Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered Podcast. I'm Dr. Neha Pathak, WebMD's Chief Physician Editor for Health and Lifestyle Medicine. Today we're gonna discuss how rising temperatures and extreme heat can impact our medications.

We will take a step-by-step approach to understanding how heat impacts the effectiveness of certain medications, and also how it may increase heat-related illness risk as a potential side effect during times of high temperatures. We'll explore how some medications themselves are impacted by heat and the best ways to store medications, especially those that require refrigeration or careful storage.

We'll also discuss how to have conversations about our medication concerns, questions about potential dose adjustments, and side effects of our medications with our prescribers and pharmacists. Whether you're planning to travel, navigating extreme weather conditions, or just want to take a proactive approach to your medication management, this episode is full of practical tips to protect your health and your prescriptions.

First, let me introduce my guest, Shea Sajwani. Shea is a pharmacist who works within areas of oncology, climate change, and global health as they relate to the pharmacy profession. She's currently an adjunct professor at the University of Ottawa and the national co-chair of the Canadian Association of Pharmacy for the Environment (CAPhE).

She also worked for many years as an oncology pharmacist at the Ottawa Hospital, with 10 years of experience in a combination of outpatient and inpatient oncology. She co-chairs the Ottawa Hospital Pharmacy Environmental Committee and is co-chair of the International Pharmaceutical Federation Policy Committee, which created and passed the first-ever international pharmacy climate change policy in 2023. That policy reached over 100 countries, representing 4 million pharmacy professionals.

Shea also represented the University of Ottawa and CAPhE at the United Nations COP 29 Conference in 2024. She is currently the co-founder of ClimaSus Health Solutions, which focuses on building tools and certifications for pharmacies to reduce their emissions and improve their climate resilience.

Welcome to the WebMD Health Discovered Podcast.

Shellyza Sajwani: Thank you so much, Neha. Thanks for having me.

Pathak: So before we begin exploring the main conversation that we want to have today around extreme heat and medications, I'd love to ask about your own “aha” moment around the work that you're doing. How did you come to realize this important intersection is where you wanted to focus your energy?

Sajwani: Sure. So, there were two things that happened. The first is that before working in the climate change space, while I was working as an oncology pharmacist, I would do a lot of volunteer work within global health. I was involved in Pharmacists Without Borders Canada as a volunteer within their governance.

Occasionally, I would also go on medical trips abroad. What I ended up finding out, which really struck me, was the inequity within global health settings. I started understanding the impact of extreme weather events and of climate in general on the health of patients in different countries.

The other thing I started noticing is that extreme heat, in particular, was a huge factor in terms of affecting health — first from a wider global setting, and then I started noticing it more and more within Canada as well. So I thought, “Okay, this is a way for me to think about global health from a macro perspective, and then also think about the health of my patients in the oncology setting as well.”

Pathak: That's really great. So today we're really gonna focus on extreme heat and medications and look at both of those lenses.

In the news, you cannot get away from heat domes impacting various parts of the U.S., Canada, and globally. So I'm really curious if you could first help us understand: how do you think about medication management when you're thinking about extreme heat?

Sajwani: Yeah, so that's a great question. I tend to separate it into two categories.

The first category is the actual quality of the medication itself. Let's say if the medication is left in a car when it's really hot outside, or it's left in a home where there's no air conditioning — what are the temperatures inside that home, and what happens to the medication itself?

The second is related to what happens when it's a hot day outside and we're taking our medications — what are the impacts on side effects, and how does that medication actually work in one's body?

Those are two very different categories, but they're a great starting point.

Pathak: So then let's dig into the first piece. Tell us what we should know about some medications, particularly those that are so common out there, from the albuterol inhaler that someone might be using to insulin. First, what medicines should we be thinking about in this category, and how do you counsel your patients around the risks during an extreme heat event?

Sajwani: Right. So there are various classes of medications, but you can think of this quite broadly:

Are there specific medications where they say to refrigerate it? Are there specific medications where it's said to keep it at room temperature? That particular recommendation in the literature or in the little patient information leaflet you get inside the medication bottle or bag comes from how the medication was developed and tested for effectiveness.

So, let's say it was tested at room temperature, but now we are in a situation where the temperature is far beyond room temperature. That basically means that the integrity of that medication might be compromised.

You might have a situation where it's 80% as effective, or 60% as effective, or not effective at all. The unfortunate part is that we don't actually know enough about the effectiveness at different temperature ranges. That testing is starting to come out in certain studies now, but typically when a medication is approved, it's not evaluated for effectiveness at other temperature ranges.

