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Transcript
Community TouchPoint Advice from a Pharmacist: Vitamins, Supplements, and Medication Safety Cassie Spray, PharmD Clinical Pharmacist Kathryn Hauenstein, PharmD PGY1 Community Pharmacy Resident Megan Kline, PharmD PGY1 Community Pharmacy Resident Objectives 1. Discuss potentially safe and unsafe vitamins and supplements for patients age 65 and older 2. Discuss potentially safe and unsafe over-thecounter products for patients age 65 and older 3. Review medication safety and medication disposal tips 4. Summarize the American Geriatric Society Beers List for Potentially Inappropriate Medication Use in Older Adults Why is This Important to Talk About? • As we age: • Amount of water in the body decreases; less water to dilute drugs • Amount of fat tissue increases; more drug can be stored in fat • Kidneys are not able to filter drugs as well • Liver is not able to break down drugs as well • Older people take more drugs and have more disorders • Increases risk of side effects and drug interactions Vitamins and Supplements • • • • • • • Apple Cider Vinegar Baby Aspirin Biotin Calcium Coenzyme Q10 Fish Oil/Krill Oil Flaxseed • • • • • • • Glucosamine/Chondroitin Iron Melatonin Vitamin B Vitamin C Vitamin D Vitamin E Apple Cider Vinegar Apple Cider Vinegar Uses Cholesterol^ Diabetes^ Digestion^ Urinary Tract Infections^ Dosage Diabetes: 30 grams daily Other dosages unknown Side Effects Low potassium, weaken bones, throat irritation Drug Interactions (Moderate) Amaryl (glimepiride), Micronase (glyburide), insulin, Glucophage (metformin), Actos (pioglitazome), Lanoxin (digoxin), Hydrodiuril (hydrochlorothiazide), Thalitone (chlorthalidone), Lasix (furosemide) *Likely Effective **Possibly Effective ^Insufficient Evidence Baby Aspirin Baby Aspirin Uses Heart protection Pain Fever reducer Dosage Heart protection: typically 81 mg daily Pain/Fever reducer: 325 to 650 mg every 4 hours, max 3.9 g per day Side Effects Bleeding, ringing in the ears, stomach ulcer Drug Interactions NSAIDs (ibuprofen/naproxen), Coumadin (warfarin), heparin, Lovenox (enoxaparin), Plavix (clopidogrel), Brilinta (ticagrelor), Ticlid (ticlopidine), Xarelto (rivaroxaban), Pradaxa (dabigatran), Eliquis (apixaban), depression medications, methotrexate Clinical Pearls Recommend talking to your doctor before starting to take aspirin every day *Likely Effective **Possibly Effective ^Insufficient Evidence Biotin Biotin Uses Biotin deficiency* Brittle Nails^ Hair Loss^ Nerve Damage related to Diabetes^ Dosage Adequate intake for >18 years old: 30 mcg daily Side Effects Well tolerated Drug Interactions Antibiotics, Accutane (isotrentinoin), Carbatrol (carbamazepine), phenobarbital, Dilantin (phenytoin) , Mysoline (primidone) may all decrease the amount of biotin in the body *Likely Effective **Possibly Effective ^Insufficient Evidence Calcium Calcium Uses Calcium deficiency Osteoporosis prevention* Cancer prevention^ Dosage Dietary Reference Intake: Females 19-50 years: 1000 mg elemental calcium >51 years: 1200 mg elemental calcium Males 19-70 years: 1000 mg elemental calcium >70 years: 1200 mg elemental calcium Side Effects Constipation, gas Drug Interactions Vibramycin (doxycycline), Minocin (minocycline), Achromycin (tetracycline), Cipro (ciprofloxacin), Levaquin (levofloxacin), Avelox (moxifloxacin), levothyroxine, Fosamax (alendronate) Actonel (risedronate), Boniva (ibandronate) *Likely Effective **Possibly Effective ^Insufficient Evidence Coenzyme Q10 Coenzyme Q10 Uses Blood Pressure** Coenzyme Q10 deficiency* Congestive Heart Failure** Muscle soreness as a result of Cholesterol-Lowering Therapy^ Migraines** Nerve Damage related to Diabetes** Dosage Muscle soreness: 100 to 200 mg daily Coenzyme Q10 deficiency: 150 mg daily Heart Failure: 100 mg twice to three times daily Blood Pressure: 120 to 200 mg twice daily Migraines: 100 mg three times daily Side Effects Nausea, vomiting diarrhea, appetite suppression, and heartburn Drug Interactions Increased concentrations of vitamin A, C, K, and E; blood pressure (Moderate) medications; chemotherapy medications; warfarin *Likely Effective **Possibly Effective ^Insufficient Evidence Fish Oil Fish Oil Krill Oil Uses Cholesterol Heart Disease* Cholesterol^ Osteoarthritis^ Dosage 2 grams twice daily Cholesterol: 1 to 3 grams daily Osteoarthritis: 300 mg daily Side Effects Fishy burp, bad breath, heartburn, Fishy