Medications & Yoga

Margeaux Amerine, Pharmacist and  RYT-200 graduate shares a list of some common medications that can have significance as they relate to a yoga practice.

Medications & Yoga

Medication use is a part of our client intake form, thus having general knowledge of their medications in relation to yoga is important for understanding their overall health, level of pain, as well as how these medications might affect their yoga practice.

Topics:

• Bone and Joint Disorders
• Cardiovascular
• Endocrine
• Neurologic
• Psychiatric
• Respiratory

Bone and Joint Disorders

Common disorders include osteoarthritis, osteoporosis, rheumatoid arthritis and gout.

1. Osteoarthritis (OA)

A common, slowly progressive disorder affecting primarily the weight bearing joints of the peripheral and axial skeleton. It is characterized by progressive deterioration and loss of articular cartilage resulting in osteophyte formation, pain, limitation of motion, deformity, and progressive disability. Inflammation may or may not be present in the affected joint.

Pharmacological Treatment: Pain relief (see neurologic section for complete list of pain relievers and their implications in relation to yoga.)

Considerations: (see neurologic section for complete list of pain relievers and their implications in relation to yoga.)

2. Osteoporosis

Characterized by low bone mass and deterioration of bone tissue leading to bone fragility and increased fracture risk.

Pharmacological Treatment:

• Calcium
• Vitamin D
• Bisphosphonates: Alendronate (Fosamax) Risedronate (Actonel), Ibandronate (Boniva)
  • Bisphosphonates bind to hydroxyapatite in bone and decrease resorption by inhibiting osteoclast adherence to bone surfaces.
• Others include but less common: Selective Estrogen Receptor Modulators (SERMs), calcitonin, estrogen and hormonal therapy, phytoestrogens, testosterone and anabolic steroids, bone formation therapy

Considerations: For patients with osteoporosis who are at risk for fractures, the aims are to prevent falls, fractures, and their complications. Developing a yoga prescription with awareness that these individuals are at increased risk for a fracture is important, however strength exercises may help prevent bone loss and decrease falls and fractures.

3. Rheumatoid Arthritis (RA)

A chronic and usually progressive inflammatory disorder of unknown etiology characterized by involving several joints, with symmetric joint involvement and systemic manifestations.

Pharmacological Treatments:

• Disease-Modifying Antirheumatic Drug (DMARD): methotrexate, hydroxycholorquine, sulfasalazine, and leflunomide
• Non-Steroidal Anti-Inflammatories: (see neurologic section for complete list)
• Biologic Agents: Enbrel, Remicade, Humira
• Corticosteroids: prednisone, methylprednisolone
  • Corticosteroids can cause severe, adverse reactions including tendon rupture and has common side effects including muscle weakness and dizziness/vertigo.

Considerations: Joint swelling, stiffness, and pain are common with RA patients. Long-term corticosteroid treatment will increase the risk for tendon rupture.

Cardiovascular Disorders: (not limited to)

Arrhythmia

Defined as loss of cardiac rhythm, especially irregularity of heartbeat.

Pharmacologic Treatment: Quinidine, Procainamide, Disopyramide, Lidocaine, Mexiletine, Tocainide, Flecainide, Propafenone, Beta-Blockers, Amiodarone, Bretylium, Dofetilide, Sotalol, Ibutilide, Verapamil, Diltiazem

Heart Failure (HF)

A clinical syndrome caused by the inability of the heart to pump sufficient blood to meet the metabolic needs of the body.

Pharmacologic Treatment:

• ACE Inhibitors: Captopril, Enalapril, Lisinopril, Quinipril, Ramipril, Fosinopril, Trandolopril
• Beta-Blockers: Carvedilol, Metoprolol, Bisoprolol
• Diuretics: Hydrochlorothiazide, Metolazone, Furosemide, Bumetanide, Torsemide
• Digoxin
• Others: Spironolactone, ARBs (losartan, candesartan, valsartan), Nitrates, Hydralazine, Amiodarone

Hyperlipidemia

An elevation of one or more of the following: cholesterol, cholesterol esters, phospholipids, or triglycerides.

