The dark consequences of drug supply shortages (2023)

The dark consequences of drug supply shortages (1)

Since the start of the Covid-19 pandemic, there has been a notable increase in the purchase of medicines through online outlets. Buying medication online can have a number of benefits for many patients, such as lower cost, increased convenience and improved access. However, many digital outlets selling medication are operating outside the bounds of the law, leaving purchasers vulnerable to substandard or even counterfeit products.

A 2017 study by the US National Association Of Boards Of Pharmacy (NABP) found that nearly 96% of websites selling prescription medicines were acting illegally. The World Health Organisation (WHO) estimates that, in over half of cases, medicines purchased online from illegal sites that conceal their address have been found to be counterfeit.

Despite these statistics, a team of researchers at Butler University and Michigan State University have found that almost 18% of US consumers buy medications online, often from sources recommended by people they know in the hopes of getting a genuine product at a lower price point. These sites include legitimate online pharmacies, but also include illegitimate retailers, as well as e-commerce sites like Amazon, social media platforms and instant messaging services.

In an increasingly online world where consumers can get more or less anything they need delivered to their door, it’s hardly surprising that they turn to the web for medicine. But when more people feel comfortable going online for these kinds of purchases, more opportunities are created for illegal actors to step in and take advantage.

Alliance for Safe Online Pharmacies (ASOP) advisor Libby Baney says: “Healthcare is not like buying shoes and purses on the internet. Your life is at stake, and it’s regulated for a reason. There are some really great, reputable online pharmacies and telemedicine companies that will provide you with legitimate, approved drugs. The challenge is knowing which is which.”

What constitutes a counterfeit?

“There’s anywhere between 35,000 and 40,000 online pharmacies that operate worldwide and of that number, 95% do operate illegally in some way,” says Butler University associate professor of pharmacy practice John Hertig, who also works with ASOP.

“Either they’re not licensed properly, they’re selling substandard or falsified medicines or they’re selling products that aren’t approved either within the jurisdiction they operate in or the jurisdiction they’re selling to – you need to have both to be considered legitimate.”

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A number of different products can be classified as counterfeit, substandard or falsified, some of which are far more harmful than others. Medication that has been legitimately and safely manufactured but has been stolen and resold by a third party still counts as a counterfeit product. This, Hertig says, is the best-case scenario in the world of illegal online pharmacies.

Far riskier for patients are products that have been entirely falsified. Some of these may simply be sugar pills, meaning patients could miss doses of medication they need but are unlikely to be directly injured by what they’re ingesting. Others may contain ingredients that are dangerous to put into the human body.

These ingredients include, but are not limited to, arsenic, uranium, brick dust, chalk and even ethylene glycol, a substance used in anti-freeze. These dangerous ingredients aren’t typically used to make up the entirety of the falsified medicine, but as a binding or filling agent. They’re used by fraudulent manufacturers when they do not have access to the compounds a legitimate producer would have.

The situation has been exacerbated in multiple ways by the Covid-19 pandemic. Many drugs have fallen into short supply due to increased demand and supply chain disruptions, leaving patients with few other directions to turn when seeking the care they need.

Hertig says: “There currently is no medication that’s on shortage that isn’t available from an illegal online website. There is not a single medication that you wouldn’t be able to get access to just by going online. There’s a direct correlation between something that’s hard to get and a criminal taking advantage of that opportunity.”

False flags

Alongside this, many people are now seeking access to false cures and treatments for Covid-19 – things no doctor will prescribe to them, but which they can easily find online. Ivermectin, a drug most commonly used to deworm horses, has dominated headlines after false claims about its ability to treat Covid-19. Action has been taken against companies claiming their saline nasal sprays can cure the disease or flogging false vaccines.

Hertig and his colleagues found that, while the 1,000 consumers they surveyed considered online pharmacies, Amazon and Google to be the safest digital outlets to purchase medication from, even places perceived as the least trustworthy, such as Kik and TikTok, were still generally seen as safe.

Even more alarmingly, 54.6% of the participants had reportedly purchased narcotics from these channels while 52% had purchased stimulant drugs. Stigma is likely to contribute significantly to these numbers, with many of these patients in legitimate need of these medications but too ashamed to visit a doctor.

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Some may also find themselves cut off from the traditional route for these medications by their healthcare provider after showing signs of addiction or dependency.

