Sunday, October 17, 2010

When High Blood Pressure Is Hard To Control......

Resistant Hypertension

The average person with high blood pressure is on 2.3 medications. Up to 30% of this population has “resistant hypertension,” defined as blood pressure that is above goal despite the use of three or more appropriate blood pressure medications at maximal doses, with one being a diuretic or “water pill.”

Obesity, excess salt intake, excessive alcohol use, having diabetes, being over 75, having left ventricular hypertrophy (thickened walls of the heart on EKG or heart ultrasound), obstructive sleep apnea (loud snoring and daytime drowsiness) or chronic kidney disease all contribute. Medications like Non Steroidal Anti Inflammatory Drugs (high doses of aspirin, ibuprofen, or naproxen), stimulant compounds (for ADHD, decongestants, and diet drugs), oral contraceptives, herbal preparations containing ephedra, and some injected anemia treatments can elevate blood pressures.

Falsely elevated readings occur when the cuff is too small for a patient's arm girth, by not getting a resting value, by poor compliance with medications, or by anxiety. Some older patients have heavily calcified arteries, and it is best to also check the pulse at the wrist when evaluating the real blood pressure.

Those who are resistant to control should be screened for secondary forms of hypertension, including kidney disease, kidney artery narrowing, and primary aldosteronism (an excess stress hormone). Less common causes of resistance include Cushing's syndrome, pheochromocytoma, hyperparathyroidism, intracranial tumors, and aortic coarctation (ask your doctor to consider these).

Blood pressure should be measured repeatedly with a proper-size cuff using good technique. Make sure that you are taking all medications as directed. Drugs that may interfere with blood pressure control should be discontinued, if possible.

A physical exam should look for damage in the retina (back of the eye), arterial blockages/narrowing, features of Cushing's syndrome, and a blood pressure checked in both arms. If you are anxious, blood pressure readings at home or work, or ambulatory blood pressure monitoring, should be considered.

Lab evaluation to look for secondary causes should now be considered to include basic labs and urine testing, first morning aldosterone/renin stress hormone levels, activities and ratios. Also, a 24-hour urine test can be obtained if there is a history of severe spikes in pressure with sweating and headache. Imaging tests for kidney artery narrowing can be considered in young patients with severe hypertension, and in older patients with vascular disease. In most cases, no secondary cause is found because the cause is often multifactorial.

Lifestyle modification with a low-salt, high-fiber, low-fat diet; weight loss; moderation of alcohol intake; and exercise should be encouraged. Treatment of sleep apnea should be started. Medication regimens should be simplified, making compliance easier.

Blood pressure can often be improved by increasing the dose or changing to a more potent diuretic. In patients with chronic kidney disease, the use of a strong diuretic used twice a day can help. Adding diuretics like spironolactone or amiloride may have additional benefit.

If blood pressure remains elevated despite the above, referral to a hypertension specialist is recommended.

Saturday, September 4, 2010

Nocturnal Leg Cramps

There are no FDA approved treatments for leg cramps and the non prescription and prescription treatment options are more from individual experiences and not from large trials proving effectiveness or safety.

That said, here are some options- trial and succeed but you may need a few trials…

1)    Nighttime leg stretches of the most prone muscle groups- gentle stretch tension not bouncing- hold for count of twenty and repeat 3-5 x

2)    B complex- B 50 3x a day- over the counter

3)    Magnesium supplements if OK with your doctor Slo Mag or Mag Ox are over the counter 1 1-2x a day-

4)    Consider trial of a week or two or three off Statin cholesterol medication if you are taking them

5)    Diltiazem immediate release 30mg at bedtime

6)    Escalating doses of gabapentin from 100mg up to 600mg as a bedtime dose- may take a few weeks to improve symptoms

7)    Quinine has been used with mixed success (if any, but some patients swear by it) for many decades. It has recently been given a black box warning as it carries a 1 in 110—1 in 200 chance of severe blood clotting, bleeding and or bone marrow toxicity risk which could prove disabling or fatal. It is an option as a short term (1-2 months to see if it helps) trial only when all else has failed and the symptoms are so severe that the patient is willing to take a risk similar to base jumping (parachuting from cliffs and tall buildings), an extreme sport, to get relief.

