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Healthy Transitions
Common Side effects and Drug Interactions
Gabriela Dimitrievski, PharmDBrian Hoff, PharmD
Katie Sandison, PharmD
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 medicationsTalk to your healthcare providers
Ask questions!
Over-the-Counter (OTC)Medications
•Tylenol•NSAIDs (Motrin/Advil/Aleve/Aspirin)•Cough and Cold•Anti-diarrheals and Laxatives•Herbal Remedies
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
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
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
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
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
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
Herbal Remedies
Herbal Supplement
Class
Medical Use
Comments
Melatonin A Jet Lag Do not mix with prescription sleep aidsDo not use if pregnant or breastfeeding
Cranberry B Urinary Tract Infection
Can interact with blood thinners and increase risk of bleedingCaution use of juices for diabetics
Aloe Vera C Skin burns Generally safe when used topically
Glucosamine and Chondroitan
A Knee osteoarthritis
Do not use if pregnant or breastfeedingDo not use with shellfish allergies
Fish Oil A CholesterolHigh blood pressure
Do not use if pregnant or breastfeedingDo not use in children < 18 years oldDo not take more than 3 grams per day
Tea Tree Oil C AcneDandruff
Do not use on open burns or woundsDo not use on dry skinTopical oil – not for oral ingestion
Coenzyme Q 10 A Coenzyme Q 10 deficiency
May lower blood sugar – caution in diabeticsMany drug interactions exists
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
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
Gastroesophageal Reflux Disease (GERD)
Histamine2- receptor antagonists
Drug How available
Famotidine (PEPCID) OTC: 10, 20mgRx: 20, 40mg
Ranitidine (ZANTAC) OTC: 75, 100mgRx: 300mg
Nizatidine (AXID) OTC: 75mgRx: 150, 300mg
Cimetidine (TAGAMET) OTC: 200mgRx: 300, 400, 800mg
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
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
Clopidogrel (Plavix)
Dofetilide (Tikosyn)
Thioridazine
Amiodarone Phenytoin Carbamazepine
Quinidine Theophylline Citalopram
Gastroesophageal Reflux Disease (GERD)
Proton Pump InhibitorsMedication
Omeprazole (Prilosec) Available OTC
Omeprazole- Sodium Bicarbonate (Zegerid)
Available OTC
Pantoprazole (Protonix)
Lansoprazole (Prevacid) Available OTC
Dexlansoprazole (Dexilant)
Esomeprazole (Nexium)
Rabeprazole (Achiphex)
Gastroesophageal Reflux Disease (GERD)
Common side effects: Headache Dizziness Diarrhea Constipation “Acid rebound”
Increased risk of osteoporosis/fractures with long-term use Limit use!
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)
High Cholesterol
“Statin” medications Atorvastatin (LIPITOR) Simvastatin (ZOCOR) Rosuvastatin (CRESTOR) Pravastatin (PRAVACHOL) Lovastatin (MEVACOR, ALTOPREV) Fluvastatin (LESCOL) Pitavastatin (LIVALO)
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
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
High Cholesterol
Statin drug interactions
Shapiro and Brown, RxPrep CourseBook 2013 ed.
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
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
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
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
Warfarin (COUMADIN)
Warfarin (COUMADIN)
Less serious side effects: Gas Feeling cold Fatigue Pale skin Changes in the way food tastes Hair loss
Warfarin (COUMADIN)
Drug interactions Warfarin interacts with MANY medications
Carbamazepine
Phenobarbital Phenytoin Rifampin St. John’s Wort
Amoxicillin Cephalosporins
Fluoroquinolones Tetracyclines
Amiodarone
Bactrim Antifungal medications
Fluvastatin Fluvoxamine
Macrolide antibiotics
Flagyl Tigecycline NSAIDs SSRIs SNRIs
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
High Blood Pressure – Beta Blockers
Common Brands Generic
Toprol-XL, Lopressor
Metoprolol
Tenormin Atenolol
Coreg Carvedilol
Zebeta Bisoprolol
Normodyne, Trandate
Labetalol
Inderal Propranolol
Common Side Effects Fatigue, depression:
usually worse within the first few weeks of taking
Dizziness Cold handsCan 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
High Blood Pressure– ACE Inhibitors
Common Brands Generic
Zestril, Prinivil Lisinopril
Altace Ramipril
Vasotec Enalapril
Capoten Captopril
Accupril Quinapril
Lotensin Benazepril
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
DizzinessAvoid Excess Over the
Counter NSAIDs- Motrin, Aleve, Advil, etc.
High Blood Pressure– Diuretics (Water Pills)
Common Brands
Generic
MaxzideHydrochlorothiazide (HCTZ)
Thalitone Chlorthalidone
Dyrenium Triamterene
Aldactone Spironolactone
Lasix Furosemide
Bumex Bumetanide
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
DizzinessNSAIDS may decrease
their effectiveness through their actions on the kidney
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!
Diabetes - Insulin
Type/Names Tips
Short-actingAspart (Novolog)Lispro (Humalog)
Regular (Humulin R, Novolin R)
Take 15-30 minutes before you eat a meal to avoid low blood sugar
Longer-actingGlargine (Lantus)Detemir (Levemir)
Some people find improved control of blood sugar by taking at night
If dose is larger than 50 U, splitting into two injections can
increase efficacy
Be aware of your signs of low blood sugar and have a plan to get control
Keep track of daily blood sugar as directed by your healthcare provider
Diabetes- Other Drugs
Drug Common Interactions and Side Effects
Sulfonylureas Glipizide
GlimepirideGlyburide
• Low blood sugar– take with food and be cautious with alcohol
• May cause some weight gain
Metformin• Diarrhea/stomach cramps –
usually get better if you build up to target dose.
• Caution must be used in patients with kidney problems
Exenatide (Byetta)
• Can slow down the absorption of other drugs – keep in mind if rapid relief needed (pain or nausea medication)
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
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!
Questions