Effects of tonic water

Summer is a time for popsicles and corn on the cob, watermelon and ice cream, and for some, beverages prepared with clear liquors. It’s well known that alcohol affects the body and mind in profound ways, but there’s more to a mixed drink than meets the liver. What about tonic water, that bitter, effervescent liquid so often called upon during the warmer months to serve as the yin to the yang of gin?

Tonic water originally existed as a way to deliver quinine, an antimalarial drug derived from the bark of the South American cinchona tree. In the early 1800s, a British officer in colonial India invented the venerable gin and tonic when he realized that alcohol helped the medicine go down in the most delightful way.

Today, tonic water still contains quinine, but the roles are reversed: a diluted, sweeter formulation of tonic water helps guide gin and vodka past the tonsils instead. Among foods and drinks that are ingested solely for reasons of taste, tonic water is unique in that it was first and foremost a medicine. Since medicines tend to have side effects, is it possible that a hidden health risk is swirling around in tonic water? The answer is yes, with some caveats. Quinine is still used to treat malaria today, although doctors typically reserve it for cases when the pathogen responsible for the disease displays resistance to newer drugs. However, you’d have to drink almost 20 liters of today’s dilute tonic water daily to achieve the daily dose typically prescribed for malaria.

That may come as bad news for anyone hoping to cure the deadly infection with a nightly tippling session, but it should come as a relief to the rest of us, because quinine comes with side effects.

Side effects so serious, in fact, they were the reason the Food and Drug Administration banned doctors in 2010 from prescribing the drug to treat nighttime leg cramps, a frequent off-label usage. The most serious of the common side effects is thrombocytopenia, a drop in the blood’s platelet count that can lead to internal and external bleeding, as well as a related condition that can cause permanent kidney damage. Worse, these and other side effects occur to some degree in up to one in 25 patients treated with medicinal doses of quinine.

Happily, the low dose of quinine found in a glass or two of tonic water isn’t enough to trigger these issues in most people. However, for the unlucky few, even the small amount of quinine in tonic water can cause thrombocytopenia (doctors call this rare occurrence a “gin and tonic purpura”).

People may also develop sensitivities and allergies to quinine as a result of occasional tonic water consumption, only to experience a full-blown reaction years later, upon taking a medicinal dose of quinine.

Quinine can pass through the placenta from mother to fetus and there is some limited evidence that it can cause birth defects, so pregnant women should avoid the drug unless a doctor prescribes it to fight malaria. People with the metabolic disorder glucose-6-phosphate dehydrogenase deficiency (G6PD) should also avoid it.

For the rest of us, from a health perspective, alcohol is a much more worrisome mixed-drink ingredient than tonic.

Pass it on: People may want to avoid tonic water if pregnant, or sensitive or allergic to quinine.

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PMC

In a linked research article, Garrison and colleagues1 report on the seasonal variability of nocturnal leg cramps. They found that new quinine prescriptions in the province of British Columbia and Internet searches using the term “leg cramps” in the United States both showed a sinusoidal pattern, with a midsummer peak and a midwinter dip. I don’t intend to question this novel finding or speculate on the mechanism underlying the apparent seasonality of the condition. Instead, I will focus on the role of quinine in the management of this common condition.

Quinine sulfate at a dose of 200–300 mg at night has been used for many years to treat nocturnal leg cramps. Usually idiopathic, these muscle cramps are common, particularly in older patients. Quinine may help by decreasing the excitability of the motor end-plate and increasing the muscle refractory period.2 A number of drugs have been proposed for the treatment of nocturnal leg cramps. Two systematic reviews published within the last five years both concluded that quinine is modestly effective (reduces cramp frequency by about a quarter, cramp intensity by a tenth and number of days by a fifth).3,4 Other pharmacologic measures were found to be either possibly effective (vitamin B complex, naftidrofuryl, calcium-channel blockers) or likely not effective (gabapentin, magnesium).3

A variety of adverse effects can occur with the usual therapeutic doses of quinine, including cinchonism (marked by tinnitus, high-tone hearing loss, photophobia and other visual disturbances, dysphoria, headache, nausea, vomiting, sweating, dizziness and postural hypotension), hypoglycemia (from the drug’s stimulatory effect on pancreatic β cells; most common in the treatment of severe malaria), hypotension (usually related to intravenous infusion of the drug), hearing and visual disturbances (including irreversible loss), gastrointestinal symptoms, cutaneous effects, conduction abnormalities (mild prolongation of the corrected QT interval, which is rare unless plasma levels are elevated), arrhythmias and hemolysis (from hypersensitivity or in patients with G6PD deficiency).2,3

Of particular concern is the potential for rare but serious hematologic adverse effects (i.e., immune thrombocytopenic purpura and drug-mediated thrombotic microangiopathy). In a study of Medicare claims data, the incidence per 1000 person-years with quinine was 1.67 for immune thrombocytopenic purpura and 0.23 for thrombotic microangiopathy. The incidence rate ratios were 4.2 (95% confidence interval 2.5–6.5) and 6.9 (95% CI 1.3–24.0), respectively, compared with diltiazem.5 Intentional or inadvertent overdose can cause serious and even fatal arrhythmias.2 Severe drug interactions with aluminum-containing antacids, cholinesterase inhibitors, cimetidine, digoxin, neuromuscular blocking agents, warfarin and other agents can take place.2 Quinine is contraindicated in patients with a known hypersensitivity, a history of immune thrombocytopenic purpura or thrombotic microangiopathy, G6PD deficiency, tinnitus, optic neuritis, prolonged QT interval or myasthenia gravis. As of Sept. 30, 2010, Health Canada had received 71 reports of serious adverse reactions suspected of being associated with quinine use (41 were either life threatening or required hospital admission).6

