Black Box Warnings: Time to Reconsider Our Disease=Drug Reflex?

(From 2020, apropos my recent comment, “First do no harm”.)

The recent news of a black box warning for psychiatric side effects from the allergy drug Singulair (montelukast) reminded me of a patient I saw ten years ago. She wanted help getting off the hook from a shoplifting charge. The judge didn’t buy it.

It is a frightening thought that medications we prescribe to help people feel better emotionally can do the opposite: Antidepressants, for example, can bring on mania, suicidal or homicidal thoughts or actions and are now known to at least some of the time cause irreversible changes in “brain chemistry”.

It is even worse, in fact horrifying, to consider that psychiatric side effects can occur with medications we think of as allergy treatments (Singulair), antibiotics (Levaquin) or antivirals (Tamiflu), immunosuppressants (methotrexate or steroids), acne treatments (Accutane), Parkinson or restless leg treatments (Requip), blood pressure medications (beta blockers), drugs for smoking cessation (Chantix) and so many others. Not that these types of side effects are all terribly common, but they are common enough to have to be a concern.

It does make you pause. Medical providers have flash card style knowledge memorized: Disease = Drug to prescribe. This knowledge is ingrained, learned reflexes that bypass commonsensical, non-pharmaceutical approaches.

The longer I’m in this business, the more I think we need to consider the options in the space between symptom/diagnosis and prescription. It isn’t as uncharted or infertile as we may think and it is often safer and less loaded with inadvertent liability.

First, do no harm.