Pharmacologic Treatment:

• Bile Acid Resins: Cholestyramine, Colestipol, Colesevelam
• Niacin
• HMG-COA Reductase Inhibitors (STATINS): Atorvastatin, Fluvastatin, Lovastatin, Pravastatin, Rosuvastatin, Simvastatin
  • Can cause generalized muscles aches (myalgia/myopathy) as well as the rare, but serious condition of rhabdomyolysis. Many patients experience muscle aches daily while taking these medications.
• Fibric Acids: Gemfibrazole, Fenofibrate
• Others: Zetia, Fish Oil Supplements

Hypertension

Persistent elevation of arterial blood pressure.

Pharmacologic Treatment:

• Diuretics: Chlorthalidone, Hydrochlorothiazide, Metolazone, Bumetanide, Furosemide, Torsemide, Amiloride, Triamterene, Spironolactone
• Beta-Blockers: Atenolol, Betaxolol, Bisoprolol, Metoprolol, Nadolol, Propranolol, Carvedilol, Labetolol
• ACE Inhibitors (angiotensin-converting enzyme inhibitors): Benazapril, Captopril, Enalapril, Fosinopril, Lisinopril, Moexipril, Perindopril, Quinapril, Ramipril
• ARBs (angiotensin II receptor blockers): Candesartan, Irbesartan, Losartan, Omesartan, Telmisartan, Valsartan
• Calcium Channel Blockers: Amlodipine, Felodipine, Nifedipine, Diltiazem, Verapamil
• Others: Alpha-Blockers, central alpha2-agonists, adrenergic inhibitors, and vasodilators

Anticoagulation

blood-thinners (anti-coagulants and antiplatelets) These medications are often used in but not limited to, cardiac patients to prevent clot formation when indicated by a specific condition.

Pharmacologic Treatment:

• Apixaban (Eliquis)
• Dabigatran (Pradaxa)
• Edoxaban (Savaysa)
• Rivaroxaban (Xarelto)
• Warfarin (Coumadin)

Considerations: Can increase a patient’s risk for bleeding and bruising. Special care should be taken in a client on Warfarin as the blood thinning effects can cause major or fatal bleeding. Reducing the risk of falls and excessive bruising should be considered when creating a yoga prescription or general yoga practice.

General Considerations for Cardiovascular Disorders:

These patients without exception need to be cleared from a medical professional before beginning any exercise regimen. Regular aerobic exercise has been shown to improve outcomes in patients with hypertension and hyperlipidemia. These disease states come with various, but not limited to, symptoms including, shortness of breath, fatigue, dizziness, palpitations, chest pain, syncope, confusion, cough, and exercise intolerance. Most medications listed to treat these conditions also come with the same adverse side effects that are similar to the symptoms they are treating. Again, it cannot be stressed enough that these patients must be cleared for physical activity before beginning yoga.

Endocrine Disorders:

Diabetes Mellitus (DM)

Group of metabolic disorders characterized by hyperglycemia and abnormalities in carbohydrate, fat, and protein metabolism. It results from defects in insulin secretion, insulin sensitivity, or both. Chronic microvascular, macrovascular, and neuropathic complications may ensue.

Pharmacologic Treatment:

• Insulin: Humalog, Novolog, Apidra, Humulin R, Novolin R, Humulin N, Novolin N, Lanuts, Levemir
• GLP-1 Receptor Agonists: Tanzium, Trulicity, Byetta, Bydureon, Victoza
• Amylin Analogue: Symlin
• Sulfonylureas: Glipizide, Glyburide, Glimiperide
• Biguanide: Metformin
• Meglitinides: Prandin, Starlix
• Thiazolidinediones: Pioglitazone, Rosiglitazone
• DPP-4 Inhibitors: Januvia, Onglyza, Tradjenta, Nesina
• SGLT2 Inhibitors: Invokana, Fargixa
• Alpha-glucoside Inhibitors: Acarbose, Miglitol
• Bile Acid Sequestrants: Welchol

Considerations: Low blood sugar or hypoglycemia is the primary side effect with most of these treatment options. Low blood sugar can lead to fatigue, dizziness, fainting. Most patients benefit from increased physical activity. Aerobic exercise can improve insulin resistance and glycemic control and may reduce cardiovascular risk factors, contribute to weight loss or maintenance, and improve wellbeing. Exercise should be started slowly in previously sedentary patients. Older patients and those with cardiovascular conditions should receive approval from medical professional before beginning exercise.