Although quinine is modestly effective, concerns regarding potential adverse effects have tempered enthusiasm about its use for nocturnal leg cramps. In 2009, the US Food and Drug Administration (FDA) explicitly noted an unfavourable risk–benefit ratio for quinine when used for leg cramps.5 Because of continued reports of serious adverse effects from this off-label use, the FDA in 2010 launched a risk-management plan about its use for leg cramps.5 In addition to a letter warning practitioners of the risk of serious and life-threatening hematologic effects, the plan required that patients be given a medication guide explaining what quinine is approved for and its potential adverse effects. The same year, practice guidelines for American neurologists on the symptomatic management of muscle cramps concluded that, although likely effective, quinine should be avoided for routine use because of the potential for toxic effects.3

Quinine does not have Health Canada approval for the treatment of nocturnal leg cramps, yet it is widely used for this indication. In the linked research article, data underlying Garrison and colleagues’ analyses show 340–576 new and 3430–4372 refilled quinine prescriptions per month in British Columbia, presumably for nocturnal leg cramps, between November 2006 and October 2007 inclusive.1 This extent of off-label use of quinine can be decreased by appropriate action. In response to the advice and action described in the preceding paragraph, the prevalent use of quinine in the US decreased by 99% during 2006–2012, from 419 675 to 6036 individuals.5

A systematic review of nonpharmacologic approaches (e.g., stretching) for leg cramps concluded there was limited evidence supporting their use.7 However, a six-week randomized trial with concealed allocation and intention-to-treat analysis published after the systematic review showed significant decreases in both the frequency (mean difference 1.2 cramps per night) and severity (mean difference 1.3 cm on 10-cm visual analog scale) of nocturnal leg cramps with nightly calf and hamstring stretches.8

Although there is consensus that quinine should not be used routinely for nocturnal leg cramps, a complete ban would be draconian. The Medicines and Healthcare Products Regulatory Agency in the United Kingdom provides sound practice advice, in my opinion. A four-week trial of quinine could be an option for fully informed patients experiencing frequent, severe cramps that disrupt their sleep, but only after treatable causes have been ruled out and nonpharmacologic measures have been shown to be ineffective.9 Trying potentially less toxic pharmacologic agents could be an option as well, although evidence supporting their efficacy is weak.3 During the trial, patients should be closely monitored and the quinine stopped after four weeks if there is no benefit.9 If treatment continues, patients should be followed and advised periodically (e.g., every three months) to try stopping the drug to reassess the benefit. A randomized controlled trial showed that advising patients to try stopping quinine temporarily was not associated with serious problems and led to a greater number stopping the agent (odds ratio of not taking quinine at 12 wk 3.32, 95% CI 1.37–8.06) compared with patients not advised to stop it.10 The merit of a “quinine holiday” during the colder months, as suggested by Garrison and colleagues, becomes moot if patients are not prescribed the agent in the first place or are periodically advised to try stopping it.

Key points

  • Quinine sulfate is widely used to treat nocturnal leg cramps in Canada.

  • Although modestly effective for this indication, quinine is not recommended for routine use because of safety concerns.

  • A four-week trial of quinine could be an option for fully informed patients experiencing frequent, severe cramps that disrupt their sleep.

  • The trial should be considered only after treatable causes have been ruled out, and nonpharmacologic and potentially less toxic pharmacologic agents have been tried.

  • Patients continuing to take quinine after four weeks should be followed and advised periodically to try stopping it.

Will tonic water prevent nighttime leg cramps?

Ask the doctor

Updated: August 20, 2019Published: September, 2016


Image: Karl Rosencrants/ Thinkstock

Q. It’s been suggested that drinking 2 to 3 ounces of tonic water before bedtime can prevent leg cramps at night. Is that true?

A. Tonic water—and the quinine it contains—have been promoted for preventing leg cramps for decades despite the lack of evidence that they are effective. Quinine is FDA-approved only for treating malaria and is sold with a warning against using it to treat leg cramps or muscle pain, because it increases the risk of bleeding and heart rhythm disturbances. Tonic water contains no more than 83 mg of quinine per liter—a much lower concentration than the 500 to 1,000 mg in the therapeutic dose of quinine tablets. Drinking a few ounces of tonic water shouldn’t be harmful, but it isn’t likely to prevent your leg cramps.

There are a few other things you can do, however. Because cramps are often caused by dehydration, make sure to get enough fluids. But avoid caffeinated and alcoholic beverages, which are dehydrating. (Don’t mix gin with that tonic!) Stretching during the day or before bed may also help prevent them.

Once a cramp starts, getting out of bed and standing on the affected leg may abort it. Using ice or heat and gently massaging the affected muscle may provide some relief.

— by Hope Ricciotti, M.D., and Hye-Chun Hur, M.D., M.P.H.
Former Editors in Chief, Harvard Women’s Health Watch

Disclaimer:
As a service to our readers, Harvard Health Publishing provides access to our library of archived content. Please note the date of last review on all articles. No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.

Qualaquin

SIDE EFFECTS

Overall

Quinine can adversely affect almost every body system. The most common adverse events associated with quinine use are a cluster of symptoms called “cinchonism”, which occurs to some degree in almost all patients taking quinine. Symptoms of mild cinchonism include headache, vasodilation and sweating, nausea, tinnitus, hearing impairment, vertigo or dizziness, blurred vision, and disturbance in color perception. More severe symptoms of cinchonism are vomiting, diarrhea, abdominal pain, deafness, blindness, and disturbances in cardiac rhythm or conduction. Most symptoms of cinchonism are reversible and resolve with discontinuation of quinine.