Saturday, March 13, 2010

About Kidney Stones

What are kidney stones?

A kidney stone is a hard gravel-like mass in the kidney, ureter tube from the kidney to the bladder or in the urethra tube that passes urine out of the body. Kidney stones are usually made of mineral salts (most commonly calcium but sometimes uric acid, the gout chemical).

What should I know and do for kidney stones?

Symptoms include:

Pain that usually begins suddenly and commonly comes in waves of intensity
Pain that is in the back or flank and seems to move to the lower abdomen, groin or legs
Dark or bloody urine
Take medication exactly as directed.
Do not drive while taking these pain medicines.
Drink at least 2-3 quarts of fluids a day (water is best) to flush out the particle(s). Reverse osmosis filtered water for drinking water has much less mineral content and might be helpful for long term use.
Strong Narcotic pain medications as well as Ibuprofen if approved by your doctor help manage pain.
Also, at a recent Urologic conference studies were presented that found Medical expulsive therapy with off label use of (non FDA approved use for kidney stones) steroids, nifedipine calcium channel blocker, Flomax (tamsulosin), (as well as considering a low dose Viagra type medication) as a potential powerful tools to reduce acute painful stones working their way down when the stones are smaller than 10mm and certainly if 3-5mm.

What should I do if I think I have kidney stones?

Strain your urine so that you can catch the stone if and when it passes. Cheesecloth works well for this, as does any porous clothing material. If you do catch the stone or little chunks of sand or gravel, take them to your doctor so it can be analyzed. Your doctor may suggest a diet change based on the type of stones you have.

You should have at least an x ray called the KUB as well as routine lab work and a urine analysis and culture with the onset of likely kidney stone. Cat scan without contrast via stone protocol is now the best study to confirm a stone and assess position size and degree of urine tube blockage. The only downside is the cost and the modestly higher radiation dose especially in those with a history of multiple stones so sometimes a simple KUB and ultrasound can be done instead.

If you are female or have more than one stone or an infection related stone a more thorough investigation including a 24 hour urine test are in order. Also, if you don’t pass a stone within 10-14 days, you should seek help from a urologist as early permanent kidney damage starts to occur when the urine tube is blocked by a stone within 14 days and if fully blocked, a kidney will become non functional by 6 weeks from onset.

Stones <4mm have greater than an 80% chance of passing on their own within the 10 day wait period. Stones 4-6mm have about a 60% chance of passing on their own. Stones 6-8mm have a 40% chance of passing and stones >8mm should be referred to an urologist immediately for removal.

To help prevent formation of kidney stones:

If you have more than one kidney stone, especially if you have a family history of stones, you are more likely to have kidney stones again. But you can take steps to help prevent them:

Exercise on a regular basis at least 3 times a week

Follow diet instructions provided by your doctor

Drink more fluids. Try to drink enough water to keep your urine clear, about 8 to 10 glasses of water per day. Slowly increase how much you drink, perhaps adding one more glass of water a day until you are drinking 8 to 10 glasses a day. This slow increase will give your body time to adjust to the extra fluids. You are drinking enough water when your urine is clear or light yellow. If it is dark yellow, you are not drinking enough fluids. If you have kidney, heart, or liver disease and have fluid restrictions, talk with your doctor before increasing how much you drink.

