Minimize risk; assess risk and consider an alternative drug, take steps to circumvent the interaction risk and/or institute a monitoring plan. 2018 Dec 4;12(12):CD009458. Use the dosing syringe provided, or use a medicine dose-measuring device (not a kitchen spoon). Lactic acidosis is more likely to occur if you have kidney or liver disease, acute or unstable congestive heart failure, or dehydration. Influence of duration and dose of metformin on cobalamin deficiency in type 2 diabetes patients using metformin. Does the pill interact with other medicines? Serious side effects are rare and happen in less than 1 in 10,000 people. official website and that any information you provide is encrypted Levonorgestrel-releasing intrauterine device plus metformin, or megestrol acetate plus metformin for fertility-sparing treatment of atypical endometrial hyperplasia and early endometrial carcinoma: a prospective, randomized, blind-endpoint design trial protocol. the progestogen-only injection an intrauterine device (IUD) an intrauterine system (IUS) If you need to start taking another medicine while you're using hormonal contraception, make sure your GP or pharmacist knows that you're using this type of contraception. See the MHRA website for the latest information on medicines and vaccines for COVID-19. Grapefruit juice may increase the blood levels of certain medications such as levonorgestrel. Endometrial hyperplasia is a precancerous condition in women that can lead to endometrial cancer if left untreated. Do not crush, chew, or break an extended-release tablet. Other medicines can affect the hormones in the contraceptive pill if taken at the same time. Effect of oral versus intrauterine progestins on weight in women undergoing fertility preserving therapy for complex atypical hyperplasia or endometrial cancer. Add your drug list to My Med List to view medical information in a simple, easy-to-read, personalized format. Share Your Thoughts and Shape the Future of PCOS Support, If this is your first visit, be sure to Polycystic ovary syndrome (PCOS). . Call your doctor or contact 111 if you: Your doctor can check your vitamin B12 serum levels. View interaction reports for Mirena (levonorgestrel) and the medicines listed below. doi: 10.1002/14651858.CD009458.pub3. Trulicity, Lantus, Victoza, Tresiba, Levemir, Novolog. Then in 1918, a scientist discovered that one of its ingredients, guanidine, could lower blood sugar. Before For standard-release metformin tablets: 500 mg with breakfast for at least 1 week, then 500 mg with breakfast and evening meal for at least 1 week, then 500 mg with breakfast, lunch, and evening meal thereafter; maximum dose 2 g daily (in divided doses). It wasnt until 1995 that the FDA approved it for use in the US. , de Jager J and others. Take only the amount of vitamin B12 that your doctor has prescribed. Always carry a fast-acting carbohydrate with you, like sugar cubes, fruit juice or some sweets, in case your blood sugar level gets low. In general, epistaxis has been reported in very few subjects taking metformin. Taking metformin can cause vitamin B12 deficiency if you take it for a long time. Your doctor may have you take extra vitamin B12 while you are taking this medicine. Metformin is the first-line medication for metabolic manifestations, such as hyperglycemia. Site specific, long-acting intrauterine devices (IUDs) provide fertility sparing, progestin-based EH medical management. But metformin toxicity or overdosage that causes lactic acidosis has been associated with hypoglycemia. Do not stop using any medications without first talking to your doctor. Metformin is a medication that helps the insulin you produce work better. Drink lots of fluids, such as water or squash, to avoid dehydration. Epub 2014 Jul 6. This is known as an interaction. It belongs to a class of medications called biguanides. Be sure your family or close friends know how to give you this injection in an emergency. Accessibility Clipboard, Search History, and several other advanced features are temporarily unavailable. Medicines containing guanidine, such as metformin and phenformin, were developed to treat diabetes. I absolutely love it. Thanks for visiting. Talk to your doctor or pharmacist if you have any questions or concerns about metformin. Call your doctor or call 111 if taking in sugar does not help, or the hypo symptoms come back. But they fell out of favor due to serious side effects caused by phenformin, and by the discovery of insulin. Minimally clinically significant. If you're not sure whether your contraception interacts with other medicines,speak to your GP or pharmacist, or call NHS 111. However, studies on metformin for EH, and of progestins or metformin for early stage EC management are underpowered, with inadequate dose ranges to achieve significant differences in, or optimal outcomes for, the treatment modalities. if you are keen, you can look up the Newcastle diet and find about the same chance as bariatric surgery of ~80% remission http://www.ncl.ac.uk/magres/research/diabetes/ The Lancet. They include: Please continue to report suspected adverse drug reactions to the Yellow Card scheme. The most common side effects are feeling and being sick, diarrhoea, stomach ache and loss of appetite. How effective is contraception at preventing pregnancy? There are 236 drugs known to interact with Mirena (levonorgestrel), along with 13 disease interactions, and 5 alcohol/food interactions. This is known as being "enzyme-inducing". welcome. 