15.2 Pharmacology II: Endocrine, Psychiatric, Neurological, Anti-infective, Respiratory, GI, and Other Drug Classes
Key Takeaways
Insulin and sulfonylureas cause hypoglycemia; GLP-1 drugs such as semaglutide cause nausea and can cause pancreatitis and gallbladder disease.
Lithium has a narrow therapeutic range, and NSAIDs, ACE inhibitors, thiazides, and dehydration can push it into the toxic range.
MAO inhibitors cause hypertensive crisis with tyramine-rich foods, and serotonergic combinations can cause serotonin syndrome.
TNF inhibitors and other biologics raise the risk of serious infection and TB reactivation, so strict asepsis matters.
Fluoroquinolones carry a boxed warning for tendon rupture, so avoid deep needling or strong stimulation around a painful Achilles tendon.
15.2 Pharmacology II: Endocrine, Psychiatric, Neurological, Anti-infective, Respiratory, GI, and Other Drug Classes
Quick Answer: Appendix B of the 2026 BIOM outline lists more than 40 medication categories. This section covers the ones not covered in Section 15.1: diabetes, thyroid, bone, and hormone drugs; psychiatric and neurological drugs (antidepressants, anti-anxiety drugs, mood stabilizers, antipsychotics, antiseizure, anti-Parkinson, antidementia, stimulants, sleep aids, and smoking cessation); anti-infectives; cancer and immune drugs; allergy, asthma, and cough medicines; GI drugs; dermatological and weight-management drugs; cannabinoids; and substances of abuse. For each, know what it treats, its important side effects, and how it changes acupuncture care. Never advise a patient to stop or change a prescription medication; refer questions to the prescriber.
High-Risk Diabetes, Antidepressant, Benzodiazepine, and Fluoroquinolone Drugs
| Drug Class | Key Medications | Primary Pharmacological Action | Critical Side Effects & Exam Focus | Acupuncture & Triage Precautions |
|---|---|---|---|---|
| Biguanides | Metformin (Glucophage) | Decreases hepatic gluconeogenesis; enhances peripheral glucose uptake; first-line Type 2 Diabetes | Gastrointestinal distress (diarrhea, cramping, nausea); Vitamin B12 deficiency; Lactic Acidosis (rare, high mortality in renal failure) | Monitor hydration; contraindicated if eGFR < 30 mL/min; recognize symptoms of lactic acidosis (hyperventilation, lethargy, severe abdominal pain) |
| Sulfonylureas | Glipizide, Glimepiride, Glyburide | Pancreatic secretagogues: stimulate beta cells to release endogenous insulin | Profound, prolonged hypoglycemia; significant weight gain | Keep fast-acting carbohydrates (juice, glucose tablets) in clinic; recognize diaphoresis as primary warning sign |
| SGLT2 Inhibitors | Empagliflozin (Jardiance), Dapagliflozin (Farxiga) | Inhibit Sodium-Glucose Cotransporter 2 in proximal renal tubules, forcing urinary glucose excretion | Mycotic genital infections, UTIs, volume depletion/orthostasis, Euglycemic Diabetic Ketoacidosis (euDKA) | Monitor for ketoacidosis (nausea, vomiting, dyspnea, metabolic acidosis) even when fingerstick glucose is normal (<250 mg/dL) |
| SSRIs / SNRIs | Sertraline (Zoloft), Fluoxetine (Prozac), Duloxetine (Cymbalta) | Inhibit presynaptic reuptake of serotonin (and norepinephrine) | Sexual dysfunction, insomnia, nausea, hyponatremia (SIADH), black box warning for suicidality in young adults; Serotonin Syndrome | Absolute contraindication to concurrent use of St. John's Wort; screen for hyperreflexia, inducible clonus, and autonomic instability |
| Benzodiazepines | Alprazolam (Xanax), Lorazepam (Ativan), Clonazepam (Klonopin) | Positive allosteric modulators of GABA-A receptors; increase chloride channel opening frequency | Profound sedation, psychomotor impairment, falls in elderly, anterograde amnesia, respiratory depression; life-threatening withdrawal | Never allow abrupt discontinuation (precipitates seizures, delirium tremens); evaluate fall risk prior to treatment; sedation compounded by opioids |
| Fluoroquinolones | Ciprofloxacin, Levofloxacin, Moxifloxacin | Inhibit bacterial DNA gyrase (topoisomerase II) and topoisomerase IV | Black Box Warning: Tendinitis and Tendon Rupture (especially Achilles tendon); peripheral neuropathy; QT prolongation | Strictly avoid deep needling, electroacupuncture, or manual therapy near Achilles tendon; advise immediate weight-bearing restriction if heel pain develops |
The Fluoroquinolone Black Box Warning: Achilles Tendon Rupture
Fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin) are broad-spectrum synthetic antibiotics frequently prescribed for urinary tract infections, respiratory infections, and diverticulitis. The FDA mandates a prominent Black Box Warning regarding disabling, potentially irreversible toxicities involving tendons, muscles, joints, and the peripheral nervous system.