Neurologic Disorders:

Pain

an unpleasant, subjective sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

• Types:
  • Nociceptive (acute) pain is either somatic (arising from skin, bone, joint, muscle, or connective tissue) or visceral (arising from internal organs such as the large intestine or pancreas).
  • Neuropathic (chronic) pain is sustained by abnormal processing of sensory input by the peripheral or central nervous system. There are a large number of neuropathic pain syndromes that are often difficult to treat (e.g. low back pain, diabetic neuropathy, post herpetic neuralgia, cancer-related pain, spinal cord injury).

Pharmacologic Treatment:

Opioid Pain Medication

Often used to treat chronic, severe pain. These medications bind to various opioid receptors, producing analgesia (pain-relief) and sedation. In general, these medications can cause sedation, dizziness, nausea, vomiting, constipation, physical dependence, tolerance, and respiratory depression.

Considerations: The effects of the opioid analgesics are relatively selective, at normal therapeutic concentrations, these agents do not affect other sensory modalities, such as sensitivity to touch, sight, or hearing, however, as the dose increases, so do the undesirable side effects. Patients in severe pain may receive very high doses of opioids with no unwanted side effects, but as the pain subsides, they may not tolerate even very low doses.

Frequently, when opioids are administered, pain is not eliminated, but its unpleasantness is decreased. Special care should be taken with these as pain perception may be modified. In treatment of acute pain or injury, exercise should be stopped completely. Yoga should only be started after approval from a medical profession. In treatment of chronic pain and long-term opioid use, extreme caution should be used with these clients. Collaboration with the primary care physical, specialist, or physical therapist is important with these individuals.

• Codeine
• Codeine/Acetaminophen (Tylenol #3, Tylenol #4)
• Fentanyl (Duragesic, Actiq) -most common form in out-patient use: patch
• Hydrocodone (Zohydro ER)
• Hydrocodone/Acetaminophen (Vicodin, Lortab, Lorcet, Norco)
• Hydromorphone (Dilaudid)
• Meperidine (Demorol)
• Methadone (Dolophine, Methadose)
• Morphine (Avinza, Kadian, MS Contin) – Immediate and Extended-Release
• Oxycodone (OxyContin, Roxicodone) – Immediate and Extended-Release
• Oxycodone/Acetaminophen (Percocet, Endocet, Roxicet)

Tramadol (Ultram)

 Non-opioid pain reliever, often used to treat acute or chronic moderate pain. Produces an analgesic effect by binding to mu opioid receptors and weakly inhibits norepinephrine/serotonin reuptake.

Consideration: Although this medication is a non-opioid pain reliever, pain perception may be modified.

Acetaminophen* (Tylenol)

Non-opioid pain reliever often used to treat acute mild to moderate pain. Produces an analgesic effect by weakly inhibiting COX-1 and COX-2 (cyclooxygenase) receptors. *These medication is available over-the-counter or OTC, meaning without a prescription.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)

Often used to treat acute and chronic mild to moderate pain with inflammation. The medications inhibit cyclooxygenase; reduce prostaglandin, and thromboxane synthesis.

Considerations: There can be increased risk for bleeding when taking these medications. These medications play an important role in acute injury by helping to decrease the ‘inflammation cycle’ by, with the exceptions of acetaminophen, preventing formation of prostaglandins produced in the response to noxious stimuli, thereby decreasing the number of pain impulses receive by the CNS. In terms of acute injury or pain, yoga should be stopped or limited and only after approval from a medical profession. You will also see chronic use of these medications for their anti-inflammatory pain relieving properties, but also come with the increase risk for developing a GI (gastrointestinal) bleed. All NSAIDs have some analgesic effects, but there is high interpatient variability in therapeutic response to NSAIDs.