Change your diet. This may be helpful, but it depends on what is causing your kidney stones. Your doctor may do more tests before deciding whether changing your diet will help reduce your risk of developing another stone. The results of these tests may suggest that it could be helpful to do one or more of the following:
Increasing how much fiber you eat. Fiber includes oat bran, beans, whole wheat breads, wheat cereals, cabbage, and carrots.
Eating less beef, pork, and poultry.
Eating a moderate or high amount of calcium-rich foods, such as dairy products. Getting your recommended amounts of calcium, combined with a diet low in sodium and protein, may decrease your risk of kidney stones.7 In older people and younger women, one study indicates that eating more calcium-rich foods reduces the risk of kidney stones.8
Avoiding foods that are high in oxalate such as dark green vegetables, nuts, and chocolate.
Not adding salt when you cook or eat. Try removing the salt shaker from your table.


If you get more kidney stones despite drinking more fluids and making changes to your diet, your doctor may give you medicine to help dissolve your stones or to prevent new ones from forming. You may also receive medicine if you have a disease that increases your risk of forming kidney stones. Which medicine you take depends on the type of stone you may have.

Medicine to prevent calcium stones

About 80% of kidney stones are calcium stones.  Calcium stones that have already formed cannot be dissolved by changing your diet or taking medicines. There are medicines that may keep calcium stones from getting bigger or may prevent new calcium stones from forming:
Thiazides (such as hydrochlorothiazide, chlorthalidone).
Potassium citrate (Urocit-K).
Orthophosphate (Neutra-Phos).
Cholestyramine (Questran).

When and why should I follow up with the doctor?

If you have nausea or vomiting and can not keep fluids down.
If you develop more intense pain in the back or abdomen
If you notice blood in your urine or your urine is dark
If you have difficulty passing you urine
If you develop fever or chills

Make sure that even if your pain has subsided or that you have passed what you think was the stone that you call your doctor’s office and let your doctor know. Also, find out if any further testing for follow- up is needed. Commonly a CAT scan or an Ultrasound is performed to make sure that there is no hidden blockage of the ureter tube which may lead to painless loss of a kidney over 4-6 weeks time. Lastly depending on the type of stone, the number of stones you have or have had and the size of your stones, your doctor may want you to follow-up for a more detailed evaluation, blood work and 24 hour urine analysis for stone forming tendencies that may have a stronger genetic component and put you at increased future risk of recurrent stones and other seemingly unrelated health problems.

Note- high amounts of protein in the diet and high amounts of sodium in the diet force an increase in urinary calcium which then binds to the usually excreted urinary oxalate from dietary sources such as fruits and vegetables and can increase stone risk.

Note on pain medications containing Tylenol/acetaminophen:

Take medications as directed, never more. Realize that there is acetaminophen in most prescription pain medications, and severe or permanent liver damage can result from prolonged use and after taking higher doses than recommended of this medicine.

Sunday, March 7, 2010

Alternative Headache Therapy

Treating the different forms of headache and chronic pain syndromes often requires an individualized approach, utilizing a team of specific professionals to achieve lasting success. Several treatment trials may be required until lasting success is achieved. Using conventional prescription medications until the right nutritional and lifestyle approach is firmly established should be considered in order to decrease suffering and disability. Also, we sometimes need to treat depression or anxiety first in order to remove roadblocks to lifestyle change.

Treatment of these conditions results in gradual and delayed improvement. Once an adequate response has occurred, we can start to eliminate several of the supplements as long as your diet and lifestyle are back on a healthy track.

To reduce Pain immediately try laying down in a dark quiet room. Put a cold moist towel over your forehead. Massage your scalp using a lot of pressure. Put pressure on your temples.

Don’t smoke. If you do, quit.

Avoid excess alcohol (especially red wine). If you drink more than two alcohol-containing beverages a few times a week or if you binge not infrequently, cut down.

Avoid caffeine/stimulants. If you drink coffee, tea, sodas, chocolate, cocoa, carob, or take supplements with caffeine, Kola nut, guarana, Ma Huang, or ephedra/sudoephedrine in over the counter diet supplements or decongestant medications, you will need to slowly wean off of these over a few weeks.

Avoid regular use of pain medications (Excedrin/ibuprofen/Tylenol etc) more than three or four times a week, or combination headache medications like Esgic or Fiorinal on a regular basis.