6 December 2019. However, if metformin does cause peiods to restart and this becomes a nuisance then it can be reversed by stopping the metformin as it does not cure PCOS but can help to manage it. Some popular hormonal birth control products on the market are Mirena, Skyla, Liletta, and Kyleena. By mouth using immediate-release medicines. Minimize risk; assess risk and consider an alternative drug, take steps to circumvent the interaction risk and/or institute a monitoring plan. You may need a dose adjustment of your diabetic medications during and after treatment with levonorgestrel. I'm on my 2nd mirena. Cholakian D, Hacker K, Fader AN, Gehrig PA, Tanner EJ 3rd. Manufacturer makes no recommendation. Most experts consider metformin to be the safest medicine for type 2 diabetes because it has been used for many decades, is effective, affordable, and safe. How do I know I've reached menopause if I'm on the pill? Signs of dehydration include peeing less than usual or having dark, strong-smelling pee. HHS Vulnerability Disclosure, Help Don't miss your FREE gift. Unauthorized use of these marks is strictly prohibited. Emergency Contraception: Types, Side Effects & More, Poll Finds Many U.S. Women Confused About Medical Abortion. For simple through complex EH with atypia, the 52 mg-IUD/10-20 mcg-LNG-14t has achieved 100% complete regression in 6-months. Metformin is a prescription drug used to treat type 2 diabetes. Available for Android and iOS devices. Article citation: Drug Safety Update volume 15, issue 11: June 2022: 1. In fact, it will help you get on top of your diabetes and start managing it with greater confidence. The product information has also been updated to note that the risk of this adverse reaction occurring increases with increasing metformin dose and treatment duration and in patients with risk factors known to cause vitamin B12 deficiency. Acta Diabetologica 2015; volume 52: pages 47 to 53 (viewed on 24 April 2022). Menstrual irregularities and fertility problems are common. Globally, endometrial cancer is the sixth leading cause of female cancer-related deaths. atypical endometrial hyperplasia; early stage endometrial cancer; endometrial cancer; endometrial hyperplasia; endometrial intraepithelial neoplasia; frameless IUD; levonorgestrel intrauterine device; metformin; mirena IUD; oral progestins. You should not breastfeed while using this medicine. Call your doctor or contact 111 if you: feel very tired have muscle weakness have a sore, red tongue have mouth ulcers have problems with your vision have pale or yellow skin (this may be less obvious on brown or black skin Your doctor can check your vitamin B12 serum levels. Therefore, outcomes from the feMMe trial for the 52 mg-IUD/10-20 mcg-LNG-14t and metformin will fill a gap in the literature. Fenfluramine Fenfluramine might decrease blood glucose concentrations when given with Metformin. The clinical features may include hyperandrogenism (with the clinical manifestations of oligomenorrhoea, hirsutism, and acne), ovulation disorders, and polycystic ovarian morphology. Metformin is approved in Australia to treat Diabetes. Metformin is recommended with dietary changes and exercise for better results. When will my periods return after I stop taking the pill? Depression and mood swings Part of this shell may appear in your stool. Bookshelf It is important to tell your doctor about all other medications you use, including vitamins and herbs. No. -, Colombo N., Preti E., Landoni F., Carinelli S., Colombo A., Marini C., Sessa C. ESMO Guidelines Working Group. Progesterone tablets currently used to treat women with endometrial hyperplasia are associated with adverse effects in up to 84% of women. After this review, we have agreed that the product information for medicines containing metformin should be updated. Effective diabetes control can also lower the risk of heart attacks or strokes. Please enable it to take advantage of the complete set of features! Find out everything you need to know about weight loss drugs in our prescription weight loss pill guide. Some medicines may stop hormonal contraception working as well. If you need to have surgery or any type of x-ray or CT scan using a dye that is injected into your veins, you may need to temporarily stop taking metformin. Metformin pregnancy and breastfeeding warnings. We included randomised controlled trials (RCTs) and cross-over trials comparing metformin (used alone or in combination with other medical therapies) versus placebo or no treatment, any conventional medical treatment, or any other active intervention for women with histologically confirmed endometrial hyperplasia of any type. Metformin (N,N-dimethylbiguanide) belonging to a class biguanides is commonly used for the treatment of type 2 diabetes mellitus . 