“When we restrict access to medicine, no matter what the reason, it’s going to be human tendency and nature to try to get access to that product via another route,” says Hertig. “When you restrict safe sources of medicine through a proper supply chain that’s been vetted by a regulatory agency, what you’re going to end up doing as an unintended consequence is point people towards more risky sources of medicine.

“It’s going to take all of us, in terms of the broader healthcare community, to engage in proper discussion and education and develop tools and regulatory frameworks that are going to make sure that we keep our patients safe.”

The road ahead

For companies that are not acting illegally, these counterfeit retailers can cause serious problems. The market for counterfeit pharmaceuticals is worth $200bn a year and growing at 20% annually – twice the growth rate of the legitimate pharmaceutical market. This forces legitimate outlets to compete with illegal actors, which may be offering a lower price point for what appears to be the same product to consumers.

The presence of illegitimate online pharmacies can damage consumer trust in digital pharmacies in general.

“It creates an unlevel playing field when you allow unregulated, unlicensed, illegal online drug sellers to be peddling cures and treatments that aren’t regulated,” Baney says. “It muddies the market. As a patient myself I want to be sure that I’m getting legitimate healthcare from a reputable organisation, but the fact that there’s a muddy, messy, illegal market creates risks and sows the seeds of distrust in what are otherwise legitimate businesses.”

ASOP has called on US policymakers to reform drug importation policies, particularly when it comes to ‘Canadian pharmacies’, outlets that appear to be supplied by licensed pharmacies in Canada and sell to US residents. These sites have no real connection to Canada at all, and do not work with a pharmacy or pharmacist licensed by a Canadian province, nor do they have a physical presence in Canada.

The alliance has also been critical of the introduction of the General Data Protection Regulation (GDPR) in the EU. GDPR, ASOP says, has drastically restricted access to the international WHOIS database, a public directory with ownership records and contact information for every domain name registered on the web.

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The law has prompted registrars and registry operators to block access to WHOIS, allowing criminals to bulk-buy domain names through which to run illegal online pharmacy scams and leaving law enforcement unable to trace their origin.

ASOP has also called for registries and registrars to lock and suspend suspicious domain names, for the reform of Section 230, and for the endorsement of bipartisan legislation, such as the PACT Act, SHOP SAFE Act, and INFORM Consumers Act, which could help reduce the powers of illegitimate medical retailers online.

Online pharmacies and the Texas abortion crisis

As well as supply shortages and falsified claims about products, political interference in access to legal medications can force consumers online. Even though a pregnant person’s right to an abortion without excessive government restriction is supposed to be constitutionally protected in the US, several states have taken steps to restrict access to abortion care.

Abortions are now banned after six weeks of pregnancy in Texas, essentially putting an end to Roe v Wade in the state. The Texas law bans abortion as soon as foetal heart activity is detected, something which happens long before many people are even aware they’re pregnant.

Even those who do realise before this point may find themselves unable to receive an appointment to undergo an abortion before the deadline set by the new law. The law has no exceptions in the case of rape or incest.

Many pregnant people in the state of Texas who wish to end their pregnancies are now turning to online pharmacies to do so. Early pregnancies can be terminated through a medical abortion, where patients take a combination of mifepristone and misoprostol to induce a miscarriage.

Aid Access, an organisation based in the Netherlands, is the only physician-run service that provides people seeking self-managed abortions in the US with this medication. Despite attempts from the US Food and Drug Administration (FDA) to put a stop to its work during the Trump administration, the organisation continues to supply the drugs.

Patients simply fill in an online form to assess their suitability for the medication. For pregnant people in Texas, the prescription is then filled by a pharmacy in India and the drugs are shipped directly to the patient’s home address. While Aid Access is one of the most legitimate actors in this space, many online vendors are readily selling mifepristone and misoprostol to patients without a prescription.

(Video) Study warns of drug supply shortages

University of California , San Francisco professor of obstetrics, gynaecology and reproductive Science Daniel Grossman says that medical abortion should be available over-the-counter (OTC) across the US, following a brief consultation with a licensed pharmacist.

While the cramping and heavy bleeding experienced by the patient as they pass the pregnancy can sound rather gruelling, medical abortion has a safer track record than other common drugs like paracetamol and Viagra and is 14 times safer than carrying a pregnancy to term. It also has a 97% success rate.

