Identifying and Managing Alcohol and Medication Interactions in Older Adults

1. Identifying and Managing Alcohol and Medication Interactions in Older Adults Patricia W. Slattum, PharmD, PhD, CGP Virginia Commonwealth University AAAG Northern Virginia Regional Conference 2011

2. Objectives • Identify medications that may interact with alcohol and potential outcomes in older adults. • Describe risk factors for adverse events from alcohol and medication interactions among older adults. • Discuss treatment issues in pain, falls, depression and insomnia when alcohol and medication interactions play a role. • Using case studies, develop strategies to manage alcohol and medication interactions in older adults.

3. The Aging Body and Medications • Our bodies experience physical changes as we age. • These changes can impact • How well medications get into and out of the body. • How the body responds to medications.

4. Changes in Body Composition with Aging • Body fat increases and body water decreases as a percent of body weight. • Example: Alcohol • Alcohol goes into body water. • With less water, blood alcohol concentrations are higher. Delafuente JC. Consult Pharm 2008, 23:324-34.

5. Changes in the Kidney and Liver With Aging • Most drugs leave the body through the liver and kidney. • Liver and kidney function decline with aging. • Drugs take longer to get out of the body. • Older adults may need lower doses or a longer time between doses. Delafuente JC. Consult Pharm 2008, 23:324-34.

6. Changes in Drug Response with Aging • Older adults may • Have decreased functional ability before taking the medication. • Be more sensitive to medications. • Be less able to compensate for the effects of medications. • This may result in unwanted effects of medications. Bowie M, Slattum P. J Geriatr Pharmacother 2007;5: 263-303

7. Atypical Presentation of Adverse Drug Events in Older Adults • Altered mental status/confusion • Fatigue • Falling • Constipation • Urinary Incontinence • Depression • Dizziness Adverse events often mistaken for normal aging! Tangiisuran B, et al. Age and Ageing 2009;38:358-359. Weingart SN, et al. Arch Intern Med 2005;165:234-240. Schmader KE, et al. Am J Med 2004;116:394-401.

8. Drug-Drug Interactions • Patient groups at increased risk: • Older adults taking multiple medications • Those seeing more than one doctor • Those being infrequently or inadequately monitored • Those with impaired liver or kidney function • Warfarin (Coumadin®) is a high-risk medication for drug interactions. • Dietary supplements, herbal products and over-the –counter medications must also be considered. • Pharmacists look for drug interactions when filling prescriptions. Mallet L, et al. Lancet 2007;370:185-91.

9. Drug-Alcohol Interactions • Mixing certain medications with alcohol can cause adverse events • Mixing alcohol with sedatives, pain medications or other drugs acting on the brain can result in increased sedation, unsteadiness or falls. • Mixing alcohol with aspirin, ibuprofen, naproxen or similar drugs can increase risk of gastrointestinal bleeding. • Mixing alcohol with blood pressure lowering medications can cause blood pressure to go too low. Harmful interactions: Mixing alcohol with Medicines Brochurehttps://pubs.niaaa.nih.gov/publications/Medicine/medicine.htm

10. Alcohol and Acetaminophen • Acetaminophen is found in many combination pain products. • Recommendations for maximum dose/day recently decreased to 3,000 mg/day. • When taken during or right after drinking increases the risk of liver damage. • Chronic drinking may increase the production of toxic metabolites of acetaminophen. http://www.rochester.edu/uhs/healthtopics/Alcohol/interactions.html https://webapps.ou.edu/alcohol/docs/13EtohandMedicationInteractions40-54.pdf

11. Treatment Issues • Pain • Depression • Insomnia

12. Pain • Many medications recommended to manage pain in older adults interact with alcohol: • Acetaminophen • Nonsteroidal Anti-inflammatory Drugs • Opiate analgesics • Some patients may be using alcohol to self-treat pain.

13. Case LR LR is an 86-year-old female whose primary complaint is dry mouth. LR lives alone in her own home, but is increasingly having difficulty with instrumental activities of daily living such as paying her bills and shopping for groceries. She dozes off frequently during the day and seems unsteady on her feet. When her daughter tries to discuss this with her, she claims that this is “normal” for someone her age and to stop worrying her. LR brings up the issue of dry mouth with each of her three doctors, but the only recommendations she has received is to suck on hard candy and drink more fluids. She doesn’t feel that these measures really help. Her daughter requests a medication assessment to determine if her medications may be contributing to her dry mouth.

14. Her current medication regimen: Morning 1 Calcium 600mg started 3 years ago 1 Gabapentin (Neurontin®) 800mg started 2 years ago 1 Potassium chloride 20mEq started 4 years ago 1 Furosemide (Lasix®) 20mg started 4 years ago 1 digoxin (Lanoxin®) 0.125 mg started 3 years ago ½ metoprolol 25mg started 8 years ago Noon 1 Duloxetine (Cymbalta®) 60mg started 3 weeks ago 1 Gabapentin (Neurontin®) 800mg started 2 years ago 2 Oxaprozin (Daypro®) 600mg started 1.5 years ago Night 2 Quetiapine (Seroquel®) 25mg started 1 year ago 1 Amitriptyline 50mg started 3 months ago 1 Temazepam (Restoril®) 15mg started 10 years ago 1 Gabapentin (Neurontin®) 800mg started 2 years ago ½ metoprolol 25mg started 8 years ago PRN:  Mylanta, Gas X, and Tylenol

15. During an interview, LR admitted to changing the administration times of some of her medications and to consuming “some” alcohol most days of the week. She also takes 1000 mg of acetaminophen in the morning and before going to bed in the evening each day.