The following ADVERSE REACTIONS have been reported with quinine sulfate. Because these reactions have been reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

General: fever, chills, sweating, flushing, asthenia, lupus-like syndrome, and hypersensitivity reactions.

Hematologic: agranulocytosis, hypoprothrombinemia, thrombocytopenia, disseminated intravascular coagulation, hemolytic anemia; hemolytic uremic syndrome, thrombotic thrombocytopenic purpura, idiopathic thrombocytopenic purpura, petechiae, ecchymosis, hemorrhage, coagulopathy, blackwater fever, leukopenia, neutropenia, pancytopenia, aplastic anemia, and lupus anticoagulant.

Neuropsychiatric: headache, diplopia, confusion, altered mental status, seizures, coma, disorientation, tremors, restlessness, ataxia, acute dystonic reaction, aphasia, and suicide.

Dermatologic: cutaneous rashes, including urticarial, papular, or scarlatinal rashes, pruritus, bullous dermatitis, exfoliative dermatitis, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, fixed drug eruption, photosensitivity reactions, allergic contact dermatitis, acral necrosis, and cutaneous vasculitis.

Respiratory: asthma, dyspnea, pulmonary edema.

Cardiovascular: chest pain, vasodilatation, hypotension, postural hypotension, tachycardia, bradycardia, palpitations, syncope, atrioventricular block, atrial fibrillation, irregular rhythm, unifocal premature ventricular contractions, nodal escape beats, U waves, QT prolongation, ventricular fibrillation, ventricular tachycardia, torsades de pointes, and cardiac arrest.

Gastrointestinal: nausea, vomiting, diarrhea, abdominal pain, gastric irritation, and esophagitis.

Hepatobiliary: granulomatous hepatitis, hepatitis, jaundice, and abnormal liver function tests.

Metabolic: hypoglycemia and anorexia.

Musculoskeletal: myalgias and muscle weakness.

Renal: hemoglobinuria, renal failure, renal impairment, and acute interstitial nephritis.

Special Senses: visual disturbances, including blurred vision with scotomata, sudden loss of vision, photophobia, diplopia, night blindness, diminished visual fields, fixed pupillary dilatation, disturbed color vision, optic neuritis, blindness, vertigo, tinnitus, hearing impairment, and deafness.

Read the entire FDA prescribing information for Qualaquin (Quinine Sulfate Capsules)

Here’s Why Tonic Water Isn’t as Healthy as You Think

Unfortunately, making healthier choices isn’t as simple as opting for diet tonic water. Calorie-free sweeteners like aspartame (Equal) and saccharin (Sweet’N Low) are a bit scandalous in the health world.

Some researchers believe that artificial sweeteners prep your body for a sugar fix and then don’t deliver. According to a 2010 study, if you’re left craving sweets after you slurp down a soda, you’re more likely to eat — and keep eating. Yang Q. (2010). Gain weight by “going diet?” Artificial sweeteners and the neurobiology of sugar cravings. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2892765/

In 2013, researchers decided to test this theory. They had 200 people replace their sugary drinks with diet varieties or water for 6 months. The conclusion? Diet-beverage drinkers actually ate fewer desserts than the water drinkers, so there’s that. Piernas C, et al. (2013). Does diet-beverage intake affect dietary consumption patterns? Results from the Choose Healthy Options Consciously Everyday (CHOICE) randomized clinical trial. DOI: 10.3945/ajcn.112.048405

A 2017 review noted that the long-term impact of sweeteners is not yet known. And they do little in the way of weight loss. In fact, the opposite may be true: Sometimes diet-beverage drinkers gain weight and have an increased risk of chronic diseases. Azad MB, et al. (2017). Nonnutritive sweeteners and cardiometabolic health: A systematic review and meta-analysis of randomized controlled trials and prospective cohort studies. DOI: 10.1503/cmaj.161390

Quinine

Generic Name: quinine (KWYE nine)
Brand Name: Qualaquin, QM-260, Quinamm

Medically reviewed by Drugs.com on Mar 25, 2019 – Written by Cerner Multum

  • Overview
  • Side Effects
  • Dosage
  • Professional
  • Interactions
  • More

What is quinine?

The U.S. Food and Drug Administration has banned the sale of all non-approved brands of quinine. Do not purchase quinine on the Internet or from vendors outside of the United States.

Quinine is used to treat uncomplicated malaria, a disease caused by parasites. Parasites that cause malaria typically enter the body through the bite of a mosquito. Malaria is common in areas such as Africa, South America, and Southern Asia.

Quinine will not treat severe forms of malaria, and it should not be taken to prevent malaria.

Some people have used quinine to treat leg cramps, but this is not an FDA-approved use. Using this medication improperly or without the advice of a doctor can result in serious side effects or death.

Quinine may also be used for purposes not listed in this medication guide.

Important Information

Quinine can cause serious side effects on your heart, kidneys, or blood cells. Stop taking quinine and call your doctor at once if you have headache with chest pain and severe dizziness, fast or pounding heartbeats, unusual bruising or bleeding (nosebleeds, bleeding gums, purple or red spots under your skin), signs of infection (fever, chills, mouth sores), severe lower back pain, or blood in your urine.

You should not take quinine if you have a heart rhythm disorder called Long QT syndrome, a genetic enzyme deficiency called glucose-6-phosphate dehydrogenase deficiency (G-6-PD), myasthenia gravis, optic neuritis (inflammation of the nerves in your eyes), if you have taken quinine in the past and it caused a blood cell disorder or severe bleeding.