“Every indication we have is that these medications are very safe and effective and so simple to use that they are appropriate for OTC sale,” Grossman says. “People can accurately figure out on their own how far along in pregnancy they are and can screen themselves for eligibility for the medications using a simple checklist.”

A 2017 study published in the journal Contraception saw researchers order 22 products from 16 different sites, 20 of which were mifepristone-misoprostol combination products and two that contained only misoprostol. They found that the 18 tablets labelled 200 mg mifepristone contained between 184.3 mg and 204.1 mg mifepristone, while the 20 tablets labelled 200 mcg misoprostol contained between 34.1 mcg and 201.4 mcg of the active ingredient.

Despite the shortcomings in misoprostol quality, the researchers concluded that people for whom clinic-based abortion is not easily available or acceptable may well consider sourcing pills from the internet to be a rational option.

Given that this practice is already being carried out, making medical abortion readily available OTC could go a long way toward ensuring patients are accessing safe and legitimate medicines and are less likely to turn to illegitimate sources.

Grossman says: “We’re hoping to build up the evidence base to help move this forward. I think the process of showing how safe and effective medical abortion is will help us move further away from this overly medicalised and restricted service to something that may not be quite OTC but is something that could at least be prescribed by a pharmacist who could then dispense the medication.”

FAQs

What do you see as some of the negative implications caused by medicine stock outs? ›

Consequences of ART and TB stock-outs are ultimately borne by patients, putting them at risk of treatment interruption or discontinuation, catastrophic expenditure [14,15], treatment failure and drug resistance [21], and ultimately increased risk of illness and death [12,22].

Why are there so many drug shortages? ›

Drug Shortages can occur for many reasons, including manufacturing and quality problems, delays, and discontinuations. Manufacturers provide FDA most drug shortage information, and the agency works closely with them to prevent or reduce the impact of shortages.

What is the biggest issue facing pharmacy today? ›

Staff Burnout, Supply Chain Disruptions, & DIR Fees Continue to Plague the Profession. Between higher demand for health care services and an economy-wide staffing shortage, it is safe to say that today's pharmacists are overworked and under-resourced.

What can be done to minimize the effect of drug shortages? ›

Recommendations to help prevent and mitigate shortages
  • Manufacturers should provide FDA with more information on the causes of the shortages and their expected durations. ...
  • Health systems should establish best practices for high-alert drugs. ...
  • FDA should require manufacturers to establish contingency plans.

What are the consequences of running out of stock? ›

The most obvious consequence of stockouts is lost revenue. If a customer goes to place an order and the item is out of stock, you lose the profit of that sale. Shoppers may opt for cheaper products. Or even worse, you may lose a customer forever, which means less recurring sales in the future.

How do drug shortages impact pharmacies and patients? ›

Medication shortages have also been reported to increase patient out of pocket costs [13, 14] and most alarmingly they have led to adverse patient events including mortality, treatment changes, inferior treatment, and medication errors [13, 15].

Why is there a shortage of 2022? ›

The supply chain just hasn't been the same since the 2020 Covid-19 pandemic began. From labor issues to inflation to closures, lots of factors have come into play that have led to food shortages and empty shelves of other essentials. And prices are going up, too.

When did drug shortage start? ›

Abstract. National tracking of drug shortages began in 2001. However, a significant increase in the number of shortages began in late 2009, with numbers reaching what many have termed crisis level. The typical drug in short supply is a generic product administered by injection.

What drugs are on shortage? ›

Drug shortages can have a significant impact on patient care and public health.
...
Current Drug Shortages.
Generic NameRevision Date
5% Lidocaine and 7.5% Dextrose InjectionJune 13, 2022
50% Dextrose InjectionNovember 14, 2022
70% Dextrose Injection Large Volume BagsNovember 21, 2022
Acetaminophen SuppositoriesOctober 25, 2022
236 more rows

Why are pharmacists declining? ›

Yes, pharmacist jobs are declining slightly.

One reason is that, as more people fill their orders online or through the mail, there will be less demand for pharmacists working in retail pharmacies and drug stores. Also, as pharmacy chains reduce the number of their retail locations, there will be fewer jobs available.

Why are pharmacies on the decline? ›

Independent pharmacies are struggling due to the vertical integration among drugstore chains, insurance companies and pharmaceutical benefit managers, which gives those companies market power that community drugstores can't match.