16. What are the signs that LR may be experiencing medication-related problems? • What are your concerns about LR’s medication use? • What are your recommendations?

17. Depression • Alcohol interacts with all classes of antidepressants. • Major depression and alcohol use disorder: either doubles the chance of having the other. • There appears to be a causal link between alcohol use disorder and major depression. • Best treatment approaches for the older adult are still unknown. Boden and Fergussen. Addiction 2011;106:906-914.

18. Case SP SP is an 82 year old white female who suffers from chronic obstructive pulmonary disorder (COPD). She had a medical history of aortic aneurysm which was treated surgically, and was diagnosed with depression in the past for which she was treated with antidepressants. She was a smoker for the last 40 years and a moderate alcohol-drinker. After moving to a senior congregate living center, she started drinking more heavily leading to incidences of falls and fractured arm. Mohanty M, Slattum PW. Age in Action 2011; Summer

19. Her prescriptions consisted of 11 medications: • Advair(combination of fluticasone & salmeterol), tiotropium, albuterol, montelukast, and Mucinex (guaifenesin and pseudoephedrine) for COPD • paroxetinefor depression • simvastatinfor cholesterol • supplements (iron and calcium) • She was also taking digoxin for congestive heart failure and primodine for tremor. However, during the interview she did not mention a history of tremor or heart failure.

20. After checking for potential drug interactions, it was found that primidone and ethanol have a moderate interaction, while paroxetine and ethanol have a minor level of drug interaction. SP decided to abstain from drinking and smoking following the three sessions of counselling with her physician. After quitting alcohol consumption, she has not reported any incidence of fall or other forms of injury. Mohanty M, Slattum PW. Age in Action 2011; Summer

21. What were the signs that SP might be experiencing a medication-related problem? • What recommendations do you have for SP?

22. Insomnia • Alcohol interacts significantly with sedatives used to treat insomnia. • Alcohol worsens sleep disorders. • Options: • Treat underlying health conditions • Evaluate medications as a contributor • Sleep hygiene: daytime exercise, limit caffeine, exposure to natural light during day, limit napping during the day, etc.

23. Case OP OP is an 80 year old WF living in an assisted living community. At the time of her medication review by a pharmacist, her family expressed concerns that she had been “loopy and out of it” recently. She also experienced a fall in the evening but was not injured. There hadn’t been any recent changes in her medications, but during the pharmacist’s interview, OP mentioned drinking wine in the evening. The medication technician, who often works on OP’s floor, stated that OP “stays up all night drinking wine and watching TV then sleeps throughout the day.” The medication technician was not sure how much she drinks nightly or whether she was drinking more than usual. OP was taking 16 scheduled prescription medications and 5 as needed medications. Mohanty M, Slattum PW. Age in Action 2011; Summer

24. Her scheduled prescriptions included: • lisinopril, nadolol, and amlodipine for hypertension • furosemide for edema • levothyroxine for thyroid replacement • albuterol for asthma • pantoprazole for gastroesophageal reflux disease (GERD) • solifenacin for urinary incontinence • citalopram, bupropion, and quetiapine for depression • trazodone for insomnia and depression • tramadol for pain • supplements of potassium and Vitamin D • Additionally, trazodone (sleep-inducer), promethazine (for nausea and vomiting), docusate (for constipation), acetaminophen and cholestyramine (for loose stool) were prescribed as needed. Mohanty M, Slattum PW. Age in Action 2011; Summer

25. What are the signs that OP may be experiencing a medication-related problem? • What recommendations do you have?

26. Evaluation of her medication regimen indicated that bupropion, quetiapine, trazodone, and tramadol have the potential to interact with alcohol increasing her CNS depression and risk for fall. The pharmacist recommended to the physician to changing trazodone to use only when needed, and to discontinue quetiapine, if possible. OP was educated about the potential risk of mixing alcohol and her medications and was advised to stop consuming alcohol by her pharmacist, physician and family. OP stopped consuming alcohol and some changes in her drug regimen were instituted, after which her functional and cognitive status improved. Mohanty M, Slattum PW. Age in Action 2011; Summer

27. Summary • Falls and other problems may be a consequence of medication and alcohol interactions in older adults. • Depression, insomnia and pain present difficult treatment decisions when alcohol is consumed concurrently. • Consider medication discontinuation in patients who continue to consume alcohol.

28. Improving the Quality of Medication Use in Elderly Patients: A Not-So-Simple Prescription “Putting the pieces of the puzzle together to create a solution remains a formidable, but not insurmountable task….All the pieces of the puzzle lie before us; it remains for us to find a way to fit them together” Jerry H. Gurwitz, M.D. Gurwitz JH, Arch Intern Med 2002; 162:1670-3 Gurwitz JH, Arch Intern Med 2002; 162:1670-3