Some people have used quinine to treat leg cramps, but this is not an FDA-approved use. Using this medication improperly or without the advice of a doctor can result in serious side effects or death.

Before taking this medicine

You should not use this medication if you have ever had an allergic reaction to quinine or similar medicines such as mefloquine or quinidine, or if you have:

  • a heart rhythm disorder called Long QT syndrome;

  • an enzyme deficiency called glucose-6-phosphate dehydrogenase deficiency (G-6-PD);

  • myasthenia gravis;

  • optic neuritis (inflammation of the optic nerve); or

  • if you have taken quinine in the past and it caused a blood cell disorder, severe bleeding, or kidney problems.

To make sure quinine is safe for you, tell your doctor if you have:

  • heart disease or a heart rhythm disorder;

  • low levels of platelets in your blood;

  • low potassium levels in your blood (hypokalemia); or

  • liver or kidney disease.

FDA pregnancy category C. It is not known whether quinine will harm an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant while using this medication.

Quinine can pass into breast milk and may harm a nursing baby. Tell your doctor if you are breast-feeding a baby.

Do not give this medication to a child younger than 16 years old.

How should I take quinine?

Follow all directions on your prescription label. Do not take quinine in larger or smaller amounts or for longer than recommended.

Take with food if quinine upsets your stomach.

Take this medication for the full prescribed length of time. Your symptoms may get better before your condition is completely cleared.

If you need surgery or medical tests, tell your caregivers ahead of time that you are using quinine. You may need to stop using the medicine for a short time.

Call your doctor if your symptoms do not improve after 2 days of treatment, or if your symptoms return after you have finished the medicine.

Store at room temperature away from moisture and heat.

What happens if I miss a dose?

Take the missed dose as soon as you remember. If you are more than 4 hours late for your dose, skip the missed dose and take the medicine at your next scheduled dose time. Do not take extra medicine to make up the missed dose.

What happens if I overdose?

Seek emergency medical attention or call the Poison Help line at 1-800-222-1222.

What should I avoid while taking quinine?

Avoid taking other anti-malaria medications without your doctor’s advice. This includes chloroquine, halofantrine, and mefloquine.

Avoid using antacids without your doctor’s advice. Use only the type of antacid your doctor recommends. Some antacids can make it harder for your body to absorb quinine.

Quinine may cause blurred vision and may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be alert and able to see clearly.

Do not use quinine to treat any condition that has not been checked by your doctor.

Quinine side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Call your doctor at once if you have:

  • fever, chills, body aches, flu symptoms, sores in your mouth and throat;

  • easy bruising, unusual bleeding (nose, mouth, vagina, or rectum), purple or red pinpoint spots under your skin;

  • headache with chest pain and severe dizziness, fainting, fast or pounding heartbeats;

  • sudden numbness or weakness (especially on one side of the body), sudden severe headache, slurred speech, problems with balance;

  • chest pain, sudden cough, wheezing, rapid breathing, coughing up blood;

  • problems with vision or hearing;

  • pain, swelling, warmth, or redness in one or both legs;

  • severe pain in your side or lower back, blood in your urine, little or no urine;

  • low blood sugar (more common in pregnant women)–headache, hunger, weakness, sweating, confusion, irritability, dizziness, fast heart rate, or feeling jittery;

  • loss of appetite, dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes); or

  • severe skin reaction — fever, sore throat, swelling in your face or tongue, burning in your eyes, skin pain, followed by a red or purple skin rash that spreads (especially in the face or upper body) and causes blistering and peeling.

Common side effects may include:

  • headache, blurred vision, changes in color vision;

  • sweating or flushing (warmth, redness, or tingly feeling);

  • mild dizziness, spinning sensation, ringing in your ears; or

  • upset stomach, vomiting, stomach pain.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

What other drugs will affect quinine?

Many drugs can interact with quinine. Not all possible interactions are listed here. Tell your doctor about all your medications and any you start or stop using during treatment with quinine, especially:

  • acetazolamide, sodium bicarbonate;

  • aminophylline, theophylline;

  • arsenic trioxide, vandetanib;

  • bosentan;

  • imatinib;

  • methadone;

  • tacrolimus;

  • St. John’s wort;

  • an antibiotic–azithromycin, clarithromycin, erythromycin, levofloxacin, moxifloxacin, pentamidine, telithromycin, tetracycline;

  • an antidepressant–amitriptyline, citalopram, clomipramine, desipramine, nefazodone, venlafaxine;

  • antifungal medication–itraconazole, ketoconazole, posaconazole, voriconazole;

  • cholesterol-lowering medicine–atorvastatin, simvastatin, lovastatin;

  • cough medicine that contains dextromethorphan;

  • heart medication–amiodarone, digoxin, dofetilide, disopyramide, dronedarone, flecainide, ibutilide, metoprolol, procainamide, propafenone, quinidine, sotalol, verapamil;

  • hepatitis C medications–boceprevir, telaprevir;

  • HIV/AIDS medication–atazanavir, delavirdine, efavirenz, fosamprenavir, indinavir, nelfinavir, nevirapine, ritonavir, saquinavir;

  • medicine to prevent or treat nausea and vomiting–dolasetron, droperidol, ondansetron;

  • medicine to treat a psychiatric disorder–chlorpromazine, clozapine, haloperidol, mesoridazine, pimozide, thioridazine, ziprasidone;

  • seizure medication–carbamazepine, fosphenytoin, oxcarbazepine, phenobarbital, phenytoin, primidone;

  • stomach acid reducers–cimetidine, ranitidine; or

  • tuberculosis medication–rifabutin, rifampin, rifapentine.