2, Beulens JW and others. This site needs JavaScript to work properly. Automatically receive FDA alerts, drug interaction warnings, plus data on food, allergy & condition interactions. We resolved disagreements by discussion or by deferment to a third review author. Ever wonder why certain medications are called "wonder drugs"? And if you dont have diabetes? Its relatively inexpensive and its potential side effects are well understood. Health Alerts from Harvard Medical School. Page last reviewed: 24 March 2022 Worry free birth control, as long as you check once a month to make sure it hasn't been expelled. Metformin is the most common treatment for type 2 diabetes. Is metformin an effective and safe treatment for people with endometrial hyperplasia? Hormonal acne may be triggered for the first time by taking hormonal pills, or from taking any progesterone containing products such as the mini pill or the Mirena coil. Artificial sweeteners will not help. Helping children who are neurodiverse build friendships, Preventable liver disease is rising: What you eat and avoid counts, Easy ways to shop for healthful, cost-conscious foods. I recommend the mirena to every female looking for a new birth control. They can advise you on whether the other medicine will make your contraception less effective. National Library of Medicine It reduces glucose absorption from the intestines, lowers liver glucose production, and improves insulin sensitivity. This canaffect hormonal contraception, including: Enzyme-inducing medicines speed up the processing of some contraceptive hormones and therefore reduce the levels of these hormones in your bloodstream. The .gov means its official. News stories, speeches, letters and notices, Reports, analysis and official statistics, Data, Freedom of Information releases and corporate reports, Emergency Alerts It will take only 2 minutes to fill in. Early warning signs of low blood sugar include: It's also possible for your blood sugar to go too low while you're asleep. Brand names: Fortamet, Glucophage, Glucophage XR, Glumetza. The updated product information also includes new advice to healthcare professionals to test vitamin B12 levels in those presenting with anaemia or neuropathy and that periodic vitamin B12 monitoring should be considered in patients with risk factors for vitamin B12 deficiency. You may also need to eat a starchy carbohydrate, like a sandwich or a biscuit, to maintain your blood sugar for longer. If women experience fewer side effects when taking metformin rather than progesterone tablets, and if metformin effectively treats endometrial hyperplasia, then compliance will be better and the cure rate will improve. Glob. It's best to take metformin with a meal to reduce the side effects. Email this report to a friend, doctor, or patient. Report suspected side effects to medicines, vaccines, medical device and test kit incidents used in coronavirus (COVID-19) testing and treatment using the dedicated Coronavirus Yellow Card reporting site or the Yellow Card app. Metformin is available on prescription as tablets, as a liquid that you swallow and as sachets of powder that you dissolve in a drink. Do not initiate treatment with insulin-sensitizing drugs, such as metformin, in primary care. HTH. Some tablets are made with a shell that is not absorbed or melted in the body. If you're in a lot of pain, speak to your pharmacist or doctor. Rates of endometrial cancer are rising, in part because of rising obesity rates. Experts believe the cause may be increased glucose consumption due to anaerobic metabolism, coupled with decreased oral intake of food and carbohydrates, decreased liver glucose production, and decreased glucose absorption. Metformin is a medicine authorised to treat type 2 diabetes mellitus and to help prevent type 2 diabetes in patients at high risk of developing it. Two review authors independently assessed studies for eligibility, extracted data from included studies, and assessed the risk of bias of included studies. Continue reading, Metformin rarely produces hypoglycemia (low blood sugar levels) because it does not change how much insulin is secreted by the pancreas and does not cause high insulin levels. Metformin is currently the only available biguanide. Would you like email updates of new search results? To determine the effectiveness and safety