Avoid strong odors, bright lights and loud noises. These can all be migraine triggers as can stress, weather change, fatigue, eyestrain, menstruation, loud noises, over exertion, and fatigue.

Avoid certain foods or food additives Some of these items may be triggers. Try to find out which if any seem to be associated with headache shortly after ingestion; Aged, canned cured, or processed meat (bologna, game, ham, herring, hot dogs, pepperoni, sausage), artificial sweeteners- Aspartamine/Nutrasweet, Avocados, Beans (pea pods, snow peas, pole, broad, lima, Italian, navy, pinto, garbanzo, and lentils), Brewer’s yeast (fresh yeast coffee cake, donuts, sourdough bread), Canned soup or bouillon cubes, most Cheeses especially aged cheese, Cultured dairy like buttermilk and sour cream, Figs, citrus fruits, Meat tenderizer (MSG), Nuts and peanut butter, Onions except for flavoring, Papaya, Passion fruit, Pickled salty or marinated foods (olives, pickles, sauerkraut, soy sauce, seasoned salt), Raisins, and Red plums.

Avoid missing meals or fasting. If you are overweight, moderate weight loss of five to ten pounds, at a level of a pound or two a week may provide benefit.

Be aware of symptoms that precede migraine such as fatigue, yawning, excitability, high energy, visual disturbances (flashes sparks, wavey lines, blind spots, and nasal congestion.

Consider early abortive treatments with Tryptan Rx medication, or Excedrin Migraine as indicated by your doctor. Realize that early treatment might prevent a full blown disabling migraine from blossoming.

Consider preventive or prophylactic treatments if you need headache medication more than 2 days a week or you are functioning poorly due to any aspect of the migraine spell on a fairly regular basis, you should consider preventive therapies. There are a few FDA approved medicines and a myriad of off label prescription medications in an array of categories such as blood pressure lowering, antidepressant and seizure prevention medications that if taken daily can lessen the severity and or reduce the frequency of migraine headaches.

Exercise- moderate levels such as a brisk walk outside for thirty minutes five times a week or swimming is very helpful, especially during daylight hours. Advance to include resistance training, stretching, and more intense aerobic exercise as time and tolerance permit. Start with a physical therapist or trainer to avoid injury.

Maintain consistent sleep/awake hours. Schedules that vary often induce headaches.

*Magnesium Slo Mag (over the counter), or Mag Ox 400 mg, one pill two times a day.

Calcium 1,200-1,500 mg per day with Zinc/vitamin D
Calcium citrate with meals two to three times a day- Citrical, Oscal-D, Cal/Mag/Zinc, or nonfat dairy sources, especially from yogurt three to four servings day as well as green leafy vegetables.

B Complex or multivitamin with Bs-Centrum silver, etc…

*Take omega 3 fatty acids or Essential Fatty Acids (4-6 grams a day is the suggested range). This ideally it should come from actual fish (salmon, sardines, cod, or small mackerel), walnuts or fresh flaxseed oil has some omega 3 fat but its biological effects may vary. Extracted fish oil capsules are generally distilled and not likely to carry many impurities such as mercury or pesticides etc. Some brands that have less fishy aftertaste are Fisol and Omega Synergy that (can be bought by ordering it on the web at; or by calling 1-800-847-8302). These can additionally be kept in the freezer further reducing aftertaste issues if present.

*Vitamin B2 (riboflavin) may help when taken in higher than the 2mg/day RDA dose. Doses of (200mg 2x a day = 400mg a day) have proven helpful at decreasing headaches over time in many people. It usually takes about 3 months to start working.

*Feverfew (Tanacetum parthenium) containing greater then 0.2% parthenolide 50-100mg a day has proven to reduce migraines, and prevent recurrent attacks as a maintenance treatment where conventional treatments have been inadequate.