This list is not complete and many other drugs can interact with quinine. This includes prescription and over-the-counter medicines, vitamins, and herbal products. Give a list of all your medicines to any healthcare provider who treats you.

Further information

Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed.

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

Copyright 1996-2018 Cerner Multum, Inc. Version: 9.01.

Medical Disclaimer

More about quinine

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  • Drug class: antimalarial quinolines
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Consumer resources

  • Quinine
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Other brands: Qualaquin

Professional resources

  • Quinine Sulfate (AHFS Monograph)
  • … +2 more

Related treatment guides

  • Myotonia Congenita
  • Nocturnal Leg Cramps
  • Malaria

Quinine, drug obtained from cinchona bark that is used chiefly in the treatment of malaria, an infection caused by the protozoan parasite Plasmodium, which is transmitted to humans by the bite of various species of mosquitoes. During the 300 years between its introduction into Western medicine and World War I, quinine was the only effective remedy for malaria; as a specific treatment for this disease, quinine benefited a great many people. The treatment of malaria with quinine marked the first successful use of a chemical compound in combating an infectious disease. Quinine was first synthesized in a laboratory in 1944; however, synthesis of the drug on a commercial scale is not economically feasible.

Quinine, an alkaloid, acts by interfering with the growth and reproduction of the malarial parasites, which inhabit the red blood cells (erythrocytes). Administration of quinine dramatically improves the condition of a person with malaria; the parasites promptly disappear from the blood, and the symptoms of the disease are quickly alleviated. When quinine treatment is terminated, however, many recovered patients experience another attack of malaria several weeks later. This recurrence stems from the failure of quinine to kill the malarial parasites in cells of the body other than the red blood cells. These parasites persist and, after a time, reinvade the red blood cells and precipitate the second malarial attack, or relapse.

Because quinine fails to produce a complete cure of malaria, better antimalarial drugs have been developed. Research during World War II produced a number of antimalarial drugs that almost completely replaced quinine. Some of them, such as chloroquine, are more effective than quinine in suppressing the growth of the blood forms of the malarial parasite; others, such as primaquine, act upon both the blood and tissue stages of the parasite, thus producing complete cures and preventing relapses. All the newer antimalarials, unlike quinine, may be completely synthesized on a commercial scale.

During the 1960s several strains of the malarial parasite Plasmodium falciparum developed resistance to the synthetic drugs, particularly the highly valued chloroquine. The parasite remained sensitive, however, to quinine, which had to be reinstated in various parts of the world as the drug of choice despite the side effects that sometimes occur when the necessarily large doses of quinine are given. Prolonged administration of quinine may produce toxic symptoms such as deafness, disturbances in vision, rash, and gastrointestinal symptoms.

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Dec. 12, 2006 — The FDA is telling people not to use the malaria drug quinine for leg cramps, citing potentially deadly side effects.

The FDA issued the advice today and ordered all unapproved drugs containing quinine off the market within 60 days.

Qualaquin, the only FDA-approved quinine drug, can be used to treat certain types of malaria; the new order doesn’t change that.

But quinine is also often prescribed to treat leg cramps. That unapproved use is too risky, says the FDA.

Quinine carries extensive warnings about possible side effects, including:

  • Potentially serious interactions with other drugs
  • Abnormal heart rhythms
  • Thrombocytopenia, a blood platelet disorder that can cause hemorrhage or clotting problems
  • Severe hypersensitivity reactions

Since 1969, the FDA has received 665 reports of serious adverse events tied to quinine, including 93 deaths.

Quinine has a narrow margin between effective and toxic doses, notes the FDA.

The doses for Qualaquin have the FDA’s approval for treatment of certain types of malaria. But the FDA hasn’t reviewed dosing for unapproved quinine drugs.

“We believe unapproved quinine products represent a serious health risk because of the widespread use of this product for treating leg cramps,” Steven Galson, MD, MPH, says in the FDA news release. Galson directs the FDA’s Center for Drug Evaluation and Research.

“Quinine needs to be dosed carefully, and FDA-approved labeling reflects the fact that the risks associated with the use of this drug for treatment of leg cramps outweigh the benefits,” Galson says.

Q: I am normally a mosquito magnet. By this time of year, I would usually have dozens of bites, and the itching would be intolerable. I would turn into a bloody mess from constant scratching.

This year, I have been drinking tonic water two or three times a day, and I haven’t had a mosquito bite in weeks. As an added bonus, I haven’t experienced leg cramps while cycling. In hot weather, I used to cramp up after two or three hours of hard riding.

Is there a limit on how much tonic you can drink before overdosing on quinine? I have read in your column that too much could be dangerous, but how much is too much?

A: Doctors used to prescribe quinine pills to prevent leg cramps. The standard dose was between 200 and 300 mg of quinine.

The Food and Drug Administration banned quinine for this purpose, but continues to allow it in tonic water. A liter normally has 83 mg of quinine. An eight-ounce glass would therefore have roughly 20 mg, about one-tenth the lowest dose doctors prescribed for leg cramps. Even three glasses daily should be OK as long as you are not sensitive to quinine.

Some susceptible people develop a dangerous blood disorder after even small doses of quinine. Symptoms of quinine toxicity include digestive upset, headache, ringing in the ears, visual disturbances, skin rash and arrhythmias.

Q: I am really upset about the latest information regarding the dangers of long-term use of PPI heartburn drugs. I have been taking one for several years for reflux.

I tried going off it and had terrible long-lasting heartburn the next day. I am going to try going off it again. Can I use something like Tums when I get that horrible heartburn, or do you have other suggestions?