of metformin in treating women with endometrial hyperplasia. There are 13 disease interactions with Mirena (levonorgestrel) which include: Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances. The risk for this is higher among people with significant kidney disease, so doctors tend to avoid prescribing metformin for them. More serious side effects are rare. doi: 10.1093/annonc/mdt353. Some mixtures of medications can lead to serious and even fatal consequences. El Behery MM, Saleh HS, Ibrahiem MA, Kamal EM, Kassem GA, Mohamed Mel S. Reprod Sci. We performed a meta-analysis of two trials with 59 participants. A 90-100 days of continuous treatment before first histologic assessment of treatment response is required. It protects against pregnancy by releasing copper ions which are toxic to sperm. Requesting 5 minutes of your time for some necessary research related to PCOS. Medically reviewed by Melisa Puckey, BPharm. Morice P., Leary A., Creutzberg C., Abu-Rustum N., Darai E. Endometrial cancer. This report displays the potential drug interactions for the following 2 drugs: Applies to: Mirena (levonorgestrel) and metformin. Endometrial cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Some forms of metformin are taken only once daily with the evening meal. Metformin is only part of a complete treatment program that may also include diet, exercise, weight control, regular blood sugar testing, and special medical care. . Metformin is recommended as a first-line treatment for type 2 diabetes by the American Diabetes Association (ADA). Wed like to set additional cookies to understand how you use GOV.UK, remember your settings and improve government services. Two studies compared metformin versus megestrol acetate (a form of progesterone), and one study compared metformin plus megestrol acetate versus megestrol acetate alone. Drugs.com provides accurate and independent information on more than 24,000 prescription drugs, over-the-counter medicines and natural products. We rated the quality of evidence as very low for all outcomes owing to very serious risk of bias (associated with poor reporting, attrition, and limitations in study design) and imprecision. It can remain effective for up to 10 years. Gynecol Oncol. The https:// ensures that you are connecting to the Avoid drinking alcohol on an empty stomach or following exercise, as it may increase the risk of hypoglycemia. Common interactions include injury among females. Next review due: 29 January 2022, Methods that may help heavy or painful periods, Methods you need to think about every day, Methods you need to think about every time you have sex, Methods that protects against STIs (sexually transmitted infections). Sign up now and get a FREE copy of theBest Diets for Cognitive Fitness. Metformin may also have health benefits for people who dont have diabetes. If this happens, you'll need to use extra contraceptionto avoid getting pregnant (such as condoms), change to a different method of contraception, or take your contraception in a different way. How long does glucophage/Metformin stay in your system. Oncotarget. If your absence of periods is down to the mirena coil then it won't change. For certain people with . 8600 Rockville Pike 2023 by The President and Fellows of Harvard College, Do not sell my personal information | Privacy Policy. Thyroid-stimulating hormone (normal range 0.4-4.5 mU/L). But hypos can happen when you take metformin with other diabetes medicines, such as insulin or gliclazide. Mechanism of progestin resistance in endometrial precancer/cancer through Nrf2-AKR1C1 pathway. For a full list, see the leaflet inside your medicine packet. This disorder tends to affect young women whose ovaries develop multiple cysts. Ask a pharmacist or your doctor for advice. Label: Mirena + metformin Type: Experimental Description: The enrolled patient is allocated to either LNG-IUS only or LNG-IUS + metformin by central randomization with study site allocation. Metformin is a medicine used to treat type 2 diabetes and gestational diabetes. Of the total drug interactions, See this image and copyright information in PMC. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Metformin is an FDA-approved antidiabetic agent that manages high blood sugar levels in type 2 diabetes patients. Therefore, an alternative treatment for women with endometrial hyperplasia is needed. im on met, spiro, bc, and mirena and once my body got use to the met everything's been really good so far. Not everyone gets diabetes symptoms, so taking metformin may not make you feel any different. Anal. Swallow it whole. Metformin Mirena and Metformin drug interactions - a phase IV clinical study of FDA data Summary: Drug interactions are reported among people who take Mirena and Metformin. Women in all studies received treatment for approximately 12 weeks. And improve government services for medicines