Healthy Transitions

Healthy Transitions

Common Side effects and Drug Interactions

Gabriela Dimitrievski, PharmDBrian Hoff, PharmD

Katie Sandison, PharmD

Take Control of your Health!

Bring your medications into your doctor appointments

Keep all of your healthcare providers informed of any changes to your health

Keep an updated medication list Include Over-the-Counter medications Include herbal supplements

Know why you are on your medicationsTalk to your healthcare providers

Ask questions!

Over-the-Counter (OTC)Medications

•Tylenol•NSAIDs (Motrin/Advil/Aleve/Aspirin)•Cough and Cold•Anti-diarrheals and Laxatives•Herbal Remedies

Tylenol

• Generic name: acetaminophen• Primary Use: pain or fever• Maximum dose: do not exceed 4,000 mg per day

(your doctor may recommend less)• Products that contain acetaminophen:

– Vicodin/Lortab/Percocet– Multi-symptom cough and cold products– Tylenol PM

• Toxicity: liver damage– Can occur when taken in large amounts or over long

periods of time– Keep out of reach of children– Cautioned use in those who regularly consume alcohol

NSAIDs

• Non-steroidal anti-inflammatory drugs (NSAIDs)• Examples:

– Ibuprofen (Advil, Motrin)– Naproxen (Aleve)– Aspirin

• Primary Use: Pain, inflammation, fever • Following the dosing tables on the package

• Adverse effects:– Overuse and high doses can decrease the protective

effects in the stomach and intestines– Aspirin: prevents blood clotting (even 81 mg ‘baby’

aspirin)– Note: aspirin should not be used in children and

teenagers due to risk of Reye’s Syndrome

Cough and Cold

Antihistamines: Benadryl, Claritin, Zyrtec Benadryl can cause drowsiness, best taken before bed Claritin and Zyrtec are non-drowsy and are recommended when

symptom relief is needed during the day Cough and mucus: Mucinex (guaifenesin) and Delsym

(dextromethorphan) Mucinex thins the mucus and is best taken with a full glass of water Delsym: some patients experience drowsiness, dizziness, headache

Decongestants: Sudafed (pseudoephedrine), Sudafed PE (phenylephrine) Sudafed is found behind the pharmacy counter with purchase limits Sudafed can increase heart rate and blood pressure Sudafed PE is safer for patients with high blood pressure not well-

controlled by medications, healthy diet, and exercise**Caution: over-use of multi-symptom formulations can be

dangerous, discuss with your pharmacist or physician

Anti-diarrheals Metamucil (fiber)

Can help naturally thicken stool

Loperamide (Imodium A-D) Pepto-Bismol: liquid or tablets These can be used when diarrhea

lasts greater than 6 hours Cautions:

Do not use these medications if you have bloody diarrhea, fever, or severe diarrhea

Some diarrhea is caused by infection and should be treated by your doctor, not with OTC medications

Pepto-bismol can possibly turn your tongue and stool black

Overuse of anti-diarrheals can lead to constipation

Laxatives Metamucil (fiber)

Safest and most natural way relieve symptoms of constipation

Can take hours to days for effect

Stool Softeners: Docusate, Colace Can take hours to days for effect

Stimulants: Senna, Biscaodyl Quicker onset, more powerful laxatives, use

with caution

Avoid mineral oil and herbal remedies for constipation

Suppositories or enemas can also be used Glycerin suppositories are the safest

treatment for small children and newborns

Herbal Remedies

• Herbal supplements are regulated by the Food and Drug Administration (FDA) as dietary supplements– Not regulated as drugs or foods

• The FDA does not evaluate the use of dietary supplements for the specific diseases they may claim to treat

• Many herbal medications can interact and cause side effects like prescription drugs– Caution should be taken when using these products

• For safety, starting herbal supplements should be discussed with your physician or pharmacist

Herbal Remedies

• Class A, B, and C recommendations– A = data allows us to assume use is beneficial– B = incomplete data allows us to accept the possibility

of a beneficial relationship– C = conflicting or lack of data to establish a beneficial

association with it’s use

• In general, medications in Class A have stronger evidence for use and are more likely to be recommended by a physician or pharmacist

Herbal Remedies

Herbal Supplement

Class

Medical Use

Comments

Melatonin A Jet Lag Do not mix with prescription sleep aidsDo not use if pregnant or breastfeeding

Cranberry B Urinary Tract Infection

Can interact with blood thinners and increase risk of bleedingCaution use of juices for diabetics

Aloe Vera C Skin burns Generally safe when used topically

Glucosamine and Chondroitan

A Knee osteoarthritis

Do not use if pregnant or breastfeedingDo not use with shellfish allergies

Fish Oil A CholesterolHigh blood pressure

Do not use if pregnant or breastfeedingDo not use in children < 18 years oldDo not take more than 3 grams per day