• Aspirin* (Bayer, Bufferin, Ecotrin, Exedrin)
• Celecoxib (Celebrex)
• Diclofenac potassium (Cataflam)
• Diclofenac sodium (Voltaren, Voltaren XR)
• Diclofenac sodium with misoprostal (Arthrotec)
• Diflunisal (Dolobid)
• Etodolac (Lodine, Lodine XL)
• Flurbiprofen (Ansaid)
• Ibuprofen (Advil, Motrin, Motrin IB)
• Indomethacin (Indocin, Indocin SR)
• Ketoprofen
• Ketorolac (Toradol) – used to treat acute, severe pain only
• Magnesium salicylate* (Bayer Select, Doan’s Pills)
• Meloxicam (Mobic)
• Nabumetone (Relafen)
• Naproxen (Naprosyn)
• Naproxen Sodium* (Aleve)
• Oxaprozin (Daypro)
• Piroxicam (Feldine)
• Sodium Salicylate (various generics)
• Sulindac (Clinoril)

Chronic neuropathy (nerve pain)

These medications work by activating or blocking various neurotransmitters and receptors on the brain. Historically, many of these medications were indicated for other uses, but with time have been given secondary indications for the treatment of neuropathy.

Considerations: These medications, specifically, do not work on the same receptors as opioids. The patient will feel decreased pain, however pain perception is not modified.

• Amitriptyline (Elavil) – Depression, migraine
• Duloxetine (Cymbalta) – Depression/anxiety, fibromyalgia, and chronic muscle or bone pain
• Gabapentin (Neurontin) – Seizures
• Nortriptyline (Pamelor) – Depression
• Pregabalin (Lyrica) – Fibromyalgia, seizures

Muscle relaxants

Often used to treat acute or chronic muscle spasms. Exact mechanism of action is unknown for many of these medications; all are centrally-acting muscle relaxants; some work on neurotransmitters in the brain resulting in sedation and alteration in pain perception, reduced spasticity, depression of central nervous system activity, as well as inhibiting monosynaptic and polysynaptic spinal reflexes.

Considerations: These medications are often used in treatment of acute injury or pain; hence all physical activity should be stopped. Chronic use of muscle relaxants is not common as acute use, and is typically seen, but not limited to, patients who have neurologic disorders such as multiple sclerosis and chronic pain due to injury; in these client’s collaboration with a primary care physician, specialist, or physical therapist is key.

• Baclofen
• Chlorzoxazone (Lorzone, Parafon Forte)
• Carisoprodol (Soma)
• Cyclobenzaprine (Flexeril, Amrix)
• Diazepam (Valium)
• Metaxalone (Skelaxin)
• Methocarbamol (Robaxin)
• Tizanidine (Zanaflex)

Topical Pain Relievers

Often used in acute or chronic mild to moderate pain. These medications are applied topically to the area of pain.

• OTC: products containing menthol, camphor, salicylates, capsaicin. (Icy-Hot, Biofreeze, Bengay, Blue-Emu, Capzasin etc…) – these should really only be for acute, short-term use.
• Lidocaine: these products contain lidocaine, which is a numbing agent.
• Lidoderm Patches: prescription only – Ointment, gels, cream: some are OTC others are prescription depending on strength.
• Diclofenac Gel (Voltaren) – Anti-inflammatory gel applied directly to painful joint. May be preferred method of chronic NSAID therapy as it decreases risk for GI bleed.
• Diclofenac Patch (Flector) – Anti-inflammatory patch applied directly to painful area.

General considerations for Neuropathic Disorders:

This information is not here for you to diagnose your client’s level of pain, but to rather understand their general pain level, duration of pain treatment, and to provide insight into their general health. In my practice, I see patients on acute and chronic pain medications everyday. In general, many patients on chronic pain medication are able to perform daily functions while taking these medications. This does not go without saying that any type of opioid intake can cause pain perception modification, respiratory depression and death in not only acute but also chronic use and any person under the care of a physician should be cleared for physical activity. Most importantly this information can provide you more insight into understanding pain in our clients. Pain itself is perceptive; one person’s level 10 pain might be another person’s level Listening and being aware are the best tools you can use.

Psychiatric Disorders

 Anxiety disorders

A constellation of disorders in which anxiety and associated symptoms are irrational or experienced at a level of severity that impair functioning.

Pharmacologic Treatment:

• Benzodiazepines: Alprazolam (Xanax), Clonazepam (Klonopin), Diazepam (Valium), Lorazepam (Ativan), Temezapam (Restoril), Triazolam (Halcion)

Considerations: Can increase risk for falls (especially in the elderly), dizziness, fatigue, impaired coordination, and drowsiness. Due to their sedative effects, extreme caution should be used if a patient is taking one of these medications while doing yoga. Treatment with these medications can be acute, or during a period of heightened anxiety or panic, as many of them have a short duration of action, or can be used chronically as daily therapy to treat some psychiatric disorders, seizure disorders or as a muscle relaxant. Having knowledge of your clients intake and frequency can help determine the appropriateness and safety related concerns in associated with a yoga practice. Collaboration with a client’s primary care physician, counselor or therapist can help to determine appropriateness and safety related concerns.