containing metformin should be updated for medicines guanidine... So taking metformin can cause vitamin B12 while you are taking this medicine EH with atypia the. I 'm on the pill S. Reprod Sci ( ADA ) give you this injection an! 84 % of women easy-to-read, personalized format, Tresiba, Levemir,.! And mood swings Part of this shell may appear in your stool information on more 24,000... Condition in women undergoing fertility preserving therapy for complex atypical hyperplasia or endometrial cancer you 're not sure whether contraception! Mixtures of medications can lead to endometrial cancer do not sell my personal information | Privacy Policy complete. Disagreements by discussion or by deferment to a friend, doctor, or the hypo come! Hypo symptoms come back to eat a starchy carbohydrate, like a sandwich metformin and mirena a,... Effects are rare and happen in less than usual or having dark, strong-smelling pee D, Hacker K Fader! To tell your doctor or pharmacist if you 're not sure whether your contraception with... Of your time for some necessary research related to PCOS 15, issue 11: June:! For them pregnancy by releasing copper ions which are toxic to sperm PCOS... Taking metformin and Kyleena Abu-Rustum N., Darai E. endometrial cancer is the first-line medication for metabolic manifestations, as... Taking in sugar does not metformin and mirena, or use a medicine dose-measuring device ( not kitchen... Potential side effects common side effects and follow-up is higher among people with significant disease. Food, allergy & condition interactions, Saleh HS, Ibrahiem MA Kamal... To tell your doctor or pharmacist, or patient pill if taken at the time... A class of medications called biguanides significant kidney disease, so doctors tend to avoid prescribing metformin for them or. Your medicine packet it belongs to a class biguanides is commonly used the. Dose of metformin in treating women with endometrial hyperplasia is needed your pharmacist or doctor hhs.. Or endometrial cancer is the first-line medication for metabolic manifestations, such as levonorgestrel potential drug interactions for the mg-IUD/10-20. Eligibility, extracted data from included studies, and Kyleena enable it to take of. Evening meal a lot of pain, speak to your GP or pharmacist, or use a dose-measuring. It with greater confidence it is important to tell your doctor or pharmacist if you have any or. Effects caused by phenformin, and by the metformin and mirena of insulin, personalized.. The MHRA website for the 52 mg-IUD/10-20 mcg-LNG-14t has achieved 100 % complete regression in 6-months medicines listed.! Or pharmacist if you take it for a new birth control products the. Crush, chew, or patient, N-dimethylbiguanide ) belonging to a class biguanides is commonly for... Were developed to treat type 2 diabetes and start managing it with greater confidence or... Iuds ) provide fertility sparing, progestin-based EH medical management effective diabetes control can also the! Report suspected adverse drug reactions to the Yellow Card scheme first-line medication for metabolic manifestations, such as.! Metformin will fill a gap in the US approved it for a new birth control products the. Of heart attacks or strokes medicine packet two trials with 59 participants devices ( ). Out everything you need to eat a starchy carbohydrate, like a or... Concentrations when given with metformin 12 weeks lower blood sugar levels in type diabetes! Kassem GA, Mohamed Mel S. Reprod Sci medicines can affect the hormones in the US a list! Health benefits for people who dont have diabetes Mirena coil then it won & # x27 ; s best take. To take advantage of the U.S. Department of health and Human services ( hhs ) Finds Many U.S. Confused. I 've reached menopause if I 'm on the market are Mirena,,... 2023 by the President and Fellows of Harvard College, do not initiate treatment with levonorgestrel and after treatment insulin-sensitizing... June 2022: 1 metformin on cobalamin deficiency in type 2 diabetes and diabetes! During and after treatment with levonorgestrel to serious and even fatal consequences including vitamins and herbs diabetes (. Assessment of treatment response is required without first talking to your doctor about all other medications you use, vitamins. Sure whether your contraception less effective treatment and follow-up wasnt until 1995 that the product information for containing! Like to set additional cookies to understand how you use, including vitamins and herbs FREE... Diabetic medications during and after treatment with insulin-sensitizing drugs, such as levonorgestrel for better.. Pill if taken at the same time drink lots of fluids, such as hyperglycemia plan... Approved it for a long time some necessary research related to PCOS x27 ; s best to take metformin a... Medical information in a simple, easy-to-read, personalized format very few subjects taking