Should people with nocturnal leg cramps drink tonic water and bitter lemon?

Pain in Multiple Sclerosis: Understanding Pathophysiology, Diagnosis, and Management Through Clinical Vignettes

Neuropathic pain and other pain syndromes occur in the vast majority of patients with multiple sclerosis at some time during their disease course. Pain can become chronic and paroxysmal. In this review, we will utilize clinical vignettes to describe various pain syndromes associated with multiple sclerosis and their pathophysiology. These syndromes vary from central neuropathic pain or Lhermitte's phenomenon associated with central nervous system lesions to trigeminal neuralgia and optic neuritis pain associated with nerve lesions. Muscular pain can also arise due to spasticity. In addition, we will discuss strategies utilized to help patients manage these symptoms.

Will Tonic Water Stop My Eyelid Twitching?

Eyelid myokymia, commonly referred to as “eyelid twitching”, is a common, benign condition that resolves in most individuals within hours to days; however, chronic cases can persist for several weeks to months, prompting the search for home remedies that may reduce the frequency or duration of symptoms. In this article, we discuss the proposed pathophysiologic mechanism and safety concerns surrounding tonic water as a treatment for eyelid myokymia.

Gabapentin for Leg Cramps: Muscling in on Quinine

Practicing clinicians come across uses of pharmacologic agents that may not always be listed in the usual references. For example, glycerin injection for nerve block, H2 antagonists in colorectal cancer, or colchicine for systemic sclerosis may represent novel, hard-to-find clinical applications. If you have encountered a new and/or unusual use of a drug, submit the information to this Hospital Pharmacy feature. Send three copies, double-spaced, 1,000 words or less, to: Thomas G. Burnakis, PharmD, Baptist Medical Center, 800 Prudential Drive, Jacksonville, FL 32207.

Risks of the Consumption of Beverages Containing Quinine

Although the United States Food and Drug Administration banned its use for nocturnal leg cramps due to lack of safety and efficacy, quinine is widely available in beverages including tonic water and bitter lemon. Numerous anecdotal reports suggest that products containing quinine may produce neurological complications, including confusion, altered mental status, seizures, and coma, particularly in older women. Psychologists need to inquire about consumption of quinine-containing beverages as part of an evaluation process.

Quinine and the ABCs of Long QT: A Patient's Misfortune with Arthritis, (Alcoholic) Beverages, and Cramps

A 91-year-old woman presented to the emergency department by ambulance after her family found her minimally responsive. Telemetry monitoring demonstrated episodes of non-sustained polymorphic ventricular tachycardia (PMVT) associated with significantly prolonged repolarization. Her medical history revealed that she was taking quinine or a derivative in three different forms: hydroxychloroquine, quinine sulfate (for leg cramps), and her gin mixed with tonic water (containing quinine). The present case is illustrative of classic etiologies and findings of acquired long QT syndrome, and serves as an important reminder for providers to take a complete medication history, including use of duplicative and alternative medicines and type of alcohol consumption.

Immune thrombocytopenia associated with consumption of tonic water

Thrombocytopenic purpura can develop from an induced antibody response that destroys platelets. Megakaryocyte production may also play a role. Although the inciting antigen is usually not identified, it is important to consider medications. This article presents the case of a man who developed sudden onset of severe thrombocytopenia associated with the ingestion of quinine-containing tonic water.

Palliative care in amyotrophic lateral sclerosis, Parkinson's disease, and multiple sclerosis

BACKGROUND

Amyotrophic lateral sclerosis, Parkinson's disease, atypical parkinsonian syndromes, and multiple sclerosis are progressive neurologic disorders that cumulatively afflict a large number of people. Effective end-of-life palliative care depends upon an understanding of the clinical aspects of each of these disorders.

OBJECTIVES

The authors review the unique and overlapping aspects of each of these disorders with an emphasis upon the clinical management of symptoms.

DESIGN

The authors review current management and the supporting literature.

CONCLUSIONS

Clinicians have many effective therapeutic options to choose from when managing the symptoms produced by these disorders.

Parasomnias and other sleep-related movement disorders

Parasomnias are common clinical complaints. Formal sleep evaluation including PSG is indicated for parasomnias that are violent and potentially injurious; disruptive to the bed partner or other household members; accompanied by excessive daytime sleepiness; or associated with medical,psychiatric, or neurologic symptoms or findings [2]. Multiple sleep latency testing should be considered for patients who have complaints of excessive daytime sleepiness. An extensive history, including medical, neurologic,psychiatric, and sleep disorder, and a review of medication, alcohol, illicit drug use, and family history of parasomnias, may provide useful clues. Distinguishing between a parasomnia and a seizure may be difficult as both can present as recurrent, stereotypical behaviors. Evaluation may be aided by an expanded EEG montage during overnight PSG studies.

Dietary levels of quinine in tonic water do not inhibit CYP2D6 in vivo

Quinine is a bitter alkaloid that is used as a flavoring agent in tonic water. Studies suggest that quinine can inhibit cytochrome P450 2D6 (CYP2D6) which could have implications for the metabolism of co-ingested drugs. We conducted a study with 11 healthy volunteers (7 men, 4 women; aged 26-54). After urinary void, each subject consumed either 1000 ml of carbonated water or 1000 ml of tonic water containing 80 mg quinine in a crossover design. Following each beverage subjects ingested an oral dose of 30 mg dextromethorphan (DM). Urine was collected for 8 h and analyzed for DM and dextrophran, its CYP2D6 mediated metabolite. The ratio of DM and its metabolite is an established measure of CYP2D6 activity. All subjects metabolized the vast majority of DM to its metabolite after both the carbonated water and the tonic water. The ratio (mean+/-S.D.) of DM to its metabolite was 0.013+/-0.028 after the carbonated water and 0.032+/-0.067 after the quinine containing water. No significant difference in the ratios was observed between the two beverages (P>0.05). We conclude that quinine as consumed in tonic water does not inhibit CYP2D6 activity in vivo. Thus, quinine should not alter the metabolism of CYP2D6 substrates taken concomitantly with tonic water.