burp, bad breath, heartburn, nausea, diarrhea, and rash nausea, and diarrhea Drug Interactions Moderate: Blood pressure medications, birth control , Alli (orlistat) Minor: Plavix (clopidogrel), Lovenox (enoxaparin), Coumadin (warfarin) Clinical Pearl Can avoid a majority of the side effects by freezing capsules (except Lovaza which should not be frozen) Moderate: Plavix (clopidogrel), Lovenox (enoxaparin), Coumadin (warfarin), Amaryl (glimepiride), Micronase (glyburide), insulin, Glucophage (metformin), Actos (pioglitazome) Minor: Alli (orlistat) *Likely Effective **Possibly Effective ^Insufficient Evidence Flaxseed Flaxseed Uses Cholesterol ** Diabetes** High Blood Pressure^ Dosage Cholesterol: 40 to 50 grams per day Diabetes: 600 mg three times daily Side Effects Bloating, flatulence, abdominal pain, diarrhea, constipation, heartburn, and nausea Drug Interactions Tylenol (acetaminophen), antibiotics, Plavix (clopidogrel), Lovenox (Moderate) (enoxaparin), Coumadin (warfarin), Amaryl (glimepiride), Micronase (glyburide), insulin, Glucophage (metformin), Actos (pioglitazome), Vasotec (enalapril), Zestril (lisinopril), Diovan (valsartan), Cozaar (losartan), Cardizem (diltiazem), Norvasc (amlodipine), Hydrodiuril (hydrochlorothiazide), estrogens, Lasix (furosemide), ketoprofen, Toprolol (metoprolol) Clinical Pearls Do not consume raw or unripe flaxseed that has not been baked *Likely Effective **Possibly Effective ^Insufficient Evidence Glucosamine/Chondroitin Glucosamine Chondroitin Uses Knee Pain^ Osteoarthritis^ Osteoarthritis** Dosage 500 mg three times daily alone or in combination with chondroitin 400 mg three times daily alone or in combination with glucosamine Side Effects Gas, bloating, and cramps Nausea, diarrhea, constipation, swelling , and hair loss Drug Interactions Major: Coumadin (warfarin) Moderate: Chemotherapeutic agents Minor: Amaryl (glimepiride), Micronase (glyburide), insulin, Glucophage (metformin), Actos (pioglitazome), Tylenol (acetaminophen) Moderate: Coumadin (warfarin) Disease Interactions Asthma, diabetes, cholesterol, blood pressure Asthma, prostate cancer Warnings/ Precautions Shellfish allergy Stop use 2 weeks prior to surgery -- Iron Iron Uses Anemia ACE Inhibitor associated cough** Heart Failure** Dosage 150 to 200 mg of elemental iron daily in divided doses Side Effects Upset stomach, constipation, nausea, and vomiting Drug Interactions Moderate: Fosamax (alendronate) Actonel (risedronate), levodopa, methyldopa, levothyroxine, Synthroid, Levothryoid, Levoxyl, CellCept (mycophenolate), Cipro (ciprofloxacin), Levaquin (levofloxacin), Avelox (moxifloxacin), Vibramycin (doxycycline), Minocin (minocycline), Achromycin (tetracycline) Clinical Pearl To increase the absorption of iron take with something containing vitamin C such as orange juice Try to take it separate from food and calcium as this can decrease iron’s absorption into the body *Likely Effective **Possibly Effective ^Insufficient Evidence Melatonin Melatonin Uses Circadian rhythm sleep disorders* Insomnia** Jet lag** Cancer** Dosage Insomnia: 3 to 5 mg about 30 minutes before bedtime, up to 10 mg daily Jet lag: 1.5 to 3 mg at 11pm in destination country Cancer: 1.5 to 6 mg daily, up to 20 mg daily Side Effects Drowsiness, headache, dizziness Drug Interactions Coumadin (warfarin) *Likely Effective **Possibly Effective ^Insufficient Evidence Vitamin B Complex Vitamin B1 Vitamin B2 Vitamin B3 (niacin) Uses Thiamine Deficiency Migraine Headache** Cholesterol* Dosage 1 to 2 mg daily 400 mg daily 1200 to 1500 mg daily Side Effects Well tolerated Diarrhea, frequent urination Flushing, itching, tingling Drug No known drug Interactions interactions Vibramycin (doxycycline), Minocin (minocycline), Achromycin (tetracycline) Alcohol, Catapres (clonidine), Questran (cholestyramine), Colestid (colestipol), Zocor (simvastatin), Lipitor (atorvastatin), Crestor (rosuvastatin), Mevacor (lovastatin), Pravachol (pravastatin) Disease -interactions -- Gout, diabetes *Likely Effective **Possibly Effective ^Insufficient Evidence Vitamin B Complex Vitamin B5 Vitamin B6 Vitamin B12 Uses Vitamin B5 Deficiency Blood pressure ** Kidney Stones ** Vitamin B12 Deficiency Fatigue^ Dosage 5 to 10 mg daily Kidney Stones: 25 to 500 mg daily 300 to 10,000 mcg daily Side Effects Diarrhea Nausea, vomiting, loss of appetite, headache, feeling tired Drug No known drug Interactions interactions Well tolerated