A: Proton-pump inhibitors (PPIs) are popular for many digestive woes. They used to be perceived as super-safe, but over time disturbing complications have surfaced. These include kidney damage, dementia, fractures, pneumonia, diarrhea and certain nutritional deficiencies (iron, vitamin B-12 and magnesium).

As you discovered, stopping suddenly can lead to rebound heartburn that may last for weeks. To avoid this withdrawal, you might wean yourself gradually and add antacids, deglycyrrhizinated licorice, ginger and probiotics.

We are sending you our Guide to Digestive Disorders so you can learn more about the details. Anyone who would like a copy, please send $3 in check or money order with a long (No. 10), stamped (68 cents), self-addressed envelope to: Graedons’ People’s Pharmacy, No. G-3, P.O. Box 52027, Durham, NC 27717-2027. It also can be downloaded for $2 from our website: www.peoplespharmacy.com.

Q: You’ve written that metformin helps keep cancer away. Then why doesn’t everyone take it? What are the side effects of metformin? Are the side effects serious enough to cancel the benefits of taking metformin if one is not diabetic?

A: Metformin is a pillar of Type 2 diabetes treatment. Recently, researchers have discovered an anti-cancer effect of metformin in the breast, pancreas, liver, colon, ovaries and prostate (Experimental and Clinical Endocrinology and Diabetes, May 2016).

Most doctors are cautious about prescribing metformin for cancer prevention because more research is needed.

Side effects can include digestive distress, rash, exhaustion and headache. The most serious, though rare, complication is lactic acidosis, associated with failure of the heart and other organs.

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In their column, Joe and Teresa Graedon answer letters from readers. Write to them in care of this newspaper or email them via their Web site: www.PeoplesPharmacy.com. Their newest book is “Top Screwups Doctors Make and How to Avoid Them.”

Before taking quinine,

  • tell your doctor and pharmacist if you are allergic to quinine, quinidine, mefloquine (Lariam), any other medications, or any of the ingredients in quinine capsules. Ask your doctor or pharmacist for a list of the ingredients.
  • tell your doctor and pharmacist what other prescription and nonprescription medications, vitamins, nutritional supplements, and herbal products you are taking or plan to take. Be sure to mention any of the following: acetazolamide (Diamox); aminophylline; anticoagulants (‘blood thinners’) such as warfarin (Coumadin) and heparin; antidepressants (‘mood elevators’) such as desipramine; certain antifungals such as fluconazole (Diflucan), ketoconazole (Nizoral), and itraconazole (Sporanox); cholesterol-lowering medications such as atorvastatin (Lipitor), lovastatin (Mevacor), simvastatin (Zocor); cisapride (Propulsid); dextromethorphan (a medication in many cough products); fluoroquinolone antibiotics such as ciprofloxacin (Cipro), gatifloxacin (Tequin) (not available in the U.S.), levofloxacin (Levaquin), lomefloxacin (Maxaquin), moxifloxacin (Avelox), norfloxacin (Noroxin), ofloxacin (Floxin), and sparfloxacin (Zagam) (not available in the U.S.); macrolide antibiotics such as erythromycin (E.E.S., E-Mycin, Erythrocin) and troleandomycin (not available in the U.S.); medications for diabetes such as repaglinide (Prandin); medications for high blood pressure; medications for irregular heartbeat such as amiodarone (Cordarone, Pacerone), digoxin (Lanoxin), disopyramide (Norpace), dofetilide (Tikosyn), flecainide (Tambocor), procainamide (Procanbid, Pronestyl), quinidine, and sotalol (Betapace); certain medications for seizures such as carbamazepine (Tegretol), phenobarbital (Luminal, Solfoton), and phenytoin (Dilantin); medications for ulcers such as cimetidine (Tagamet); mefloquine (Lariam); metoprolol (Lopressor, Toprol XL); paclitaxel (Abraxane, Taxol); pimozide (Orap); rifampin (Rifadin, Rimactane); certain selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), and paroxetine (Paxil); sodium bicarbonate; tetracycline; and theophylline. Your doctor may need to change the doses of your medications or monitor you carefully for side effects. Many other medications may also interact with quinine, so be sure to tell your doctor about all the medications you are taking, even those that do not appear on this list.
  • do not take antacids that contain magnesium or aluminum (Alternagel, Amphogel, Alu-cap, Alu-tab, Basaljel, Gaviscon, Maalox, Milk of Magnesia, or Mylanta) at the same time as you take quinine.Talk to your doctor or pharmacist about how long you should wait between taking this type of antacid and taking quinine.
  • tell your doctor if you or anyone in your family has or has ever had a prolonged QT interval (a rare heart problem that may cause fainting or irregular heartbeat), an abnormal electrocardiogram (ECG; a test that measures the electrical activity of the heart), and if you have or have ever had G-6-PD deficiency (an inherited blood disease), or if you have or have ever had myasthenia gravis (MG; condition that causes weakness of certain muscles), or optic neuritis (inflammation of the optic nerve that may cause sudden changes in vision). Also tell your doctor if you have ever had a serious reaction, especially a bleeding problem or problems with your blood after taking quinine in the past. Your doctor will probably tell you not to take quinine.
  • tell your doctor if you have or have ever had a slow or irregular heartbeat; low levels of potassium in your blood; or heart, kidney, or liver disease.
  • tell your doctor if you are pregnant, plan to become pregnant, or are breast-feeding. If you become pregnant while taking quinine, call your doctor.
  • if you are having surgery, including dental surgery, tell the doctor or dentist that you are taking quinine.
  • tell your doctor if you use tobacco products. Cigarette smoking may decrease the effectiveness of this medication.