This also applies to refrigerated medications. For example, a medication may be effective if kept in the fridge and stable outside of the fridge for a certain number of hours or days, but not more than that. That means if there's a power outage or if a medication is delivered over a long distance without proper cooling, the medication may no longer be effective.

So these are important things to think about.

If you’re in a place without air conditioning, or if the AC isn’t working, there are still ways to help. For medications recommended to be kept at room temperature, try to store them in the coolest and driest areas of the home. Avoid bathrooms because of humidity, and avoid hot areas like sunny windows. Basements are often better. Kitchen cabinets can sometimes be cooler too.

Outside of this, there’s a growing advocacy movement arguing that access to air conditioning should be considered a human right, because safe storage of medications is so important.

Pathak: And I think it’s so important — and the specific tips you gave are so important — because so many of us think of our “medicine cabinet” as that cabinet in our bathroom. So it’s really key to think about the different ways you’ve advised to safely store our medications, particularly if we don’t have air conditioning or if our air conditioner breaks down during one of these extreme heat events.

I’d love to shift then to that second piece you talked about, which is potential risks from side effects when you’re on certain medications during extreme heat events. This is something that really worries me as a physician. We prescribe these medications to help patients, but we don’t want to be part of the reason people have more complications or side effects.

So talk to us about some of the things we should know about these classes.

Sajwani: Absolutely. And you're very right to be concerned and worried about the situation. The one thing we tend to talk about in this space is the entire medical curriculum, or the pharmacy curriculum, or the nursing curriculum has been taught under the assumption of a stable ecological system. So that means that there are very concentrated efforts to update that curriculum to consider things like extreme heat and how that affects medication management, for example.

So one example of this is that, let's say your medication itself causes a problem of kidney toxicity, in the sense that it's a rare or occasional side effect. It can happen uncommonly — not to everybody, but it can happen. Then, let's say if it's really hot outside, why do we tell people to drink a lot of water? We're worried that they will get dehydrated. Sometimes with dehydration, the issue is that you don't get enough flow to the kidneys, and that can also cause kidney toxicity. So there's actually an increased risk of kidney toxicity in patients who have medications which can uncommonly cause kidney problems in situations where it's really hot outside, because you will actually see that kidney toxicity more often.

We call it renal toxicity in our work, but I'm just basically using terminology that will make it a little bit easier.

The second area to think about is the situation where there are challenges with sweating. Certain medications can actually affect how well you can sweat. A really good example of this is certain antidepressants, for example, which can affect how well you can sweat. Sweating is really important in situations of extreme heat. So if you can't sweat, that's a problem, in the sense that it can affect how at risk you are of heat stroke and heat exhaustion.

That doesn't necessarily mean you should stop your antidepressant if it's hot outside. It just basically means that you should be monitored more carefully when you are going through these medications.

I forgot to say earlier that for what we call renal toxicity, the medications that can cause an increased risk of renal toxicity, if you haven't heard them now, some examples include some medications that we use for heart problems, like ACE inhibitors and diuretics. Medications that we use for blood pressure as well are also included within that. So if you're uncertain, you can have a look at that list of side effects that come in that prescription bag you get from the pharmacy, and you can see if renal toxicity is listed as a side effect.

Pathak: I'd love to ask about any other sort of concerns or medications that you worry about in the event of extreme heat, or if you know it's summer and patients are gonna be outside and out in the sun more commonly.

Sajwani: Absolutely. So, there are a few other examples as well. We have a specific terminology in medicine called a “narrow therapeutic window.” And what does that mean? That basically means that if you dose it a little bit too high, you can get a lot of side effects, and if you dose it a little bit too low, that means it can sometimes have issues with effectiveness.

Any medication that has a narrow therapeutic window — examples include digoxin or lithium — can be impacted by changes in fluids in your body that happen with dehydration, which can also impact toxicity.

Another really good example is medications that cause rashes. Sometimes what will happen is that if you go out in the sun and the medication itself has a high incidence of specific types of rashes, you can actually have really significant sun-specific toxicities. So usually, in your counseling — in your pharmacy counseling, or when your physician is speaking to you — they will say, “Okay, just be careful if you're spending too much time in the sun,” because there can be some challenges specifically with this medication.