• Antidepressants: escitalpram, imipramine, paroxetine, venlafaxine
• Azapirones: buspirone
• Diphenylmethane: hydroxyzine

Major Depressive Disorder

Characterized by one or more major depressive episodes without a history of manic, mixed, or hypomanic episodes.

Pharmacologic Treatment:

• Selective Seratonin Reuptake Inhibitors (SSRI): Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline
• Serotonin/Norepinephrine Reuptake Inhibitors: Venlafaxine, Duloxetine, Desvenlafaxine (Pristiq), Levomilnacipran (Fetzima)
• Aminoketones: Buproprion
• Triazolopyridine: Nefazodone, Trazodone
• Tricyclic Antidepressants: amitriptyline, Clomiprimine, Doxepin, Imiprimine, Despiramine, Nortripyline,
• Monoamine Oxidase Inhibitors: Phenelzine, Tranylcypomine
• 5-HT1A Receptor Antagonist: Vilazodone (Viibryd)
• 5-HT3 Receptor Antagonist: Vortioxetine (Brintellix)
• Noradrenergic Antagonists: Mirtazipine

Considerations: Most medications to treat these condition come with corresponding side effects to include, but not limited to, dizziness, fatigue, headache, impaired coordination, drowsiness, anxiety, sedation, insomnia, orthostatic hypotension; this should be taken into consideration when designing a yoga practice. Counseling, stress management, cognitive therapy, meditation, supportive therapy, and exercise can be powerful tools and should be used collaboration with other care providers such as counselors, therapists, or medical professional; this includes the treatment of other psychiatric disorders such as Alzheimer’s and Schizophrenia.

Respiratory Disorders: (not limited to)

Asthma

A chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. Episodes of wheezing, breathlessness, chest tightness, and coughing.

Chronic Obstructive Pulmonary Disease

Progressive airflow limitation that is not fully reversible. Airflow limitation is usually both progressive and associate with an abnormal inflammatory response of the lugs to noxious particles or gasses. The most common conditions comprising COPD are chronic bronchitis and emphysema.

Pharmacologic Treatment:

• Inhaled Beta-agonists: Albuterol, Formoterol, Salmeterol, Levalbuterol
• Anticholinergics: Ipratropium, Tiotropium
• Oral Corticosteroids: Prednisone, Methylprednisolone, Prednisone
  • Corticosteroids can cause severe, adverse reactions including tendon rupture and has common side effects including muscle weakness and dizziness/vertigo.
• Inhaled Corticosteroids: Beclomethasone, Budesonide, Flunisolide, Fluticasone, Mometasone, Triamcinolone
• Others: Theophyline, Cromolyn, Accolate, Montelukast

Considerations: A medical professional should clear clients with these conditions before beginning an exercise regimen. In contrast to oral corticosteroid therapy where unwanted side effects like tendon rupture, muscle weakness and dizziness are a concern, inhaled corticosteroids have less systemic absorption. Beta-agonists can have unwanted side effects to include wheezing, chest tightness, trouble breathing, nervousness, tremor, chest pain, palpitations, nausea, or dizziness. Due to the nature of these conditions and associated side effects, collaboration with a medical professional is important for the safety of the individual.

General considerations on Respiratory Disorders:

This information is not meant for you to diagnose or plan treatment for your client, but to better understand and aid you and your client in developing a safe yoga practice. It cannot be stressed enough that these common medical conditions, but not limited to, come with increased risk when patients partake in physical activity, thus making sure they care cleared by their physician for physical activity and collaboration with their care providers is crucial for their safety, as well as your own.

This information is not all-inclusive and if you have any questions regarding medications related to yoga, please feel free to email me at mcschoofs@gmail.com.

Sources:

Wells, Barbara G., Joseph T. DiPiro, Terry L. Schwinghammer, and Cindy W. Hamilton. Pharmacotherapy Handbook. Sixth ed. New York: McGraw-Hill Medical Pub. Division, 2006. Print.