Stop taking Quinine for night-time leg cramps

Most of the serious side effects reported from the use of quinine have been in patients taking it off-label to treat leg cramps or RLS. Some of the more serious ones that can result in hospitalization, serious illness, and death include:

  • thrombocytopenia—decreased blood platelets (cells that help the blood to clot)
  • cardiac problems, including an abnormal heart rhythm (too fast, too slow or irregular)
  • rashes and other allergic reactions
  • thrombotic thrombocytopenic purpura—a rare, often fatal blood condition that causes clotting throughout the body
  • hearing problems
  • eye problems
  • electrolyte imbalance (the amount of minerals and fluids in the body)
  • kidney failure
  • lung toxicity

Quinine can also interact with other medications, including antiarrhythmics (e.g. amiodarone, disopyramide, dofetilide, quinidine, sotalol); digoxin; blood thinners; drugs to control seizures; and neuromuscular-blocking drugs (used during surgery).
You should not take quinine if you have certain hereditary heart conditions, such as a prolonged QT interval (a rare problem that may cause fainting or an irregular heartbeat); an abnormal electrocardiogram (ECG; a test that measures the electrical activity of the heart); or if you have or have ever had G-6-PD, or glucose-6-phosphate dehydrogenase, deficiency (an inherited blood disease). Additionally, you should avoid quinine if you have myasthenia gravis (a condition that causes weakness of certain muscles), or optic neuritis (inflammation of the optic nerve that may cause sudden changes in vision), or if you have had an allergic reaction to quinine or similar medicines such as mefloquine or quinidine.
Side effect symptoms to watch out for:
Indicating low blood sugar (hypoglycemia)

  • shakiness
  • dizziness or lightheadedness
  • sweating
  • nervousness or irritability
  • sudden changes in behavior or mood
  • headaches
  • numbness or tingling around the mouth
  • weakness
  • pale skin
  • hunger
  • clumsy or jerky movements

Severe symptoms related to low blood sugar (hypoglycemia)

  • confusion
  • seizures
  • loss of consciousness

Serious side effects
Call your doctor immediately if you experience any of the following:

  • rash
  • hives
  • itching
  • hoarseness
  • difficulty breathing or swallowing
  • swelling of the face, throat, lips, eyes, hands, feet, ankles, or lower legs
  • fever
  • blisters
  • stomach pain
  • vomiting
  • diarrhea
  • blurriness or changes in color vision
  • inability to hear or see
  • faintness
  • easy bruising
  • unusual bleeding
  • blood in the urine
  • dark or tarry stools
  • nosebleeds
  • sore throat
  • changes in heartbeat
  • chest pain

Other side effects
Tell your doctor if any of these symptoms are severe or do not go away:

  • nausea
  • restlessness
  • difficulty hearing or ringing in the ears
  • confusion
  • nervousness

Bottom line. Quinine is widely prescribed to treat leg cramps (and less frequently, other cramping disorders) even though the FDA and the drug’s prescribing information specifically caution that it should not be prescribed for those conditions. CR medical advisers suggest: Talk with your doctor about all drug and nondrug treatments for leg cramps. The risk of serious or life-threatening side effects from quinine and the lack of convincing evidence for its use outweigh the potential benefit of the drug for any condition except malaria.

What are the side effects, cons disadvantages of drinking tonic water? How safe is it especially during pregnancy? Is tonic water fattening or does it make you gain weight? Is the quinine in tonic water bad for you? Is Slimline and Diet Tonic Water bad for you? Read on to find out. Also find out tips and ideas on how to prevent the bad effects of tonic water.

How is Tonic Water bad for you? Is Tonic Water fattening or Safe during Pregnancy?

Just like any other drink (beverages and alcoholic drinks), tonic water could be having bad effects. Inasmuch as tonic water is commonly used as a mixer in gins and vodka including the slime tonic and diet tonic as well could pose potential dangers –side effects- to your health.

While you go about at your local bar or restaurant enjoying tonic water it is important to know the dangers associated with drinking it too much on your health. Just like any other drink, tonic water could be a danger either influencing fattening or a hazard to your pregnancy.

How is drinking too much tonic water bad for you?

Too much intake of tonic water could be having serious effects to some people –not all. Tonic water has quinine chemical component in it. Too much consumption means an increase of quinine which some people are sensitive to. The reported case of a few unlucky individuals includes bleeding.

Tonic water is known to have high fructose corn syrup as one of the ingredients. Too much intake could be a cause of weight gain. This makes you prone to diabetes and other health related conditions such as cancer and high blood pressure.

Is tonic water fattening?

Increase in weight has been found to cause health related conditions such as heart attack, stroke, diabetes, some form of cancer, breathing difficulties among others. Any additional more weight (at least 20%) than what is considered as normal for your height is considered risky.

While solid foods are commonly the prime source of calories and fat intake, liquids and drinks you take in can also affect your weight gain to a shocking extent. According to Dana James, a certified dietician nutritionist and the founder of Food Coach NYC, people do not take into account what they drink. If you realize how much you are consuming from beverages then you are able to tell how much weight you will add.

Most of the drinks we take daily including tonic water have added sugar and studies point out that they contribute to weight gain and type 2 diabetes. In fact calories from drinks may influence fattening more than the calories from food.

Tonic water has more of the added sugar usually the high fructose corn syrup which contributes to weight gain. The added sugar in tonic water contributes to about 32 grams of carbohydrate from a 12 ounce per serving and 124 calories. According to American Heart association, beverage that exceeds 6-to -9 teaspoon is not recommended. Tonic water has about 8 teaspoon of added sugar for every serving which pass the limit recommended.