Another example is if you are on a particular medication like chemotherapy. A lot of specific chemotherapies also have a narrow therapeutic window, meaning that if you dose it too low, there are considerations for that, and if you dose it too high, there are a lot of side effects. Some of them also cause issues with renal toxicity, too. So because of that, we want to be extra careful when we are looking at chemotherapy. When providers themselves are prescribing chemotherapy, they need to be thinking about fluid requirements as well.

Sometimes, unfortunately, we're in a situation where things have changed quite rapidly. We are starting to see heat waves that were definitely not there 15 years ago. Because of that, not all providers are going to be thinking about this on a daily basis. So the biggest takeaway I can think of with regards to this category is to say: speak to your pharmacist or your physician. Say, “I know it's gonna be really hot outside. Are there specific considerations with my medications that I need to be concerned about?” That will basically clue in anyone who's not already thinking about this.

Pathak: I think it's really important to know, one, to anyone who's listening, that health professionals are starting to recognize this. And two, to your earlier point, we don't yet know what that means for adjusting your doses or telling you to take something or stop taking something. That's not necessarily what we're suggesting.

Right now, it's more of just an awareness that there are potential interactions. And if you know that, maybe on that extreme heat day when you get that alarm on your phone saying, “We're in a heat wave,” that hopefully alarms you to think, “Hey, I actually am on a bunch of medications. Maybe I don't go out and exercise today for such a long period of time. Or maybe I really need to make sure that I'm hydrating myself or making sure I'm storing my meds properly.”

Are you seeing any sort of systems that are sending out alerts directly to patients to give them that information?

Sajwani: We're seeing a mixed bag. So on one end, you know, you can subscribe, for example, to the Weather Network, and they will have notifications to say, okay, you know, it's really hot outside. We are starting to see some public health advisories, for example, on websites. So Health Canada will, you know, have certain things about heat on their website. Similarly, other groups have this as well. It's interesting that you mentioned this because groups like the Canadian Pharmacy Association have also been starting to put out infographics in collaboration with the Canadian Association of Pharmacy for the Environment on heat and medication management, let's say to pharmacists.

One thing that we are trying within CLSs is thinking about the pharmacy also as a medium for sending out information like this too. I really like that you mentioned that this doesn't necessarily mean that you should stop your medications, because this is really, really critical — there could be other complications related to stopping your medications.

I think the first two major takeaways that I can think of are: number one, just thinking about, okay, if it's really hot, do you want to be going outside for long periods of time or not? Are you thinking about your hydration? Are you thinking about your sunscreen, your hat, all that stuff? And then second, are you speaking to your provider about it — whether that be your physician, a nurse, your pharmacist — but also when you get to the pharmacy, mentioning that, “Oh, it's really hot. Would this affect my medications and my medication side effects as well?”

Because typically, again with pharmacists, they're usually thinking about the heat affecting the quality of the medication, but we are working on more education on the side effects specifically as well.

Pathak: And I think something that is really interesting to me: generally, when patients are taking one medication, they're not just taking one. There's potentially two, three, four, or five or more on board. So now we're talking about heat, we're talking about polypharmacy.

So multiple medicines that are on board, underlying health conditions — it can get pretty complicated pretty fast. So I'd love to kind of get your guidance on how to slow down and have that conversation with your pharmacist when you're picking up those medications.

Sajwani: So in Canada, we have something called a meds check — it's basically a medication review. You can book something like that with your pharmacist, and they will go through each of your medications and review the dose, but also review: okay, what are the side effects? What are you experiencing? Is there a current indication for that medication or not? Something like that is very helpful to do in the middle of a situation like this.

For example, one key thing that we recommend to providers is to increase monitoring with regards to lab tests, particularly in the inpatient setting, but also in the outpatient setting — increasing your monitoring of these patients during this time.

I don't know the U.S.-specific terminology for meds check, but I think if you mention medication review, it's very similar, and you can book something like that with your pharmacist as well.

Pathak: I love that advice. So we definitely, in the primary care setting, are always trying to do a medication reconciliation, but I think that you don't necessarily have to wait till that annual checkup. I love that recommendation of really thinking about it proactively.

And then as you were talking, I was also thinking about myself as a caretaker. So often I'm going to pick up the medications for my 88-year-old father, and I'm going to pick up the medications for my mother. And so I think when we are in that caregiver role, it also strikes me to really do a couple of things: to build on what you're saying, but also to check in with our elders during this timeframe.

Because they're not necessarily going out of the home, but they may not know that there are these risks. So they may be in a situation where their air conditioner breaks down, or, like my parents, they like to keep it 80 degrees no matter what time of year it is. So, you know, just to talk to them as well about some of these impacts.