“MigreLief” combines Magnesium, B2/Riboflavin and Feverfew) 1 tablet twice a day $17 to $25 a month

*Butterbur Petasites Hybridus in extract form known as Petadolex 150mg a day- as published in “Neurology” reduced the frequency of migraines by almost 50%– costs $40- $50 a month.- may cause upset stomach or burping – may also help in asthma and allergies

*Co-Enzyme Q10 100mg as a gel 3 x a day may reduce headache frequency by a third- worth a try for a month or two. If you find a good source it should only cost $40 a month but can be very expensive.

Sinus Buster capascin hot pepper nasal spray can help with chronic sinus congestion, sinus and migraine headache control as well as per noted from the Princeton Longevity Center 11/07,

Acupuncture has proved quite helpful for both acute treatment of pain symptoms as well as the maintenance of more chronic arthritic or inflammatory problems.

Less well proven approaches that some patients have reported success with include:

Evaluating for unfavorable bacterial overgrowth in the intestinal tract and removing, replacing, and repopulating and retaining a healthy balance of intestinal flora with probiotic supplements may also play a role in treating more serious inflammatory conditions.

Detoxification with a combination medical foods and elimination diets may also help achieve a reduction in the inflammatory process causing arthritis and chronic pain. It may also help to detoxify one’s system further reducing inflammation.

Fatigue- American Ginseng for, 200-2,000 mg per day as needed.

Insomnia- Chamomile tea and Valerian capsules at bedtime.

Thursday, March 4, 2010

Domestic Violence: Protecting Yourself and Your Children

It is much more common than you think.

What is domestic violence?

Domestic violence is abuse by a caregiver, a parent, a spouse or an intimate partner. It can take many forms. Here are some types of abuse: Physical abuse is the use of physical force; sexual abuse means any forced sexual activity; emotional abuse includes threats, constant criticism and put-downs. Controlling access to money and controlling activities are other abusive behaviors.

What should I know about domestic violence?

Violence against a partner or a child is a crime in all states. Each year, at least 2 million women are abused in this country. Abuse happens to people of all races, ages, incomes and religions.
People who are hurt by their partners or parents do not cause the abuse. Alcohol and drugs do not cause abuse, although they can make the violence worse. Abuse can begin, continue and increase during pregnancy.

What can I do if my children or I am abused?

First, make sure you and your children are safe. Go to a safe place, such as the home of a friend or a relative or an emergency shelter. Take your children with you. Call the police if you think you can't leave home safely or if you want to bring charges against your abuser.
If possible, take house keys, money and important papers with you. Do not use drugs or alcohol at this time because you need to be alert in a crisis. The staff members at emergency shelters can help you file for a court order of protection.

What are other ways I can get help if I am abused?

Talk to your doctor, who can treat any medical problem, provide support and make referrals. Call an emergency shelter and ask about counseling and support groups for you and your children. Nurses, social workers and other health care professionals can also help you.

Other Organizations

Domestic violence center W. Chester 610 431 1430
Crime victims center Inc  610 692 7420
Crime victims center of Chester Co. Sexual assault 610 692 7273
Chester Co Legal aid services 610 436 4510
National Coalition Against Domestic Violence
National Domestic Violence Hotline

Sunday, February 28, 2010

Patient Centered Medical Home

This video depicts the patient centered medical home, which was modeled on concierge practice.  Watching it will give you an overview of what my practice team does every day for our patients.

Monday, February 15, 2010

ALLI - Weight Loss Medication Option

Orlistat or Prescription Xenical (over the counter ALLI)
 How it works

Orlistat (Xenical), a novel drug was FDA approved in 1999 for use in those with obesity. It is different than over the counter “fat blockers” which are often soluble fibers (commonly found in psyllium –Metamucil-, beans, fruits and vegetables, especially prunes), chitins, or soap like substances. These may soak up variable amounts of fat or form fat globules in the stomach or a test tube, but the digestive process usually breaks these down later.

This new drug actually chemically binds and inactivates the enzyme that is produced in stomach and pancreatic juices called lipase. Lipase works by cleaving off the fatty fingers from the comb-like dietary fats, breaking the dietary fats down into an absorbable form. By dulling this lipase enzyme, absorption of fat is decreased by over thirty percent. This non-irritating fat passes through the small intestine undigested, and passes in the stool.

