Heat and Medications

• Review patient's medication list with them, highlighting medications that may need to be adjusted because of interactions with heat. This is especially important for patients, who take multiple medications that may amplify risks of harm from heat via different mechanisms.
• Remind patients to avoid abruptly stopping any medications without having a plan in place.
• Consider adjusting medication dose or frequency during hot weather months based on potential medication interactions with heat and an assessment of symptom severity. Any changes in medication dose or schedule should be individualized, will be drug-class dependent, and should consider risks and benefits for patients.
• Consider adjusting fluid restrictions on hot days, especially for patients who take medications that may lead to dehydration or affect electrolytes.
• Talk to your patients about signs and symptoms that heat may be interacting with their medications, when to seek medical care, which symptoms are an emergency, and what to do in an emergency.
• Document any medication or fluid adjustments to be made on hot days and when to resume normal medication schedule. Encourage patients to reflect information discussed with you related to heat and medications in the medication section of their Health Action Plan.
• Ask your patient to identify a point of contact to check on them if they take medications that may increase the risk of harm from heat, especially older patients and patients with altered cognition.
• Counsel patients taking medications that increase sun sensitivity:
  • Antifungal medications like flucytosine, griseofulvin, and voriconazole and antibiotics like metronidazole, tetracyclines and fluoroquinolones can increase sun sensitivity and lead to a sunburn-like rash.
  • For patients on these medications, sun avoidance, protective clothing and hats, and broad-spectrum sunscreen that filters out UVA and UVB rays, with an SPF of 30 or higher, are recommended.

• Provide guidance on proper storage of medications. Counsel patients not to leave medications in a car or other places that can get excessively hot.
  • Inhalers, for example, can burst in hot environments, such as car trunks on hot days.
  • EpiPens may malfunction or deliver less epinephrine when exposed to heat.
  • Insulin, which should be stored in a refrigerator, may become less effective if left in the heat for prolonged periods.
• Help your patients develop a power outage plan, including how they will manage medications that require refrigeration, like insulin, or medical devices that require electricity, like nebulizer machines, ventilators, and oxygen concentrators during a power outage.

• Encourage your patients to seek a cool environment. Ask whether your patients have an air conditioner at home and if they can afford to turn it on in hot weather.
  • Encourage your patients to use an air conditioner (AC) if they have it. Suggest setting an AC to a safe 78 degrees or “low” cool to provide comfort, save on electricity costs, and conserve energy.
  • Guide people who don’t have or use AC due to energy costs or other reasons to visit family, friends, or neighbors even for a couple of hours to stay cool when their home is too hot. During a heat wave, they can call 311 or search Cool Options NYC to find a cooling center.
  • Refer patients without an AC, if they are eligible, to apply for a free AC through the Home Energy Assistance Program (HEAP) Cooling Assistance program. They may need to provide medical documentation.

• May cause:
  • Increased sweating
  • Increased urination
  • Impaired heat perception

• Acetaminophen
  May cause:
  • Heat related liver injury increase risk for acetaminophen hepatoxicity
• Aspirin
  May cause:
  • Increased heat production with overdose
  • Kidney injury with dehydration
• Nonsteroidal anti-inflammatory drugs (NSAIDS)
  May cause:
  • Kidney injury with dehydration

• Example: Sulfonamides
  May cause
  • Kidney injury risk with dehydration

• Examples: Diphenhydramine, Doxylamine, Promethazine
  May cause:
  • Decreased sweating
  • Impaired thermoregulation

• Example: Indinavir
  May cause
  • Kidney injury risk with dehydration

• Example: Carbamazepine
  May cause:
  • Dizziness and weakness, especially after increased dose
• Example: Oxcarbazepine
  May cause:
  • Increased sweating
  • Increased urination
• Example: Topiramate
  May cause:
  • Decreased sweating

Antihypertensives

• Angiotensin converting enzyme inhibitor (ACEi) and Angiotensin II receptor blockers (ARBs)
  Examples: ACEi: Enalapril, Lisinopril, Ramipril; ARB: Valsartan, Losartan
  May cause:
  • Decreased blood pressure
  • Increased risk of fainting and falls
  • Reduced thirst sensation
• Angiotensin receptor-neprilysin inhibitors (ARNIs), combination drug including ARB
  Examples: Sacubitril and Valsartan
  May cause:
  • See ARBs
• Beta blockers
  Examples: Atenolol, Metoprolol, Propranolol
  May cause
  • Reduced superficial vasodilation
  • Decreased sweating
  • Reduced blood pressure
  • Increased risk of fainting and falls
• Calcium channel blocker
  Examples: Amlodipine, Felodipine, Nifedipine
  May cause:
  • Decreased blood pressure
  • Increased risk of fainting and falls
  • Electrolyte imbalance
• Diuretics
  Examples: Furosemide, Hydrochlorothiazide, Acetazolamide
  May cause:
  • Electrolyte imbalance
  • Volume depletion, dehydration, and increased risk of fainting and falls
  • Reduced thirst sensation

Antianginals

• Nitrates
  Examples: Glyceryl Trinitrate, Isosorbide Mononitrate
  May cause:
  • Worsened hypotension

Anti-platelet medications

• Examples: Clopidogrel, Aspirin
  May cause:
  • Reduced superficial vasodilation

• Example: Methylenedioxymethamphetamine (MDMA) (and alternatives)
  May cause:
  • Reduced sweating
  • Reduced skin blood vessel dilation
  • Impaired heat perception

• Antipsychotics
  Examples: Haloperidol, Olanzapine, Quetiapine, Risperidone
  May cause:
  • Impaired sweating
  • Impaired temperature
• Mood stabilizer
  Example: Lithium
  May cause:
  • Diabetes insipidus induced water loss and risk for fainting, falls
  • Electrolyte imbalance
  • Risk for toxicity in setting of dehydration because of narrow therapeutic index
• Selective serotonin reuptake inhibitors (SSRI) and Serotonin and norepinephrine reuptake inhibitors (SNRI)
  Examples: SSRI: Fluoxetine, Sertraline; SNRI: Duloxatine, Venlafaxine
  May cause:
  • Increased sweating
• Tricyclic antidepressants (TCA)
  Examples: Amitriptyline, Clomipramine
  May cause:
  • Decreased sweating

• Example: Cocaine
  May cause
  • Reduced sweating
  • Reduced dilation of skin blood vessels
  • Impaired heat perception
• Examples: Amphetamine, Methylphenidate
  May cause:
  • Increased body temperature

• Example: Levothyroxine
  May cause:
  • Excessive sweating