- Pathophysiology: Fluoroquinolones chelate magnesium, induce oxidative stress, inhibit tenocyte proliferation, and accelerate extracellular matrix collagen degradation by upregulating matrix metalloproteinases (MMPs).
- Clinical Presentation: Tendinopathy occurs predominantly in the Achilles tendon (>90% of cases), but also affects the patellar tendon, quadriceps tendon, rotator cuff, and biceps tendon. Tendon rupture can occur within 48 hours of starting therapy or may be delayed for up to several months after completing the medication course.
- High-Risk Populations: Patients aged >60 years, individuals with renal failure or organ transplants, and patients receiving concurrent systemic corticosteroids (which multiplies tendon rupture risk by more than 10-fold).
- Acupuncture Clinical Management: If a patient presents with posterior ankle, heel, or Achilles pain and has a history of recent fluoroquinolone use: (1) Do not perform deep needling, electroacupuncture, or aggressive manual manipulation on or around the Achilles tendon (contraindicating deep needling at KI 3, BL 60, BL 61, KI 4); (2) Instruct the patient to immediately avoid vigorous weight-bearing exercise; (3) Arrange immediate orthopedic evaluation with diagnostic ultrasound or MRI to evaluate structural fibrillar disruption.
Diabetes, Thyroid, Bone, and Hormone Drugs
| Class | Examples | Key side effects and precautions |
|---|---|---|
| Insulin | Rapid-acting (lispro), long-acting (glargine) | Hypoglycemia (shaking, sweating, confusion); ask about meals and recent doses before treatment |
| GLP-1 receptor agonists and dual agonists | Semaglutide (Ozempic, Wegovy), tirzepatide (Mounjaro, Zepbound) | Nausea, vomiting, constipation, gallbladder disease, pancreatitis (severe upper abdominal pain radiating to the back); used for diabetes and weight management |
| DPP-4 inhibitors | Sitagliptin | Generally well tolerated; rare pancreatitis and joint pain |
| Levothyroxine | Synthroid | Take on an empty stomach and at least 4 hours apart from calcium, iron, and antacids; over-replacement causes palpitations, anxiety, atrial fibrillation, and bone loss |
| Antithyroid drugs | Methimazole, propylthiouracil | Rare agranulocytosis: sore throat with fever needs urgent evaluation; liver injury |
| Bisphosphonates (osteoporosis) | Alendronate, zoledronic acid | Take alendronate with a full glass of water, stay upright 30 minutes; esophagitis; rare jaw osteonecrosis and atypical femur fractures |
| Hormone replacement therapy | Estrogen with or without a progestin | Blood clots, stroke, and breast cancer risk with combined therapy; estrogen alone raises endometrial cancer risk if the uterus is present |
| Birth control | Combined pills, patch, ring; progestin-only pills, implants, IUDs | Combined estrogen methods raise clot risk and are avoided in smokers 35 and older; some antibiotics and St. John's wort reduce effectiveness |
| Fertility drugs | Clomiphene, letrozole, injected gonadotropins | Hot flashes, multiple pregnancy, ovarian hyperstimulation syndrome (abdominal swelling, rapid weight gain, shortness of breath) |
| Sexual dysfunction (PDE5 inhibitors) | Sildenafil, tadalafil | Headache, flushing, nasal congestion; dangerous hypotension with nitrates |
Psychiatric Drugs
| Class | Examples | Key side effects and precautions |
|---|---|---|
| Tricyclic antidepressants (TCAs) | Amitriptyline, nortriptyline | Dry mouth, constipation, urinary retention, sedation, dizziness on standing; dangerous heart rhythm problems in overdose |
| MAO inhibitors | Phenelzine, tranylcypromine | Hypertensive crisis with tyramine-rich foods (aged cheese, cured meats) and some decongestants; serotonin syndrome with other serotonergic drugs |