Sajwani: Absolutely. I can't emphasize how important this is. Because along with the impacts of heat to medication management and medication quality, you also have the heat impacts to the conditions themselves, right? And even if the person was not taking any medications, the elderly are particularly at risk for heat-related health impacts.

So keeping a close eye on people who are quite vulnerable I think is really important: kids, babies, people with chronic conditions, young people in general, but also people with chronic conditions. Pregnant people are all at risk related to heat-related toxicities.

And typically health-related agencies will have specific recommendations related to each of these groups as well.

Pathak: I love that. Such important advice — and to really sort of think about, again, you talked about that therapeutic window, but we're also talking about sort of a smaller window of risk at a certain point when you have these complications.

So whereas you might have been able to push yourself in the heat had you had no other medical conditions, no other medications on board — as you start to add more and more conditions, age, medications, that window to tip yourself into dangerous conditions can get really small.

So, so important to recognize all of these risks. Is there any final thought you want to leave for our listeners when it comes to what they should be thinking about, what they need to know about their medications, particularly in an extreme heat event?

Sajwani: I would just say — remember with regards to refrigeration in particular, there can be a situation where your refrigerator, for example, doesn't have power. So just having a plan for if the refrigerator were to go out: how would I keep my medications cool for a certain period of time? And does my city have any kind of cooling centers that I can go to, to just walk around if I lose my air conditioning or if I don't have air conditioning?

I would also say that I feel there are a lot of equity issues here too, where certain populations have less access to air conditioning than others. You also have multiplying effects with regards to, let's say, if you can't afford your medications and therefore you have conditions that are not treated, and then you have heat on top of that. So there are groups, including the Canadian Association of Pharmacy for the Environment, that are also particularly thinking about equity issues on top of this.

The last thing I will say is that it's unfortunate what's happening, right? What we are trying to do is look at reducing emissions, and now the climate crisis is here, and we're also thinking about how to manage extreme heat as well. One thing I have found quite fulfilling is trying to reclaim the agency I do have in this situation, especially when extreme heat does happen — to say, okay, these are the steps I'm going to take when it's really hot outside, for my family, for my patients.

And I find that reclaiming agency in particular situations can be particularly helpful for mental health as well.

Pathak: That's just so tremendously helpful, and I think, you know, you mentioned this earlier as well. I think it's important for us to not think about these risks as something that increase just when there's extreme heat, but we're having just warmer temperatures earlier and for longer periods. So there's also some of the risks of complications.

If you're on these medications, even if you're not getting that alert on your phone that, you know, we're in the midst of a heat dome, you really need to be having these conversations with your pharmacist or your healthcare professional, I think earlier than when summer traditionally started for you when you were younger.

Sajwani: Absolutely. I just wanted to say, maybe one last thing about the oxygen mask. Sometimes I can identify with this, where one might think that, okay, I have these people who have really difficult conditions or they're vulnerable, who I care about. And one is not necessarily also thinking about oneself in terms of the hydration, the taking care, and the heat.

And, you know, we are all vulnerable to this, right? I think just making sure that one thinks about the basics with regards to managing oneself in extreme heat. And then that will make our mental health and our physical health better enough to be able to also help others as well.

Pathak: I love that point. As a mom sort of sandwiched between everyone else's needs, I definitely have packed my kids' water bottles and then not even given a thought to my own water bottle. So I love that. And I thank you so, so much for your time.

Sajwani: Thank you. Thank you for having me.

Pathak: My key takeaways from this discussion are that extreme heat is something that we need to worry about for our health, but also for the effectiveness of our medications. Medications are tested and approved under controlled temperatures, so when they're exposed to extreme heat or poor storage conditions, they may degrade or lose potency, potentially making them less effective.

Medication side effects can also be amplified by heat and increase the risk of dehydration and kidney problems, especially because some medications impact our ability to sweat and how tight our blood vessels get. Your prescriber and pharmacist play a key role in heat-related medication management. Ask questions, communicate your concerns, and discuss appropriate medication storage and management plans if you're anticipating or in the midst of an extreme heat event.

To find out more information about Shell Ani and all of her work, make sure to check out our show notes. Thank you so much for listening. Please take a moment to follow, rate, and review this podcast on your favorite listening platform. If you'd like to send me an email about topics you are interested in or questions for future guests, please send me a note at [email protected].

This is Dr. Neha Pathak for the WebMD Health Discovered Podcast.