Will pharmacists ever be replaced? ›

The pharmacy of the future will likely not be fully automated, as pharmacists provide expert level insight, knowledge and management when it comes to pharmaceuticals. For the foreseeable future, AI and robots will not be able to compete with the expertise of pharmacists.

How can we prevent the shortage of supplies? ›

8 Ways to Fix Shortage Issues
  1. Expedite Parts. ...
  2. Improve Forecasting. ...
  3. Improve Lead Time Accuracy. ...
  4. Eliminate Single Point Failures. ...
  5. Develop a Shortage Attack Team (or better shortage management processes) ...
  6. Improve Supplier Collaboration. ...
  7. Ensure accurate inventory data. ...
  8. Regularly update PFEP.

Which cause of drug shortages is most likely to lead to a shortage of a large number of critical acute drugs at the same time? ›

A: A major reason for these shortages has been quality/manufacturing issues. However there have been other reasons such as production delays at the manufacturer and delays companies have experienced receiving raw materials and components from suppliers. Discontinuations are another factor contributing to shortages.

How can we prevent drugs in our community? ›

Some important principles are: Avoid mass awareness campaigns. Targeted interventions are more useful in drug abuse prevention. Focus on the positive aspects of not using drugs. This includes messages on saying 'NO' to drugs and resisting peer pressure.

What is the consequence of too much or too little inventory? ›

Inventory is purchased to be resold at a profit, and having too much inventory on hand can result in working capital being tied up as goods. Inventory loses value over time as degradation occurs and demand diminishes, leading to an eventual loss of revenue.

What are the consequences if the inventory is not maintained effectively? ›

Poor inventory management can have significant consequences including: Higher holding costs. The longer you hold inventory, the higher your costs. Thus, without good inventory management and information, you may stock up on too much of a product, erode cash flow, and risk holding dead stock that has become obsolete.

What happens when pharmacy is out of stock? ›

Manufacturer shortage

The Manufacturer hasn't made enough to supply demand. In this case, they may limit the amount of medication each pharmacy can order. When this happens, we will send a few days' supply of the medication, and will send the amount owed when the medication is back in stock.

Are pharmacies to blame for opioid crisis? ›

Last week, a federal jury in Ohio found that several major pharmacy chains operating in two of the state's counties contributed to opioid overdose deaths there. It was the first verdict to be handed down by a jury in an opioids case—and the first to implicate the pharmacy retailers in the broader public health crisis.

What does a drug shortage mean? ›

A drug product shortage is defined as a supply issue that affects how the pharmacy prepares or dispenses a drug product or influences patient care when prescribers must use an alternative agent. (

What should I stock up on now? ›

My Top 10 Foods to Stock Up on Now to Prepare for Food Shortage
  • Legumes: Beans and Lentils.
  • Rice (and Other Whole Grains?)
  • Basic Meats That Matter.
  • Salt.
  • Healthy Fats and Oils.
  • Don't Forget the Flavor.
  • Shelf-Stable Protein Beyond the Meat.
  • The Trifecta of Nuts.
12 Oct 2022

What is behind the supply chain crisis? ›

The causes of supply chain disruptions

As we move into the second half of 2022, shippers and carriers are continuing to face challenges due to the geopolitical environment, rising fuel costs, and inflation.

How can we prepare for a shortage in 2022? ›

How to Prepare for Food Shortage
  1. Build an Emergency Kit. Start with the creation of a kit filled with everything you'll need during emergency events, including food, water, and medical supplies. ...
  2. Stock Up on Non-Perishables. ...
  3. Create a Bountiful Garden. ...
  4. Raise Chickens or Other Animals. ...
  5. Learn These Long Term Storage Tips.
16 Oct 2022

Is there a drug shortage in the United States? ›

The U.S. is experiencing a rapidly increasing frequency of drug shortages, which have caused numerous difficulties for clinicians, health care facilities, patients, and federal regulators.

What is the oldest drug store? ›

Santa Maria Novella Pharmacy is thought to be the oldest apothecary in the world, reports host Jane Pauley. Pharmacy director Gianluca Foa says it dates back to 1221, when its Dominican monks here began experimenting with alchemy.

