cabinet are now ruined. But over time, extremes of temperature can be problematic. And so, cool and dark is the rule of thumb, but not cold.

Erin Stein: My kitchen and I assume many people's kitchens, we have cabinets around the stove, and they get hot when we're using the stove.

Gillian Goddard: That might not be the best cabinet.

Erin Stein: Might not be the best cabinet to keep your medicine in, but some of us keep things in the kitchen if we have to take it with food. We don't want to forget to take it. 

Gillian Goddard: Right. Yeah.

Erin Stein: So, it's in the kitchen, but put it in a different cabinet that's not next to the stove.

Gillian Goddard: Yeah. The bathroom's not a particularly great place to keep medications, actually.

Erin Stein: True. Steamy.

Gillian Goddard: Even though a lot of times people do keep things in the bathroom because they're like brushing their teeth and take their medicine, which is a great habit stack to remember to take your medicine. It depends on the medication. The other place your medicines really don't belong ever is in your checked baggage.

Erin Stein: Mm, mm.

Gillian Goddard: Not because they're going to get lost, although they could. And that would be bad. But because the baggage compartment of the plane gets very, very, very, very cold. And much colder than most medications can withstand.

Erin Stein: True.

Gillian Goddard: Also, the glove compartment of your car.

Erin Stein: Try to keep it an even temperature. Although if it's something you take every day, I don't think keeping it in the bathroom's going to be a big deal. Right.

Gillian Goddard: Well, no, because if you have thirty pills and you go through the bottle with within thirty days, it's probably fine yeah.

Erin Stein: They're not in there long enough. But storing stuff long term in a steamy bathroom like cold medicine you save up for that winter day.

Gillian Goddard: Right. Right. The Tylenol. Exactly. Exactly. The takeaway is we probably think about side effects too much as opposed to not enough.

Erin Stein: Yeah, I think that's true. It's not that it's not important, but it's also not necessarily the most important.

Gillian Goddard: Exactly.

Erin Stein: And you're not going to get all fifty things.

Gillian Goddard: You'd be pretty special if you did.

Erin Stein: If you look at these lists, it would be impossible to have all of them because so many of them are the opposite. 

Gillian Goddard: Because some of them are opposite.

Erin Stein: One I was looking at was like you're growing extra hair, but also hair loss.

Gillian Goddard: Yeah.

Erin Stein: Hopefully that was informative.