Download Vitamins, Supplements and Medication Safety

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