There is no significant absorption of Xenical into the blood stream. The medication appears to be harmlessly passed in the stool as well. There are almost no known significant drug-to-drug interactions, making it a safer alternative for those with other medical problems.

More is not better. The standard dose of one pill with each fat containing meal seems to give maximum fat blocking benefit. Conversely, if one eats a nonfat or very low fat meal (for instance bran cereal with skim milk, fruit and a multivitamin for breakfast), there is no weight loss benefit in taking the medication at this time. Xenical should be taken an hour before or up to an hour after eating a fat containing meal.

Cost saving tip
One can save significantly on the cost of this medication by avoiding fat in one or two meals a day, therefore only needing the Xenical once or twice, not three times a day. Fruit, fiber cereal, skim milk and a multivitamin for breakfast, low fat turkey or other healthy choice sandwich (with fat free cheese or mayo) and a V-8 for lunch, and a regular dinner with a Xenical is a cost effective way to save calories and money with this weight loss program. It is best to keep a small store of medication in a wallet or purse compartment for those unexpected meal times.

Side effects
Based on the mechanism of action, there are expected but largely avoidable side effects. These side effects can also be looked at as a major benefit to this weight loss program as it trains the user not to binge on high fat foods or else pay the consequences. Bright orange or brown oily drops are often found floating in the toilet water for several days after a high fat meal. Initially, increased frequencies of BMs are common. At times, a small amount of relatively odorless orange or brown oil may slip out when passing gas, so one needs to be watchful for hygiene, and avoid gas forming foods or take beano to help lessen potentially embarrassing events. Patients on Xenical may need to do periodic “Xenical checks” after passing gas, using a restroom to test wipe. These side effects are generally short lived in the first weeks of starting Orlistat, but may continue for months or recur after a high fat meal. You rapidly become more attuned to throwing out scraps and not finishing the high fat items leftover by the kids or at restaurants. Even so, only about five percent of people tested on the medication stopped it due to side effects.

Theoretically, Xenical may inhibit the absorption of fat-soluble vitamins in our diet. One should therefore take a multivitamin at bedtime or at a time several hours separate from the Xenical to ensure proper nutrition.

Avoiding side effects
One can avoid side effects and improve the weight loss potential from Xenical by decreasing fat and increasing fiber intake. Studies have shown that side effects can be lowered by fifty percent in those on high fiber diets. Before starting Xenical, I suggest you get used to a high fiber diet first. The average American diet has 10-12 grams of fiber per day. We really need 20-30 grams a day. It may take two or three weeks for your intestines to adjust to this high level of fiber. Only after you have adjusted to a high fiber diet should you start your Xenical treatment program.

Whole grain foods as well as beans, fruits and vegetables (and lots of them) are good sources of fiber. Lettuce is not. Cereals (if you can tolerate fat free milk or milk substitutes) such as Fiber One or All Bran (extra fiber or bran buds) are excellent sources of high fiber. Kashi “Go Lean” cereal tends to cause gas but can be tried. You can sprinkle some of your preferred cereal on top of the fiber for flavor. I also suggest adding fruit (other than starchy bananas) for flavor and nutritional value. Other options for those on the go are the Metamucil fiber bars or Citrucel or Fibercon tablets with plenty of water, or you can add the new tasteless powdered soluble “Benefiber” to your food and drink. Have a bowl of fiber cereal if you are feeling the urge to nibble, or before or after dinner if you are feeling hungry. For variety, try a piece of fruit and lots of water as a chaser to take the edge off your hunger.

Also, you should avoid the Olestra (non-absorbable fat) snack products recently made available. These also increase the delivery of non-absorbed fat through the intestinal tract and increase the risk of side effects on Xenical.