| Other antidepressants | Bupropion, mirtazapine, trazodone | Bupropion lowers the seizure threshold (avoid in seizure and eating disorders); mirtazapine causes sedation and weight gain; trazodone causes sedation and dizziness |
| Other anti-anxiety drugs | Buspirone, hydroxyzine | Dizziness, sedation; buspirone takes weeks to work |
| Mood stabilizers | Lithium, valproate, lamotrigine | Lithium has a narrow therapeutic range: toxicity causes tremor, vomiting, diarrhea, confusion, and unsteadiness; NSAIDs, ACE inhibitors, thiazide diuretics, and dehydration raise lithium levels. Valproate harms the liver and fetus. Lamotrigine can cause a serious rash (Stevens-Johnson syndrome) |
| Antipsychotics | First generation: haloperidol. Second generation: olanzapine, quetiapine, risperidone, aripiprazole, clozapine | Movement disorders (stiffness, restlessness, tardive dyskinesia), weight gain, diabetes, high lipids; clozapine can cause severe neutropenia. Neuroleptic malignant syndrome (fever, rigidity, confusion, unstable vital signs) is an emergency |
Neurological Drugs
| Class | Examples | Key side effects and precautions |
|---|---|---|
| Antiseizure | Levetiracetam, phenytoin, carbamazepine, valproate, gabapentin, pregabalin | Dizziness and sedation; levetiracetam mood changes; phenytoin gum overgrowth; carbamazepine low sodium, serious rash, and many drug interactions. Gabapentin and pregabalin are also used for nerve pain. Never stop abruptly |
| Anti-Parkinson | Carbidopa-levodopa, pramipexole, ropinirole, selegiline | Nausea, dizziness on standing, involuntary movements; dopamine agonists can cause sudden sleepiness and impulse-control problems (gambling, spending) |
| Antidementia | Donepezil, rivastigmine, galantamine, memantine; anti-amyloid antibodies (lecanemab, donanemab) | Cholinesterase inhibitors cause nausea, diarrhea, slow heart rate, and vivid dreams; anti-amyloid antibodies can cause brain swelling or bleeding (ARIA), with extra concern in patients on anticoagulants |
| CNS stimulants and ADHD drugs | Methylphenidate, amphetamines; non-stimulant atomoxetine | Insomnia, reduced appetite, raised heart rate and blood pressure, anxiety; misuse potential |
| Sleep medications | Zolpidem, eszopiclone; suvorexant; trazodone | Next-day drowsiness and falls; zolpidem and related drugs carry a boxed warning for complex sleep behaviors (sleepwalking, sleep-driving). Older sedating antihistamines (diphenhydramine) cause confusion in older adults |
| Smoking cessation | Nicotine replacement, varenicline, bupropion | Varenicline causes nausea and vivid dreams; bupropion lowers the seizure threshold |
Anti-infective Drugs
| Class | Examples | Key side effects and precautions |
|---|---|---|
| Antibiotics | Penicillins (amoxicillin), cephalosporins, macrolides (azithromycin), tetracyclines (doxycycline), sulfonamides, clindamycin, fluoroquinolones | Allergy and anaphylaxis (especially penicillins); diarrhea and C. difficile infection; azithromycin QT prolongation; doxycycline sun sensitivity and reduced absorption with calcium, iron, and antacids; fluoroquinolone tendon rupture (above) |
| Antivirals | Acyclovir and valacyclovir (herpes, shingles), oseltamivir (influenza), HIV antiretrovirals, nirmatrelvir with ritonavir (COVID-19) | Ritonavir and many antiretrovirals have major drug interactions; St. John's wort can make HIV drugs fail |
| Antifungals | Fluconazole, terbinafine, topical azoles, nystatin | Fluconazole raises warfarin levels and has many interactions; terbinafine and oral azoles can harm the liver |
Cancer and Immune Drugs
- Chemotherapy: low blood counts (infection and bleeding risk), nausea, hair loss, mouth sores, fatigue, and nerve damage (taxanes and platinum drugs).