Cordarone (amiodarone), Vasotec No known drug (enalapril), Zestril (lisinopril), interactions Diovan (valsartan), Cozaar (losartan), Cardizem (diltiazem), Norvasc (amlodipine), Hydrodiuril (hydrochlorothiazide), phenobarbital, phenytoin *Likely Effective **Possibly Effective ^Insufficient Evidence Vitamin C Vitamin C (Ascorbic Acid) Uses Iron Absorption* Common Cold** Dosage Common Cold: 600 to 1000 mg daily Side Effects Nausea, vomiting, heartburn Drug Interactions Moderate: chemotherapy medications, estrogens, Zocor (simvastatin), Lipitor (atorvastatin), Crestor (rosuvastatin), Mevacor (lovastatin), Pravachol (pravastatin), niacin, HIV medications, Coumadin (warfarin) Clinical Pearl Taking more than 2 grams per day can increase your risk of kidney stone formation *Likely Effective **Possibly Effective ^Insufficient Evidence Vitamin D Vitamin D Uses Vitamin D deficiency Bone softening Osteoporosis* Fall prevention* Cancer prevention** Cognitive function^ High blood pressure^ High cholesterol^ Diabetes^ Dosage Vitamin D deficiency: 800 to 1000 units daily Fall prevention: 400 to 1000 units daily Side Effects Vitamin D intoxication Drug Interactions Antacids containing aluminum, Alli (orlistat) *Likely Effective **Possibly Effective ^Insufficient Evidence Vitamin E Vitamin E Uses Vitamin E Deficiency Cardiovascular Disease (found to be ineffective) Diabetes ^ Dosage 22 IU (15 mg) per day Side Effects Nausea, diarrhea, cramps, fatigue, weakness, and headache Drug Interactions Plavix (clopidogrel), Lovenox (enoxaparin), Coumadin (warfarin), chemotherapy medications, Neoral or Sandimmune (cyclosporine), Cardizem (diltiazem), Cardene (nicardipine), Calan (verapamil), ketoconazole, itraconazole, fentanyl, Cozaar (losartan), Prozac (fluoxetine), Prilosec (omeprazole), Zofran (ondansetron), Inderal (propranolol), Allegra, (fexofenadine), Zocor (simvastatin), Lipitor (atorvastatin), Crestor (rosuvastatin), Mevacor (lovastatin), Pravachol (pravastatin), niacin *Likely Effective **Possibly Effective ^Insufficient Evidence Over-the-Counter Medications Cough and Cold Allergy Heartburn and sour stomach Diarrhea and Constipation Pain Over-the-Counter Medications Cough and Cold Medications • • • • The Do’s The Don’ts Possible Side Effects Drink lots of fluids Rest Saline nasal spray Throat lozenges (caution with sugar content) • Caution with combination products • Diphenhydramine • Chlorpheniramine • Caution with dextromethorphan and cough syrups (sugar and alcohol content) • Nasal decongestants and pseudoephedrine • Increased risk of side effects • Confusion, blurred vision, constipation, problems urinating, dry mouth • Drowsiness and dizziness • Increased blood pressure, headache, trouble sleeping, hallucinations Over-the-Counter Medications Cough and Cold Medication Examples Over-the-Counter Medications Allergy Medications The Do’s • • • • Loratadine Fexofenadine Cetirizine Limit exposure to pollen The Don’ts • • • • • Diphenhydramine Chlorpheniramine Dimenhydrinate Clemastine Nasal decongestants and pseudoephedrine Possible Side Effects • • • • • • • Confusion Blurred vision Constipation Problems urinating Dry mouth Light-headedness Increased blood pressure, headache, trouble sleeping, hallucinations Over-the-Counter Medications Allergy Medication Examples Over-the-Counter Medications Pain Medications The Do’s The Don’ts Possible Side Effects • See your doctor for severe pain or mild pain lasting more than 2 week • Only use for shortterm • Participate in regular physical activity • RICE: Rest, ice, compression, elevation • Use high doses • Long-term use without a doctor’s approval • Take more than 3000 mg per day of acetaminophen • Take an NSAID on an empty stomach • Drink alcohol while taking these medications • Stomach bleeding and ulcers with long-term use • Internal bleeding if using other blood thinners • Fluid retention • Increased blood pressure • Kidney damage • Liver damage Over-the-Counter Medications Pain Medication Examples Over-the-Counter Medications Heartburn and Sour Stomach Medications The Do’s The Don’ts Possible Side Effects • Avoid foods that worsen symptoms • Do not eat within 2-3 hours of bedtime • Elevate the head of your bed • Take OTC antacids for mild symptoms • Take OTC H2-blocker for moderate symptoms • Take OTC PPI for a short, 14-day course to prevent symptoms • Take an OTC PPI for • Increased risk of more than 14 days or fractures, low more than 