Tea Tree Oil C AcneDandruff

Do not use on open burns or woundsDo not use on dry skinTopical oil – not for oral ingestion

Coenzyme Q 10 A Coenzyme Q 10 deficiency

May lower blood sugar – caution in diabeticsMany drug interactions exists

Herbal Remedies

• Caution: ‘G-herbs’ = increased risk of bleeding– Ginger – Class B use for nausea– Garlic – Class A use for high blood pressure and cholesterol– Ginkgo – Class A use for Alzheimer's dementia– Ginseng – Class B use for improving mental performance

• Drug-interactions in the liver– Echinacea – Class B use for Cold symptoms– Garlic – Class A use for high blood pressure and cholesterol– Black Cohosh – Class C use for menopause– Red Yeast Rice – Class A use for cholesterol– St. John’s Wort – Class A use for mild-moderate depression– Saw Palmetto – Class A use for BPH– Milk Thistle – Class B for liver disease and cirrhosis

Gastroesophageal Reflux Disease (GERD)

Many treatment options available both over-the-counter and by prescription

Most common prescription agents: Histamine2-receptor antagonists (H2RAs) Proton pump inhibitors (PPIs)

Agent usually chosen based on degree of symptoms


Histamine2- receptor antagonists

Drug How available

Famotidine (PEPCID) OTC: 10, 20mgRx: 20, 40mg

Ranitidine (ZANTAC) OTC: 75, 100mgRx: 300mg

Nizatidine (AXID) OTC: 75mgRx: 150, 300mg

Cimetidine (TAGAMET) OTC: 200mgRx: 300, 400, 800mg


Common side effects: Headaches Tiredness Sleepiness Dizziness Constipation or diarrhea

If elderly: Confusion, especially at higher doses and with

decreased kidney function Memory problems, disorientation, fall risk


Drug interactions: Medications that require an acid environment to

work: antifungal medications, calcium carbonate, iron, and some HIV medications

Cimetidine (Tagamet) specifically has many drug interactions

Clopidogrel (Plavix)

Dofetilide (Tikosyn)

Thioridazine

Amiodarone Phenytoin Carbamazepine

Quinidine Theophylline Citalopram


Proton Pump InhibitorsMedication

Omeprazole (Prilosec) Available OTC

Omeprazole- Sodium Bicarbonate (Zegerid)

Available OTC

Pantoprazole (Protonix)

Lansoprazole (Prevacid) Available OTC

Dexlansoprazole (Dexilant)

Esomeprazole (Nexium)

Rabeprazole (Achiphex)


Common side effects: Headache Dizziness Diarrhea Constipation “Acid rebound”

Increased risk of osteoporosis/fractures with long-term use Limit use!


Drug interactions: Medications that require an acid environment to

work: antifungal medications, calcium carbonate, iron, and some HIV medications

May lead to increased levels of methotrexate, phenytoin, raltegravir, saquinavir, tacrolimus, voriconazole, and warfarin

Omeprazole (Prilosec), and possibly others, should not be used together with clopidogrel (Plavix)

High Cholesterol

“Statin” medications Atorvastatin (LIPITOR) Simvastatin (ZOCOR) Rosuvastatin (CRESTOR) Pravastatin (PRAVACHOL) Lovastatin (MEVACOR, ALTOPREV) Fluvastatin (LESCOL) Pitavastatin (LIVALO)

High Cholesterol

Possible side effects of statins: Digestive problems:

Nausea Gas Diarrhea Constipation

Blood sugar increases Memory loss or confusion

Usually reversible when medication is stopped Increased risk of cataracts

High Cholesterol

Serious side effects: Muscle pain and

damage Higher doses of

medication Age > 65 years old Decreased kidney

function Untreated

hypothyroidism Use of fibrates

Liver damage Unusual tiredness or

weakness Loss of appetite Abdominal pain Dark-colored urine Yellowing of the skin or

eyes

High Cholesterol

Statin drug interactions

Shapiro and Brown, RxPrep CourseBook 2013 ed.

High Cholesterol

Simvastatin Doses of 80mg/day should be restricted to patients

who have been stable on this dose (> 12 months) without evidence of muscle toxicity

Rosuvastatin May increase effects of warfarin Dose limits with cyclosporine, ritonavir-boosted

protease inhibitor treatment, and gemfibrozil Use with other cholesterol/lipid lowering medications,

such as fibrates and niacin, may increase risk of muscle pain and damage

High Cholesterol

Fluvastatin Closer monitoring when used with warfarin

Pitavastatin Minimal interactions Should not be used with cyclosporine Dose limits with erythromycin and rifampin use Monitor when used with warfarin

Warfarin (COUMADIN)

Uses: Prevention and treatment of blood clots and clots in

the lungs Prevention and treatment of clots and associated

complications in patients with atrial fibrillation and/or heart valve replacement

Decrease in the risk of death, recurrent heart attack, and clot events like stroke or systemic clotting after a heart attack

