Community TouchPoint · Apple Cider Vinegar Uses Cholesterol^ Diabetes^ Digestion^ Urinary Tract...
Transcript of Community TouchPoint · Apple Cider Vinegar Uses Cholesterol^ Diabetes^ Digestion^ Urinary Tract...
Community TouchPoint
Cassie Spray, PharmDClinical Pharmacist
Kathryn Hauenstein, PharmD PGY1 Community Pharmacy Resident
Megan Kline, PharmDPGY1 Community Pharmacy Resident
Advice from a Pharmacist: Vitamins, Supplements, and Medication Safety
1. Discuss potentially safe and unsafe vitamins and supplements for patients age 65 and older
2. Discuss potentially safe and unsafe over-the-counter 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
Objectives
• 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
Why is This Important to Talk About?
• Apple Cider Vinegar
• Baby Aspirin
• Biotin
• Calcium
• Coenzyme Q10
• Fish Oil/Krill Oil
• Flaxseed
Vitamins and Supplements
• Glucosamine/Chondroitin
• Iron
• Melatonin
• Vitamin B
• Vitamin C
• Vitamin D
• Vitamin E
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)
Apple Cider Vinegar
*Likely Effective **Possibly Effective ^Insufficient Evidence
Baby Aspirin
Baby Aspirin
Uses Heart protectionPainFever reducer
Dosage Heart protection: typically 81 mg dailyPain/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 deficiencyOsteoporosis prevention*Cancer prevention^
Dosage Dietary Reference Intake:Females
19-50 years: 1000 mg elemental calcium>51 years: 1200 mg elemental calcium
Males19-70 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 dailyBlood Pressure: 120 to 200 mg twice dailyMigraines: 100 mg three times daily
Side Effects Nausea, vomiting diarrhea, appetite suppression, and heartburn
Drug Interactions(Moderate)
Increased concentrations of vitamin A, C, K, and E; blood pressure medications; chemotherapy medications; warfarin
*Likely Effective **Possibly Effective ^Insufficient Evidence
Fish Oil
Fish Oil Krill Oil
Uses CholesterolHeart Disease*
Cholesterol^Osteoarthritis^
Dosage 2 grams twice daily Cholesterol: 1 to 3 grams dailyOsteoarthritis: 300 mg daily
Side Effects Fishy burp, bad breath, heartburn, nausea, diarrhea, and rash
Fishy burp, bad breath, heartburn, nausea, and diarrhea
Drug Interactions Moderate: Blood pressure medications, birth control , Alli (orlistat)Minor: Plavix (clopidogrel), Lovenox (enoxaparin), Coumadin (warfarin)
Moderate: Plavix (clopidogrel), Lovenox (enoxaparin), Coumadin (warfarin), Amaryl (glimepiride), Micronase (glyburide), insulin, Glucophage (metformin), Actos (pioglitazome)Minor: Alli (orlistat)
Clinical Pearl Can avoid a majority of the side effects by freezing capsules (except Lovaza which should not be frozen)
*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(Moderate)
Tylenol (acetaminophen), antibiotics, Plavix (clopidogrel), Lovenox (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 agentsMinor: 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 allergyStop use 2 weeks prior to surgery
--
Iron
Iron
Uses AnemiaACE 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 dailyJet lag: 1.5 to 3 mg at 11pm in destination countryCancer: 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 Interactions
No known druginteractions
Vibramycin (doxycycline), Minocin (minocycline), Achromycin (tetracycline)
Alcohol, Catapres (clonidine), Questran (cholestyramine), Colestid (colestipol), Zocor (simvastatin), Lipitor (atorvastatin), Crestor (rosuvastatin), Mevacor (lovastatin), Pravachol (pravastatin)
Diseaseinteractions
-- -- Gout, diabetes
*Likely Effective **Possibly Effective ^Insufficient Evidence
Vitamin B Complex
*Likely Effective **Possibly Effective ^Insufficient Evidence
Vitamin B5 Vitamin B6 Vitamin B12
Uses Vitamin B5 Deficiency
Blood pressure **Kidney Stones **
Vitamin B12 DeficiencyFatigue^
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
Well tolerated
Drug Interactions
No known drug interactions
Cordarone (amiodarone), Vasotec (enalapril), Zestril (lisinopril), Diovan (valsartan), Cozaar (losartan), Cardizem (diltiazem), Norvasc (amlodipine), Hydrodiuril (hydrochlorothiazide), phenobarbital, phenytoin
No known drug interactions
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 deficiencyBone softeningOsteoporosis*Fall prevention*Cancer prevention**Cognitive function^High blood pressure^High cholesterol^Diabetes^
Dosage Vitamin D deficiency: 800 to 1000 units dailyFall 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 DeficiencyCardiovascular 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
Cough and Cold
Allergy Pain
Heartburn and sour stomach
Diarrhea and Constipation
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
Allergy Medications
The Do’s The Don’ts Possible Side Effects
• Loratadine • Fexofenadine• Cetirizine • Limit exposure to
pollen
• Diphenhydramine• Chlorpheniramine• Dimenhydrinate • Clemastine • Nasal
decongestants and pseudoephedrine
• Confusion• Blurred vision• Constipation• Problems urinating • Dry mouth• Light-headedness• Increased blood
pressure, headache, trouble sleeping, hallucinations
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 short-term
• 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 bleedingand 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
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 more than 14 days or more than 3 courses in a year without doctor’s approval
• Use a PPI to treat symptoms
• Take high doses of H2-blockers
• Take high doses of antacids for more than 2 weeks
• Increased risk of fractures, low magnesium and infections
• Only prevent symptoms
• May cause confusion
Diarrhea and Constipation Medications
The Do’s The Don’ts Possible Side Effects
• Drink plenty of fluids• Talk to a doctor
about all constipation
• See a doctor for diarrhea lasting more than 2 days
• Eat adequate amounts of fiber in the diet or supplement fiber or psyllium
• Take antidiarrheal if you experienceblood in the stool or fever
• Take laxatives without a doctor’s approval
• Fluid loss and dehydration
• Electrolyte imbalance
• Constipation• Aspiration with
mineral oil• Diarrhea• Mask the symptoms
of internal bleeding
Over-the-Counter Medications
• 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 Storage
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
• 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
Disease Drug Advice Reasoning
Heart Failure NSAIDs, Actos, Avandia
Avoid Increases fluid retention
History of Falls Lunesta, Ambien, Xanax, SSRIs
Avoid unless safer alternativenot available
Increased risk of dizziness, fainting and additional falls
ChronicConstipation
Detrol, oxybutynin, Verapamil, amitriptyline
Avoid unless no other alternatives
Worsen constipation
Insomnia Sudafed, Adderall, Ritalin
Avoid Act as astimulant
Beers List Examples
Drug Advice Reasoning
Doxazosin, Prazosin, Terazosin
Avoid using for blood pressure control
Risk of dizziness uponstanding and fainting
Nitrofurantoin Avoid for reduced kidney function
Does not get into the urine and will not fight infection
Amitriptyline, Imipramine, Clomipramine
Avoid Many side effects, risk of dizziness, drowsiness
Lunesta, Ambien Avoid use longer than 90days
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
Beers List Examples
• 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
Conclusion
Disclaimer: Always talk to your doctor before starting or stopping any medication, vitamins or supplements.
Contact information:
Cassie Spray, PharmD
County Line Medical Pavilion
317-497-6330