A bottle Tonic water

Is tonic water safe during pregnancy?

Taking tonic water during pregnancy can be fatal and should be avoided. Most pregnant mothers usually get leg cramps during especially during their later stages. Studies have shown that they resort to tonic water as home remedy to ease the pain oblivious of the risk they are putting themselves into.

Tonic water contain quinine as it s key ingredient. According to Professor Dr.Andreas Hensel (the president of BfR) the enjoyment of quinine –containing beverages might not cause any risk for most people, regular in take can be harmful to some. He continues by specifying that pregnant women should avoid such beverages for precautionary reasons. However, tonic water is known to have regulated amount of quinine (indicated on the nutritional Fact labels) which may not have severe reaction unless you are sensitive to it.

Diet Tonic Water Side Effects-Is Diet Tonic Water bad for you?

Diet tonic water is carbonated drink which are generally calorie free and considered to be healthy probably a suitable replacement of regular tonic water. Most consumers prefer it to maintain a healthy weight pattern. Switching to diet tonic water might not guarantee you the safety at all. One study found out that daily intake of diet soft drink is linked to an increase risk of stroke. Consuming too much of diet tonic water has a way of influencing the brain’s ability to assess the amount of calories consumed hence causing one to eat more.

Quinine Tonic Water Side Effects-Is Quinine in Tonic Water Bad for you?

Too much intake of quinine exposes your body to potential risks. The consumption of tonic drinks lead to a build of quinine in your body. So, how is quinine unsafe for your body? Some people are sensitive to quinine thus experiencing allergic reactions.

Quinine can also cause a condition known as cinchonism/quinism: is a pathological condition that is brought by an overdose of quinidine or from it s natural source (cinchona bark).

Another shocking condition as a result of quinine is the hearing impairment. Studies related to the use of quinine link it to hearing distortion which could be in severe cases being permanent and irreversible.

Some other side effects of quinine include:

  • Irregular heart beat
  • Sometimes unusual bleeding may occur (thrombocytopenia)
  • Fever and in some cases fatigue
  • Visual problems, blurry visions
  • Skin rash or allergic reactions.
  • Too much consumption of quinine in tonic water may cause diarrhea ,nausea, stomach upset, vomiting.

However, the use of quinine in health sector has been limited by the FDA. This should not stop you from ordering your favorite gin and tonic just in case you find yourself in a bar.

Is Slimline Tonic Water bad for you?

This is a type of carbonated tonic water drink that is calorie –free with the same taste of that regular tonic water? Owing to zero sugar content, some consumers prefer combining it with alcoholic drinks or taking it on its own. For weight loss, it has gained popularity as it adds no calorie at all and therefore a sure way of cutting down the intake of sugar. This has health benefit as it helps tonic water fan to keep away from type 2 diabetes.

Little or no reported cases of the side effects are known from consumption of slimline tonic water.

Tips to prevent the bad effects of tonic Water

Who said that taking tonic water should come with side effects? If you only exercise a little caution the next time you find yourself in a bar then tonic water should be enjoyable.

To avoid the risks associated with tonic water, consider these secrets:

  • Avoid taking too much tonic water. You certainly do not want to end up diabetic. Too much sugar in take has been found to be the root cause of type 2 diabetes. You should instead take as low as possible. Or rather try getting used to diet tonic waters if you find yourself addictive to sugars.
  • Taking tonic water during pregnancy is not safe at all. However, if you have to drink make sure the consumption is as low as possible. If you find it hard, drink with the authorization of a doctor.

More Interesting and informative articles on Tonic Water

  1. Tonic Water vs Club Soda-What is the difference between Tonic Water and Club soda? Are they the same?
  2. Best Tonic Water Drinks & Brands, Reviews + Where to Find/ Buy
  3. Tonic Water for Leg Cramps-Is Tonic Water good & does it help at Night and during Pregnancy?
  4. Tonic Water Nutrition Facts-How Many Carbs, Much Sugar, Minerals, Vitamins & Proteins
  5. Tonic Water Calories-How many Calories in Diet, Slime line Tonic Water- Gin & Vodka?
  6. Tonic Water Ingredients-Quinine, Canada Dry, Diet, Fever Free & Schweppes

Carbonated Water-Club Soda, Seltzer & Sparkling Mineral Water

Learn more about other types, brands of carbonated water.

Club Soda Water

  1. What is club Soda -Water? Ingredients and How to Make Recipes
  2. Is Club Soda Bad or Good for you? Health Benefits & Side Effects
  3. Club Soda Nutrition, Calories, Carbs Facts -Vodka & Schweppes
  4. Club Soda vs Seltzer vs Sparkling Mineral vs Tonic Water-Differences & Similarities

Sparkling Mineral Water

  1. Best Sparkling Water Brands List: Flavored, Italian, French, Perrier & how to choose
  2. Is Sparkling Water Bad/ Good for you? Benefits of Sparkling Mineral Water + Side Effects

Seltzer Water

  1. What is Seltzer Water? Is it Bad for you or Healthy? Benefits, Calories, Flavored & Best Brands

Regular Drinking Water

  1. Facts About Drinking Water-Health, Unsafe, Interesting, Economics, Nutrition
  2. Can / Does Drinking Water Help you Lose Weight? Calculate How Much Water for Weight Loss &Tips
  3. The Benefits of Drinking Water- Weight Loss, Skin, Hair & Health
  4. Drinking Too Much Water – Can You Die? Side Effects & Symptoms

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