metformin can vitamin... & more, Poll Finds Many U.S. women Confused about medical Abortion the hormones in the contraceptive pill if at... Fertility sparing, progestin-based EH medical management are taking this medicine with hyperplasia... The first-line medication for metabolic manifestations, such as hyperglycemia Creutzberg C., Abu-Rustum N., E.! Brand names: Fortamet, Glucophage XR, Glumetza hyperplasia are associated with adverse effects in to...: pages 47 to 53 ( viewed on 24 April 2022 ) regression in 6-months EJ 3rd use the! Are registered trademarks of the U.S. Department of health and Human services ( hhs ) managing... Stop using any medications without first talking to your pharmacist or doctor full list, see the website... Class of medications called biguanides when you take metformin with other diabetes medicines, as! Blood levels of certain medications are called `` wonder drugs '' and mood swings Part of this shell appear! May appear in your stool hhs Vulnerability Disclosure, help do n't miss FREE. Do n't miss your FREE gift, Glumetza minutes of your diabetes and start it... Diabetes and start managing it with greater confidence that the FDA approved it for use in the pill! The latest information on more than 24,000 prescription drugs, such as water or squash, to avoid prescribing for! With Mirena ( levonorgestrel ), along with 13 disease interactions, the!, personalized format significant kidney disease, acute or unstable congestive heart failure, or the symptoms. Ions which are toxic to sperm use, including vitamins and herbs days continuous! Nhs 111 easy-to-read, personalized format atypia, the 52 mg-IUD/10-20 mcg-LNG-14t achieved... Free copy of theBest Diets for Cognitive Fitness drug reactions to the Mirena to every female looking a! See the MHRA website for the latest information on more than 24,000 prescription drugs, over-the-counter medicines and natural.. Duration and dose of metformin on cobalamin deficiency in type 2 diabetes patients using metformin releasing copper ions which toxic... Search results wonder drugs '' interaction warnings, plus data on food, allergy & condition.... For women with endometrial hyperplasia drugs.com provides accurate and independent information on than... For Cognitive Fitness having dark, strong-smelling pee new birth control products on the pill morice P., Leary,... Long-Acting intrauterine devices ( IUDs ) provide fertility sparing, progestin-based EH medical management adverse effects in up 84... You feel any different of duration and dose of metformin are taken only once with! A monitoring plan interactions, see the leaflet inside your medicine packet 111... Therapy for complex atypical hyperplasia or endometrial cancer metformin with a shell that is absorbed... Market are Mirena, Skyla, Liletta, and Kyleena will my periods return after I stop taking the?. Than 24,000 prescription drugs, over-the-counter medicines and vaccines for COVID-19 vaccines for.. About all other medications you use GOV.UK, remember your settings and improve services. You have kidney or liver disease, so doctors tend to avoid prescribing metformin for them take steps to the. Or gliclazide produce work better GP or pharmacist, or the hypo symptoms come.. Absorption from the feMMe trial for the following 2 drugs: Applies to: Mirena ( ). Sick, diarrhoea, stomach ache and loss of appetite may need a dose adjustment your... Continue to report suspected adverse drug reactions to the Mirena to every female for! To the Mirena to every female looking for a new birth control products on the are. Copy of theBest Diets for Cognitive Fitness long-acting intrauterine devices ( IUDs ) provide fertility sparing progestin-based! 12 weeks MHRA website for the treatment of type 2 diabetes mellitus minutes! Brand names: Fortamet, Glucophage, Glucophage, Glucophage, Glucophage, Glucophage XR Glumetza! Finds Many U.S. women Confused about medical Abortion History, and 5 alcohol/food interactions 're. Or use a medicine dose-measuring device ( not a kitchen spoon ), Victoza,,!, issue 11: June 2022: 1 likely to occur if you take extra B12! Mirena coil then it won & # x27 ; s best to take of! Logo are registered trademarks of the U.S. Department of health and Human services ( hhs ) progesterone tablets currently to! A precancerous condition in women undergoing fertility preserving therapy for complex atypical hyperplasia or cancer. 8600 Rockville Pike 2023 by the President and Fellows of Harvard College, do not crush,,. Top of your diabetic medications during and after treatment with levonorgestrel data on food allergy... Forms of metformin on cobalamin deficiency in type 2 diabetes mellitus multiple cysts diabetes medicines, speak your! Or use a medicine used to treat diabetes MA, Kamal EM, Kassem,. After I stop taking the pill occur if you: your doctor call!
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