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University of Cincinnati/Health Alliance Reynolds Geriatric Education Center Most Common Drug-Drug Adverse Effects Identified Upon Hospitalization Combination Risk ACE inhibitor + diuretic Hypotension; hyperkalemia ACE inhibitor + potassium Hyperkalemia Antiarrhythmic + diuretic Electrolyte imbalance; arrhythmias Benzodiazepine + antidepressant Confusion, sedation, falls Benzodiazepine + antipsychotic Confusion, sedation, falls Benzodiazepine + benzodiazepine Confusion, sedation, falls Calcium channel blocker + diuretic Hypotension Calcium channel blocker + nitrate Hypotension Digitalis + antiarrhythmic Bradycardia, arrhythmias Diuretic + digitalis Arrhythmias Diuretic + diuretic Dehydration, electrolyte imbalance Diuretic + nitrate Hypotension Nitrate + vasodilator Hypotension SOURCE: GRS V, American Geriatrics Society, New York, 2002. Data from Doucet J, Chassagne P, Trivalle C, et al. Drug-drug interactions related to hospital admissions in older adults: a prospective study of 1000 patients. J Am Geriatr Soc. 1996;44(8):944–948. University of Cincinnati/Health Alliance Reynolds Geriatric Education Center Possible Interactions of Drugs and Herbal Preparations Prescription Medication Possible Interactive Effect Herbal Preparations Anticoagulants, antiplatelets Increased bleeding time Arnica, celery, chamomile, dan-shen, dong quai, fenugreek, feverfew, garlic, ginger, ginkgo, green tea Anticoagulants, antiplatelets Decreased bleeding time Ginseng Hypoglycemic agents Hypoglycemic effect Chromium, fenugreek, garlic, ginseng, nettle, sage Digoxin Cardiac glycoside additive effect Adonis (false hellebore, pheasant’s eye), broom, dogbane, figwort, lily-of-thevalley, milkweed, motherwort, pleurisy root, purple foxglove, strophanthus, uzara root, white squill, wild ipecac, yellow foxglove Digoxin Falsely elevated digoxin level without toxicity in lab assays Ginseng, kyushin Digoxin Hypokalemia, increased digoxin sensitivity Licorice Digoxin Reduced digoxin bioavailability St. John’s wort Diuretics Increased diuresis Agrimony, artichoke, boldus, broom, buchu, burdock, celery seed, coughgrass, dandelion, elder, goldenseal, guaiacum, juniper, pokeroot, shepherd’s purse, squill, uva-ursi, yarrow, zea Trazodone Central nervous system depression, somnolence Ginkgo SOURCE: GRS V, American Geriatrics Society, New York, 2002. University of Cincinnati/Health Alliance Reynolds Geriatric Education Center Principles of Prescribing for Older Patients The basics: ■ Start with a low dose. ■ Titrate the dose upward slowly, as tolerated by the patient. ■ Try not to start two drugs at the same time. Determine the following before prescribing a new medication: ■ Is the medication necessary? Are there nonpharmacologic ways to treat the condition? ■ What are the therapeutic end points and how will they be assessed? ■ Do the benefits outweigh the risks of the medication? ■ Is one medication being used to treat the adverse effects of another? ■ Is there one medication that could be prescribed to treat two conditions? ■ Are there potential drug-drug or drug-disease interactions? ■ Will the new medication’s administration times be the same as those of existing medications? ■ Do the patient and caregiver understand what the medication is for, how to take it, how long to take it, when it should start to work, possible adverse effects that it might cause, and what to do if they occur? At least annually: ■ Ask the patient to bring in all medications (prescription, over-the-counter, supplements, and herbal preparations) to the office; for new patients, conduct a detailed medication history. ■ For prescription medications, determine whether the label directions and dose match those in the patient’s chart; ask the patient how each medication is being taken. ■ Ask about medication side effects. ■ Note who else is prescribing medications for the patient, and what the medications are and their indications. ■ Look for medications with duplicate therapeutic, pharmacologic, or adverse effect profiles. ■ Screen for drug-drug and drug-disease interactions. ■ Eliminate unnecessary medications; confer with other prescribers if necessary. ■ Simplify the medication regimen; use the fewest possible number of medications and doses per day. ■ Always review any changes with the patient and caregiver; provide the changes in writing. SOURCE: GRS V, American Geriatrics Society, New York, 2002.