- Hormonal cancer therapy: tamoxifen (hot flashes, blood clots, endometrial cancer) and aromatase inhibitors such as anastrozole and letrozole (joint pain, bone loss).
- Immunotherapy: checkpoint inhibitors can cause immune-related inflammation of the colon, lungs, liver, thyroid, or skin.
- Immune modulators and biologics: methotrexate (liver toxicity, low blood counts; taken weekly, not daily), TNF inhibitors such as adalimumab and etanercept (serious infections and TB reactivation, so patients are screened before starting), and JAK inhibitors such as tofacitinib (boxed warnings for serious infections, clots, cancer, and heart events). Use strict asepsis and watch for signs of infection.
Allergy, Asthma, and Cough Medicines
| Class | Examples | Key side effects and precautions |
|---|---|---|
| Antihistamines | Second generation: loratadine, cetirizine, fexofenadine. First generation: diphenhydramine | First-generation drugs cause sedation, confusion, and urinary retention, especially in older adults |
| Decongestants | Pseudoephedrine, phenylephrine | Raise blood pressure and heart rate, cause insomnia; caution in hypertension |
| Intranasal corticosteroids | Fluticasone | Nosebleeds, nasal irritation |
| Leukotriene modifier | Montelukast | Boxed warning for mood and behavior changes, including suicidal thoughts |
| Asthma and COPD inhalers | Albuterol (rescue), inhaled corticosteroids, long-acting bronchodilators (salmeterol, tiotropium) | Albuterol causes tremor and a fast heart rate; inhaled steroids cause oral thrush (rinse the mouth after use). Patients with asthma should bring their rescue inhaler to treatment |
| Cough medicines | Dextromethorphan, guaifenesin, benzonatate, codeine | Dextromethorphan with SSRIs or MAOIs can cause serotonin syndrome; benzonatate is dangerous if swallowed by young children; codeine is not used in children under 12 |
Gastrointestinal Drugs
| Class | Examples | Key side effects and precautions |
|---|---|---|
| Acid reducers | Proton pump inhibitors (omeprazole), H2 blockers (famotidine), antacids | Long-term PPIs: low B12 and magnesium, C. difficile, fractures; antacids reduce absorption of many drugs |
| Antinausea | Ondansetron, metoclopramide, promethazine, prochlorperazine | Ondansetron QT prolongation and constipation; metoclopramide tardive dyskinesia; sedation |
| Antidiarrheal | Loperamide, bismuth subsalicylate | Do not use loperamide with bloody diarrhea or high fever; very high doses cause heart rhythm problems. Bismuth turns the stool and tongue black and contains salicylate (avoid in children with viral illness and with anticoagulants) |
| Stool softeners and laxatives | Docusate (softener), psyllium (bulk), polyethylene glycol (osmotic), senna and bisacodyl (stimulant) | Bulk laxatives need plenty of water; stimulant laxatives cause cramping; overuse causes electrolyte problems |
Dermatological and Weight-Management Drugs
- Dermatological: topical corticosteroids (skin thinning with long use), topical and oral retinoids (sun sensitivity; isotretinoin is highly teratogenic, requires strict pregnancy prevention, and makes skin fragile), and topical antifungals. Avoid aggressive gua sha or cupping on retinoid-treated skin.
