Medication use in PMD, what is safe and when to use caution
Historically, it was thought that mito patients should avoid many medications as they could impact mitochondrial function. However, we now know that many medications are well-tolerated when taken for routine care.
It is important to remember that side effects can occur with any medicine in any patient. It is, therefore, essential to follow the advice of your healthcare provider and read the information about the medicine.
In 2019, the “Safety of drug use in patients with a primary mitochondrial disease: An international Delphi-based consensus” paper was published. This updated consensus paper established new guidelines for safe medication use in patients with primary mitochondrial disease. Specific drugs, drug groups, and clinical or genetic conditions are described separately in the paper.
From this paper, the International Mito Patients Association (IMP) created a “List of Medicines to be Used with Caution” document, which includes two tables. Table 1 is a “List of drugs studied and considered safe to use,” and Table 2 is “Attention regarding drug prescription in patients with a mitochondrial disease”
Table 1. List of Drugs Considered Safe to Use
Category | Generic Name |
---|---|
ACE Inhibitors | Captopril, perindopril, enalapril, lisinopril |
Analgesics – Antipyretics | acetaminophen (Paracetamol), salicylates |
Anesthetics | artisan, bupivacaine, lidocain, halothane, isoflurane, sevoflurane, barbiturates, fentanyl, ketamine, midazolam / benzodiazepine, propofol |
Antiarrhythmics | amiodarone, beta blockers |
Antibiotics | ceftriaxone, chloramphenicol, linezolid, quinolones, tetracylines |
Antidiabetic drugs | biguanide drugs (metformin), thiazolidinedione (glitazones) |
Antiepileptic drugs | barbiturates, carbamazepine, gabapentin, levetriacetam, oxcarbazepine, perampanel, phenytoin, rufinamide, stiripentol, topiramate |
Antipsychotic / neuroleptic drugs / antidepressants | amitriptyline, amoxapine, chlorpromazine, clozapine, fluoxetine, fluphenazine, haloperidol, quetiapine, risperidone |
Antiretroviral drugs | eg zidovudine, abacavir |
Bisphosphonates | eg pamidronate, alendronate |
Cannabidiol | |
Chemotherapeutics | eg carboplatin, doxorubicin, ifosfamide |
Ethanol | |
Fibrate drugs | clofibrate, ciprofibrate |
Immunotherapeutics | interferons |
NSAIDs | eg diciofenac, indomethacin, naproxen |
Statins | ceftriaxone, chloramphenicol, linezolid, quinolones, tetracylines |
Steroids | eg hydrocortisone, dexamethason, prednisone |
Table 2. List of Drugs with Cautions
Category | Points of Attention |
---|---|
Valproic acid (sodium valproate) | Should be used only in exceptional circumstances. Should absolutely not be given to patients with mutations in a gene called POLG or to patients with symptoms suspicious for POLG disease. Should not be used in patients with liver disease. |
Aminoglycosides (antibiotics) | In case of specific mitochondrial DNA mutations (12S rRNA) these antibiotics may cause hearing loss. In emergency situations ahminoglycosides could be used while the benefits of the drug are more important then. If long-term treatment is necessary one should screen for these mutations and / or switch to another antibiotic regime. |
Neuromuscular blocking drugs (used for anaesthesia) | In patients with muscle disease these drugs should preferably not be used or, if necessary, under strict monitoring. |
Specific Situation | |
General anaesthesia and surgery | The time of fasting before surgery should be as short as possible. During prolonged anaesthesia fluid and caloric intake should be guaranteed by glucose infusion, unless the patient is on a ketogenic diet. |
Duration of treatment | Side effects may develop when medication is used for a longer period. It must be assessed for each individual patient whether the need for long-term treatment outweighs the possible side effects. |
Kidney failure | Kidneys remove certain medicines from the blood. If the kidneys do not work properly, too much medicine remains in the blood. This may cause more side effects. Dosage and / or dosing frequency should be adjusted for these medicines. |
High lactic acid in blood | Patients with a mitochondrial disease may have an increased blood acidity due to high lactic acid. In that case, drugs that can make the blood acidic should preferably not be used or, if necessary, under regular monitoring of blood values. |