How much do drug shortages cost the US each year? ›



Drug shortages add time and expense as providers search for therapeutic alternatives and manage supplies, adding $230 million6 a year to U.S. drug costs and $216 million a year7 in increased labor costs.

Why are there shortages? ›

It's because of labor shortages and supply-chain issues, from food manufacturers to grocery stores. There simply aren't enough people to “make the goods, move the goods and sell the goods,” says Jim Dudlicek, a representative for the National Grocers Association.

How does the FDA define a drug shortage? ›

The Federal Food, Drug, and Cosmetic Act (FD&C Act) defines a “drug shortage” as “a period of time when the demand or projected demand for the drug within the United States exceeds the supply of the drug.” FD&C Act s.

Which is the most serious type of drug recall? ›

Class I recalls are the most serious type. The FDA defines a Class I recall as one that involves “a dangerous or defective product that could cause serious health problems or death.”

Why are so many pharmacists quitting? ›

While this would typically indicate a shortage of qualified personnel, it may actually be due to pharmacist burnout amid the increased pressure from COVID, strenuous working conditions, and billing and reimbursement challenges.

Why are pharmacists paid so much? ›

Not only do pharmacists dispense drugs, but they are critical in making sure that prescribed medications are safe for patients. Because of this extensive training and knowledge, pharmacists are compensated with higher-than-average salaries. Most people understand that working as a pharmacist can be a well-paying job.

Are pharmacists called doctors? ›

Pharmacists are doctors.

You probably don't refer to your pharmacist as “doctor.” In fact, when you meet pharmacists at your local apothecary, they will likely introduce themselves by their first name. However, they are indeed doctors. As of the year 2004, a doctor of pharmacy degree (Pharm.

What causes a red flag at the pharmacy? ›

A red flag could be indicative of abuse or misuse, over or under compliance, drug-drug interactions, or a “forged or altered prescription.” Such issues would be reviewed and resolved by a pharmacist “before filling any prescription” as part of the “prospective drug use review,” the testimony states.

Do pharmacies make money on prescriptions? ›

A typical independent pharmacy generates more than 90% of its revenues from prescriptions. Here are some basic definitions to clarify the pharmacy profit story: Gross profit equals a pharmacy's revenues minus the cost of products (net of discounts and returns) bought from a manufacturer or a wholesaler.

Where do pharmacies buy their drugs from? ›

Pharmacies purchase drugs from wholesalers, and occasionally directly from manufacturers. After purchasing these drugs, pharmacies must safely store and dispense these drugs to patients.

Is pharmacy a declining field? ›

Employment of pharmacists is projected to decline almost 2 percent during the decade of 2020 to 2030.

Do pharmacists make a good living? ›

Glassdoor, a job and recruiting site, reports an attractive average base pay for pharmacists of $119,742 as of May 2022.

What percent of pharmacists are happy? ›

15% very satisfied. 26% satisfied. 27% somewhat dissatisfied. 17% extremely dissatisfied.

What are the effects of a shortage? ›

If there is a shortage, the high level of demand will enable sellers to charge more for the good in question, so prices will rise. The higher prices will then motivate sellers to supply more of that good. At the same time, the rising prices will make demand go down.

Why is shortage easily solved? ›

Typically, shortages are temporary and can be fixed by replenishing the supply of goods and products. There are three conditions that can create a shortage: - Increase in demand — occurs when consumers suddenly demand more of a product. For example, demand for a new automobile that a manufacturer cannot fulfill.

How can the government solve the problem of shortage in the market? ›

Supply chain with regulations. On the demand side, because supply shortages can be caused by panic buying, the government can regulate consumer purchasing by limiting the quantity of a product that can be bought to the essential value. We call this purchase regulation.

Why are there so many shortages right now 2022? ›

In 2021, as a consequence of the COVID-19 pandemic, global supply chains and shipments slowed, causing worldwide shortages and affecting consumer patterns.

What is the main cause of drug abuse? ›

Peer pressure is a strong factor in starting to use and misuse drugs, particularly for young people. Lack of family involvement. Difficult family situations or lack of a bond with your parents or siblings may increase the risk of addiction, as can a lack of parental supervision.