- Weight management: GLP-1 drugs (above), phentermine (raises heart rate and blood pressure, insomnia), orlistat (oily stools and reduced absorption of fat-soluble vitamins A, D, E, and K), and naltrexone-bupropion.
Cannabinoids and Substances of Abuse
- Cannabinoids: dronabinol and nabilone (synthetic THC) are approved for chemotherapy-related nausea, and dronabinol for AIDS-related appetite loss; a purified CBD product (Epidiolex) is approved for certain seizure disorders. THC impairs coordination and judgment and can trigger anxiety or psychosis. CBD inhibits liver enzymes and can raise levels of drugs such as warfarin and clobazam.
- Substances of abuse: alcohol, opioids (including illicit fentanyl), benzodiazepines, cocaine and methamphetamine (high blood pressure, fast heart rate, overheating, chest pain, stroke), and cannabis. The animal sedative xylazine is increasingly mixed into illicit fentanyl; it causes deep sedation and severe skin wounds and is not reversed by naloxone, but naloxone should still be given in a suspected overdose because opioids are usually present. Withdrawal and overdose are covered in Section 12.9.
A 56-year-old male with Type 2 diabetes mellitus presents for acupuncture treatment of chronic neck stiffness. He reports that his primary care physician recently added metoprolol to his daily regimen of metformin and glipizide for blood pressure management. While on the treatment table, the patient suddenly appears pale, disoriented, and is sweating profusely across his forehead and neck, but he denies feeling any heart racing or hand tremors. What physiological mechanism explains this clinical presentation?
Beta-adrenergic blockade suppresses the sympathetic catecholamine warning signs of tachycardia and tremor, leaving cholinergic-mediated diaphoresis as the primary somatic sign of hypoglycemia.
Metformin toxicity has caused acute lactic acidosis, which selectively paralyzes autonomic cardiac pacing fibers while stimulating excessive eccrine sweating.
Glipizide has induced profound hyperglycemia, triggering an osmotic shift that suppresses cardiac adrenergic receptors while causing diaphoresis.
An acute panic reaction has occurred, wherein sympathetic activation is completely blunted by central nervous system adaptation to acupuncture needling.
A 68-year-old male receiving acupuncture for chronic low back pain mentions that he completed a 10-day course of ciprofloxacin three days ago for an acute bacterial prostate infection. He now reports new-onset sharp, aching pain and mild swelling over the posterior aspect of his left heel and lower calf, which worsens when walking. Which clinical assessment and procedural decision is mandated?
The patient has acute gouty arthritis of the retrocalcaneal bursa; apply strong manual sedation needling at BL 60 (Kunlun) and KI 3 (Taixi).
The patient has localized gastrocnemius myofascial trigger points; perform vigorous dry needling and dry cupping over the posterior calf.
Fluoroquinolone-induced tendinopathy with rupture risk; withhold deep local needling and manual stress, and refer for orthopedic evaluation.
The symptoms reflect transient post-viral arthralgia; apply indirect moxibustion and encourage daily eccentric calf-strengthening exercises.
A patient taking lithium for bipolar disorder has started taking ibuprofen daily for knee pain and now has a coarse tremor, diarrhea, and confusion. What is the most likely explanation?
Serotonin syndrome caused by combining ibuprofen with lithium
Lithium toxicity, because NSAIDs reduce lithium clearance and raise its level
A normal, harmless side effect of starting a daily NSAID that needs no action
Opioid withdrawal after stopping a prescribed pain medication
A patient taking phenelzine (an MAO inhibitor) asks about over-the-counter remedies for a cold. Which product is the greatest concern?
A saline nasal spray used several times a day to rinse the nose
Honey stirred into warm water or herbal tea for the sore throat
A pseudoephedrine decongestant or dextromethorphan cough syrup
A cool-mist humidifier running in the bedroom overnight
Sections you finish are checked off in the contents.