Collateral benefits
Due to its mode of action, Xenical lowers cholesterol, blood sugar in diabetics, and blood pressure in hypertensive patients to a modest degree. It also may help those suffering from constipation. It also discourages people from eating high fat meals and hopefully helps them make healthier food choices incorporating more fruits and vegetables into the diet.

Tuesday, January 5, 2010

Depression May Be a Side Effect of Other Medications You are Taking

When someone is feeling depressed or blue for a prolonged period, they often feel that they are carrying around an invisible, deeply painful and condition. Many persons with depression are also being treated for other medical conditions, and may have contributing factors that perpetuate the feeling of internal pain. A careful history as well as an honest review of over the counter and prescription medications as well as lifestyle issues such as social stress, work, sleep, diet and alcohol or other substance use needs to be factored into planning a strategy to reduce pain.

You and your doctor need to also evaluate your risk of bipolar disorder (Manic Depression), panic disorder, and suicidal risk early in the conversation, all of which require a slightly or substantially different approach.

It is important that you recognize that depression can be mild moderate or severe. If severe, it can be a serious life threatening condition. Treatment often requires a step wise process that often takes at least a few months to yield substantial improvement, so you and your health care provider need to maintain a longer term horizon of expectations. Your health care provider should have several strategies that can at least take away some of the immediate pain while you are waiting for longer term improvement.

Several medication classes can cause an unexpected or idiosyncratic reaction to a given individual and act as an anchor to improvement or actually lead to your current depressive episode. Keep in mind that even if you are taking a medication listed below and have concern about its side effects, any change or withdrawal of medication should occur only after you and your health care provider have had discussions about the relative risk : benefits of any such changes.

Common medications that are more commonly associated with unexpected psychic pain include;

1) Blood pressure and heart disease medications;
Central alpha 2 receptor agonist class- Reserpine, Methyldopa & Guanfacine (Aldomet & Tenex- older blood pressure lowering medications), Clonidine (Catapress- another older blood pressure medication also used for drug and alcohol withdrawal), as well as potentially Tizanidine (Zanaflex a muscle relaxant often used in the treatment of chronic pain),
Beta blockers (many brands- used to lower blood pressure and reduce heart rate and to treat coronary heart disease as well as congestive heart failure).
Digoxin (Lanoxin- used for heart rate slowing as well as congestive heart failure)
Diuretics (many brands- used to lower blood pressure but can especially lead to low mood if associated with lower blood and tissue levels of potassium and sodium salts)

2) Sedative-hypnotic agents;
Barbituate class (many different medications used for control of seizure disorders, headache treatment- Esgic, Fioricet etc, as well as for sleep. Common preparations have Butalbitol, Meprobamate, chloral hydrate as well as Phenobarbital.
Benzodiazepine class (many different medications used for helping with sleep, and to reduce anxiety, panic and stress. They are also commonly used and are often appropriate in conjunction with antidepressant medications both short term and long term to reduce side effects and control anxiety. Common names include Lorazepam/Ativan, Alprazolam/Xanax, Clonezapam/Klonepin.
Alcohol especially if used medicinally on a regular basis or in excess by the patient to aid with control of anxiety, pain and insomnia.
Other sleep aids, OTC and Rx may play a role here as well and need to be discussed with your doctor.

3) Anti-inflammatory agents and opiates;
Opiates/Narcotic agents are commonly used to treat acute and chronic pain syndromes and are obtained both by prescription and sometimes by illicit means.
Anti-inflammatory steroids used to treat acute and chronic inflammation, pain, allergic and autoimmune conditions. Common names are; Dexamethasone/Decadron, Prednisone, Medrol/ Medrol dose pack. Use and withdrawal can both be associated with depressed mood. Keep in mind if you are taking any steroid for more than 2 weeks be certain to discuss a slow weaning process with your health care provider to prevent a major side effect from too rapid a withdrawal from anti-inflammatory steroid use.

4) Hormones;
Oral contraceptives
Estrogen and estrogen withdrawal
Anabolic steroids used for muscle bulking and most commonly obtained through illicit means