What are 3 careers that a person could have that would deal with drugs? ›

  • Counselors, Therapists and Doctors. The primary job that comes to mind when people think of recovery is the addiction counselor. ...
  • Administrative Workers. ...
  • Social Workers. ...
  • Vocational Counselors. ...
  • Nurses and Detox Support Specialists. ...
  • Sober Companions and Drug and Alcohol Workers. ...
  • Not for Everyone.
6 Oct 2018

How can we solve the problem of drugs? ›

Explore your addiction treatment options
  1. Detoxification. ...
  2. Behavioral counseling. ...
  3. Medication may be used to manage withdrawal symptoms, prevent relapse, or treat any co-occurring mental health condition such as depression or anxiety.
  4. Long-term follow-up can help to prevent relapse and maintain sobriety.

What are negative findings in medicine? ›

A substantial part of the observations made by clinicians are entered into patient records as 'negative findings', i.e. as statements documenting that something is not the case. Typical examples are statements such as 'no headache', or 'no known drug allergies'.

What are the negatives of medication? ›

The risks of medicines are the chances that something unwanted or unexpected could happen to you when you use them. Risks could be less serious things, such as an upset stomach, or more serious things, such as liver damage.

What are the 8 types of drugs? ›

Top 8 Drug Categories
  • Stimulants.
  • Inhalants.
  • Cannabinoids.
  • Depressants.
  • Opioids.
  • Steroids.
  • Hallucinogens.
  • Prescription drugs.
24 Jul 2019

What are the disadvantages of modern medicine? ›

There are several disadvantages of the system that include inter alia , side effects of therapeutics; genesis of iatrogenic disorders, inadequacy in treating chronic diseases such as arthritis, hyperacidity, and allergies; time consuming and very costly process of discovery of a new drug; lack of remedies in case ...

What are adverse effects? ›

An unexpected medical problem that happens during treatment with a drug or other therapy. Adverse effects may be mild, moderate, or severe, and may be caused by something other than the drug or therapy being given. Also called adverse event.

What are six possible negative consequences of poor medical documentation? ›

Grave consequences of poor documentation include the following: Wrong treatment decisions. Unnecessary, expensive diagnostic studies. Unclear communication among consultants and referring physicians, which could lead to issues with follow-up evaluations and treatment plans.

What are 5 examples of common medication errors and their potential consequences? ›

Types of Medication Errors
  • Prescribing.
  • Omission.
  • Wrong time.
  • Unauthorized drug.
  • Improper dose.
  • Wrong dose prescription/wrong dose preparation.
  • Administration errors include the incorrect route of administration, giving the drug to the wrong patient, extra dose, or wrong rate.
3 Jul 2022

What are pertinent negatives and positives? ›

Pertinent positives, which are disease-specific and can be learned by rote, are used to “rule in” a particular diagnosis. Pertinent negatives, which require more analytical and creative thinking, are gleaned from the differential diagnosis and function to “rule out” other diagnostic possibilities.

What states is gabapentin a controlled substance 2022? ›

As of July 2022, these states consider gabapentin a schedule V controlled substance:
  • Alabama.
  • Kentucky.
  • Michigan.
  • North Dakota.
  • Tennessee.
  • Virginia.
  • West Virginia.
26 Jul 2022

Why are pharmacies running out of meds? ›

Drug Shortages can occur for many reasons, including manufacturing and quality problems, delays, and discontinuations.”

When a pharmacy is out of stock How long does it take? ›

In many cases, medicines that are out-of-stock are ordered for the next business day to be filled. However, specialty medicines or medicines that have a certain control schedule may take well more than one business day to arrive. This adds time to the prescription filling process.

Why is medicine important to society? ›

the functionalist perspective on health and medicine emphasizes that good health and effective medical care are essential for a society's ability to function. Ill health impairs our ability to perform our roles in society, and if too many people are unhealthy, society's functioning and stability suffer.

Why medicine is important in our life? ›

Medicines are chemicals or compounds used to cure, halt, or prevent disease; ease symptoms; or help in the diagnosis of illnesses. Advances in medicines have enabled doctors to cure many diseases and save lives. These days, medicines come from a variety of sources.

What are 3 common side effects of medication? ›

Common side effects include upset stomach, dry mouth, and drowsiness.
...
Unwanted or Unexpected Drug Reactions
  • start taking a new drug or dietary supplement (for example, vitamins)
  • stop taking a drug that you've been on for a while, or.
  • increase or decrease the dose (amount) of a drug that you take.
8 Aug 2022

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