Warfarin (COUMADIN)

Major side effects of warfarin = bleeding risk Severe bleeding Bruises that come about without an injury Prolonged/frequent nose bleeds Black stools or bleeding from the rectum

Importance of monitoring to help prevent bleeding complications

Warfarin (COUMADIN)

Warfarin (COUMADIN)

Less serious side effects: Gas Feeling cold Fatigue Pale skin Changes in the way food tastes Hair loss

Warfarin (COUMADIN)

Drug interactions Warfarin interacts with MANY medications

Carbamazepine

Phenobarbital Phenytoin Rifampin St. John’s Wort

Amoxicillin Cephalosporins

Fluoroquinolones Tetracyclines

Amiodarone

Bactrim Antifungal medications

Fluvastatin Fluvoxamine

Macrolide antibiotics

Flagyl Tigecycline NSAIDs SSRIs SNRIs

Warfarin (COUMADIN)

Common Interactions NSAIDs

Aspirin, ibuprofen, naproxen, etc. Use with warfarin can increase bleeding risk

Nutritional and natural/herbal products as big culprits of drug interactions

Vitamin K Green, leafy vegetables Do NOT have to avoid; key is to stay consistent

High Blood Pressure – Beta Blockers

Common Brands Generic

Toprol-XL, Lopressor

Metoprolol

Tenormin Atenolol

Coreg Carvedilol

Zebeta Bisoprolol

Normodyne, Trandate

Labetalol

Inderal Propranolol

Common Side Effects Fatigue, depression:

usually worse within the first few weeks of taking

Dizziness Cold handsCan make it more

difficult to realize when your blood sugar is low if you have diabetes – be cautious with insulin, check your blood sugar often

High Blood Pressure– ACE Inhibitors

Common Brands Generic

Zestril, Prinivil Lisinopril

Altace Ramipril

Vasotec Enalapril

Capoten Captopril

Accupril Quinapril

Lotensin Benazepril

Common Side Effects Dry cough – If this

occurs, call your physician, as this is a common side effect that will not taper with time

Potassium and Kidney levels may change – your physician will monitor this

DizzinessAvoid Excess Over the

Counter NSAIDs- Motrin, Aleve, Advil, etc.

High Blood Pressure– Diuretics (Water Pills)

Common Brands

Generic

MaxzideHydrochlorothiazide (HCTZ)

Thalitone Chlorthalidone

Dyrenium Triamterene

Aldactone Spironolactone

Lasix Furosemide

Bumex Bumetanide

Common Side Effects Frequent Urination –

take in the morning and earlier in the day to avoid waking up at night

Electrolytes (potassium, calcium, sodium) may change, your doctor will monitor

DizzinessNSAIDS may decrease

their effectiveness through their actions on the kidney

High Blood Pressure – Calcium Channel Blockers

Amlodipine (Norvasc) Can cause swelling in the lower legs Dizziness

Verapamil (Calan), Diltiazem (Cardizem) Constipation Drug Interactions – MANY, consult your healthcare

provider before starting any new medication Cholesterol reducing medications (statins) Transplant medications (tacrolimus, cyclosporine,

everolimus) Anti-arrhythmic drugs (amiodarone, sotalol) Many others!

Diabetes - Insulin

Type/Names Tips

Short-actingAspart (Novolog)Lispro (Humalog)

Regular (Humulin R, Novolin R)

Take 15-30 minutes before you eat a meal to avoid low blood sugar

Longer-actingGlargine (Lantus)Detemir (Levemir)

Some people find improved control of blood sugar by taking at night

If dose is larger than 50 U, splitting into two injections can

increase efficacy

Be aware of your signs of low blood sugar and have a plan to get control

Keep track of daily blood sugar as directed by your healthcare provider

Diabetes- Other Drugs

Drug Common Interactions and Side Effects

Sulfonylureas Glipizide

GlimepirideGlyburide

• Low blood sugar– take with food and be cautious with alcohol

• May cause some weight gain

Metformin• Diarrhea/stomach cramps –

usually get better if you build up to target dose.

• Caution must be used in patients with kidney problems

Exenatide (Byetta)

• Can slow down the absorption of other drugs – keep in mind if rapid relief needed (pain or nausea medication)

Diabetes- Low Blood Sugar

Blood sugar level <70 mg/dL

What do you do? Take in 15 grams of quick

acting carbohydrate/sugar source Ex: ½ cup juice or regular

soda (not diet), quick dissolving candy (NOT sugar-free), glucose tablets, 2 tablespoons raisins

Wait 15-20 min, re-check blood sugar

Eat a normal snack to keep sugar steady

Tips for Improving Medication Use

Pillboxes Help with organizing your medications Make complicated regimens less frustrating

Keep an updated medication list Pharmacists and physicians can help you

update any time you have your medications changed

Bring all of your bottles in to your physician, including OTCs and herbals

Ask questions – no thought too small!

Questions

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