Healthy Transitions

1. Healthy Transitions Common Side effects and Drug Interactions Gabriela Dimitrievski, PharmD Brian Hoff, PharmD Katie Sandison, PharmD

2. 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 medications • Talk to your healthcare providers • Ask questions!

3. Over-the-Counter (OTC)Medications Tylenol NSAIDs (Motrin/Advil/Aleve/Aspirin) Cough and Cold Anti-diarrheals and Laxatives Herbal Remedies

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Herbal Remedies

11. 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

12. 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

13. Gastroesophageal Reflux Disease (GERD) • Histamine2- receptor antagonists

14. Gastroesophageal Reflux Disease (GERD) • 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

15. Gastroesophageal Reflux Disease (GERD) • 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

16. Gastroesophageal Reflux Disease (GERD) • Proton Pump Inhibitors

17. Gastroesophageal Reflux Disease (GERD) • Common side effects: • Headache • Dizziness • Diarrhea • Constipation • “Acid rebound” • Increased risk of osteoporosis/fractures with long-term use • Limit use!

18. Gastroesophageal Reflux Disease (GERD) • 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)

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

20. 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

21. 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

22. High Cholesterol • Statin drug interactions Shapiro and Brown, RxPrep CourseBook 2013 ed.

23. 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

24. 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

25. 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

26. 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

27. Warfarin (COUMADIN) • Other important side effects: • Hives, rash, itching • Chest pain, pressure • Nausea, vomiting • Fever or flu-like symptoms • Joint or muscle aches • Diarrhea • Tingling or numbness in any part of the body

28. Warfarin (COUMADIN) • Less serious side effects: • Gas • Feeling cold • Fatigue • Pale skin • Changes in the way food tastes • Hair loss

29. Warfarin (COUMADIN) • Drug interactions • Warfarin interacts with MANY medications

30. 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

31. High Blood Pressure – Beta Blockers • Common Side Effects • Fatigue, depression: usually worse within the first few weeks of taking • Dizziness • Cold hands • Can 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

32. High Blood Pressure– ACE Inhibitors • 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 • Dizziness • Avoid Excess Over the Counter NSAIDs- Motrin, Aleve, Advil, etc.

33. High Blood Pressure– Diuretics (Water Pills) • 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 • Dizziness • NSAIDS may decrease their effectiveness through their actions on the kidney

34. 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!

35. Diabetes - Insulin

36. Diabetes- Other Drugs

37. 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

38. 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!

39. Questions