3 courses in magnesium and a year without doctor’s infections approval • Use a PPI to treat • Only prevent symptoms symptoms • Take high doses of H2- • May cause confusion blockers • Take high doses of antacids for more than 2 weeks Over-the-Counter Medications Heartburn and Sour Stomach Medication Examples Over-the-Counter Medications Diarrhea and Constipation Medications The Do’s The Don’ts • Drink plenty of fluids • Take antidiarrheal if • Talk to a doctor you experience about all blood in the stool or constipation fever • See a doctor for • Take laxatives diarrhea lasting without a doctor’s more than 2 days approval • Eat adequate amounts of fiber in the diet or supplement fiber or psyllium Possible Side Effects • Fluid loss and dehydration • Electrolyte imbalance • Constipation • Aspiration with mineral oil • Diarrhea • Mask the symptoms of internal bleeding Over-the-Counter Medications Diarrhea and Constipation Medication Examples Medication Storage Medication Storage • Stored in a cool, dry place away from children and pets • Bathrooms are not an ideal location • Heat and moisture can cause breakdown of tablets and capsules • If stored in the kitchen, keep away from hot appliances, below the sink or in direct sunlight • Pill boxes are a great tool to help store medications Medication Storage • Medications stored in the refrigerator • Unused insulin such as Lantus, Levemir, Humalog • Unused Byetta (exenatide) • Unused Fortical or Miacalcin (calcitonin) nasal spray • Biologic medications: Humira, Enbrel • Unused Xalatan eye drops • Duac (benzoyl peroxide/clindamycin) gel • Many antibiotic suspensions Medication Storage • Medications stored in their original container • Brilinta (ticagrelor) • Tekturna (aliskiren) • Edarbi (azilsartan) and Edarbyclor (azilsartan/chlorthalidone) • Pradaxa (dabigatran) • Aggrenox (dipyridamole/aspirin) • Horizant (gabapentin enacarbil) • Nitrostat (nitroglycerin) under the tongue tablets • Creon (pancrelipase) • Effient (prasugrel) • Many HIV medications Medication Disposal Medication Disposal • Community or National drug “take back” days • Check with local pharmacies, police stations and fire stations • If not available, follow these instructions: 1. Remove from container 2. Mix with undesirable substance such as coffee ground or kitty litter 3. Place mixture in sealable bag or empty can and place in garbage 4. Scratch out any personal information before throwing away pill bottles Medication Disposal • Needles and other sharps: Medication Safety Beers List • Consensus document from the American Geriatric Society on medications to use caution or avoid in patients 65 years and older • Based on potential side effects, drug interactions and duplication of medications • Prescribing decisions should be individualized and final decision lies with you and your doctor Beers List Examples Disease Drug Advice Reasoning Heart Failure NSAIDs, Actos, Avandia Avoid Increases fluid retention History of Falls Lunesta, Ambien, Avoid unless Xanax, SSRIs safer alternative not available Increased risk of dizziness, fainting and additional falls Chronic Constipation Detrol, oxybutynin, Verapamil, amitriptyline Avoid unless no other alternatives Worsen constipation Insomnia Sudafed, Adderall, Ritalin Avoid Act as a stimulant Beers List Examples Drug Advice Reasoning Doxazosin, Prazosin, Terazosin Avoid using for blood pressure control Risk of dizziness upon standing and fainting Nitrofurantoin Avoid for reduced kidney function Does not get into the urine and will not fight infection Amitriptyline, Imipramine, Avoid Clomipramine Many side effects, risk of dizziness, drowsiness Lunesta, Ambien Avoid use longer than 90 days Increased risk of falls, fractures and delirium Ibuprofen, Meloxicam, Sulindac, etc. Avoid chronic use unless no other alternative Increase risk of GI bleed and ulcers Conclusion • As we age, the body processes vitamins, supplements and medications differently • There are many supplements out there with few showing proven benefits • Even medications for short-term conditions, such as the common cold, can have negative side effects • It is important to always talk to your doctor or pharmacist about over-the-counter medication use Disclaimer: Always talk to your doctor before starting or stopping any medication, vitamins or supplements. Contact information: Cassie Spray, PharmD County Line Medical Pavilion [email protected] 317-497-6330