An article came out in 2019 that offered some very useful and practical information about medication excipients for patients and providers alike. One of the unfortunate realities of this world is that the patient community does not always have access to full-text articles of scientific literature, so I decided to summarize some of the highlights here.
Schofield and Afrin evaluated 5 different MCAS patient cases to discuss clinically noted patterns in medication excipient reactions. Findings included scenarios such as:
- the addition of sodium lauryl sulfate when the pharmacy switched drug formulations
- reactions to benzyl alcohol and dyes in capsules
- differences in ingredients in orally disintegrating tablets as opposed to dye-free tablets
- cotton vs. wood sources of microcrystalline cellulose from two different pharmacies, and
- trigger point injections containing alcohol-based vs. alcohol-free agents.
In all of the cases, the patients had significant resolution of symptoms following the change back to a better-tolerated formulation.
The authors point out that there are a number of things that patients and doctors should consider in order to reduce the risk and/or identify the issue:
- Excipient reactivity may not be instantaneous and can sometimes include chronic vs. acute symptoms.
- The FDA has a Daily Med Website and patients are encouraged to review all meds online before picking them up from the pharmacy to ensure that the excipients and manufacturer have not changed.
- Patients are also encouraged to make a spreadsheet of the excipients that they know they tolerate well, which can assist in ruling things in and out when there are multiple excipients in one medication. They are also encouraged to also list their allergies by excipient (once identified) as opposed to brand or generic overall name.
- Dyes and alcohols are a good starting point when investigating excipients.
- FD&C dyes (particularly the red, yellow and blue) are common triggers for this patient population. Keep in mind not all colored meds contain dyes, and not all white medications are dye-free. Ferric oxide dye sources may be better tolerated than FD&C.
- Patients may be able to take the contents of certain medications without the capsules themselves. Others have different responses to oral meds vs. IV meds. Multidose medication vials often contain preservatives.
- Compounding pharmacies are encouraged, particularly for patients who are severely reactive.
- The authors also note, “While dyes and alcohols are a good place to start, other excipients which have been problematic in some MCAS patients include sodium lauryl sulfate, artificial sweeteners, talc, polyethylene glycol, magnesium stearate, shellac, povidone, crospovidone and sodium hydroxide. Some MCAS patients even react to usually very well-tolerated ingredients, e.g. microcrystalline cellulose, gelatin.”
Of course, the holistic provider in me cannot sign off without mentioning that many patients do better with more natural supplements as opposed to prescription and over the counter drugs. And many patients do eventually find themselves able to transition away from mast cell targeting medications once they’ve worked with a professional who is knowledgeable in natural medicine/functional medicine and can put the whole picture together. However, it’s important to note that supplemental products need to be regarded with the same scrutiny, and they often also contain excipients and preservatives.
This is a great article that provides some nice pearls of wisdom. Thanks Dr. Schofield for sharing your patient cases!
Reference:
Schofield, J. R., & Afrin, L. B. (2019). Recognition and Management of Medication Excipient Reactivity in Patients With Mast Cell Activation Syndrome. In Am J Med Sci (Vol. 357, Issue 6).
