1. Healthy Transitions COMMON SIDE EFFECTS AND DRUG INTERACTIONS Gabriela Dimitrievski, PharmD Brian Hoff, PharmD Katie Sandison, PharmD

2. 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 medications Talk to your healthcare providers  Ask questions!

3. Over-the-Counter (OTC) Medications TYLENOL NSAIDS (MOTRIN/ADVIL/ALEVE/ASPIRIN) COUGH AND COLD ANTI-DIARRHEALS AND LAXATIVES HERBAL REMEDIES

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Herbal Remedies Herbal Supplement ClassMedical Use Comments MelatoninAJet LagDo not mix with prescription sleep aids Do not use if pregnant or breastfeeding CranberryBUrinary Tract Infection Can interact with blood thinners and increase risk of bleeding Caution use of juices for diabetics Aloe VeraCSkin burnsGenerally safe when used topically Glucosamine and Chondroitan AKnee osteoarthritis Do not use if pregnant or breastfeeding Do not use with shellfish allergies Fish OilACholesterol High blood pressure Do not use if pregnant or breastfeeding Do not use in children < 18 years old Do not take more than 3 grams per day Tea Tree OilCAcne Dandruff Do not use on open burns or wounds Do not use on dry skin Topical oil – not for oral ingestion Coenzyme Q 10ACoenzyme Q 10 deficiency May lower blood sugar – caution in diabetics Many drug interactions exists

11. 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

12. Gastroesophageal Reflux Disease (GERD) Many treatment options available both over-the- counter and by prescription Most common prescription agents:  Histamine 2 -receptor antagonists (H 2 RAs)  Proton pump inhibitors (PPIs) Agent usually chosen based on degree of symptoms

13. Gastroesophageal Reflux Disease (GERD) Histamine 2 - receptor antagonists DrugHow available Famotidine (PEPCID)OTC: 10, 20mg Rx: 20, 40mg Ranitidine (ZANTAC)OTC: 75, 100mg Rx: 300mg Nizatidine (AXID)OTC: 75mg Rx: 150, 300mg Cimetidine (TAGAMET)OTC: 200mg Rx: 300, 400, 800mg

14. 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

15. 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 AmiodaronePhenytoinCarbamazepine QuinidineTheophyllineCitalopram

16. Gastroesophageal Reflux Disease (GERD) Proton Pump Inhibitors Medication Omeprazole (Prilosec)Available OTC Omeprazole- Sodium Bicarbonate (Zegerid) Available OTC Pantoprazole (Protonix) Lansoprazole (Prevacid)Available OTC Dexlansoprazole (Dexilant) Esomeprazole (Nexium) Rabeprazole (Achiphex)

17. Gastroesophageal Reflux Disease (GERD) Common side effects:  Headache  Dizziness  Diarrhea  Constipation  “Acid rebound” Increased risk of osteoporosis/fractures with long- term use  Limit use!

18. 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)

19. High Cholesterol “Statin” medications  Atorvastatin (LIPITOR)  Simvastatin (ZOCOR)  Rosuvastatin (CRESTOR)  Pravastatin (PRAVACHOL)  Lovastatin (MEVACOR, ALTOPREV)  Fluvastatin (LESCOL)  Pitavastatin (LIVALO)

20. 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

21. 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

22. High Cholesterol Statin drug interactions Shapiro and Brown, RxPrep CourseBook 2013 ed.

23. 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

24. 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

25. 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

26. 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

27. Warfarin (COUMADIN) Other important side effects:  Hives, rash, itching  Chest pain, pressure  Nausea, vomiting  Fever or flu-like symptoms  Joint or muscle aches  Diarrhea  Tingling or numbness in any part of the body

28. Warfarin (COUMADIN) Less serious side effects:  Gas  Feeling cold  Fatigue  Pale skin  Changes in the way food tastes  Hair loss

29. Warfarin (COUMADIN) Drug interactions  Warfarin interacts with MANY medications CarbamazepinePhenobarbitalPhenytoinRifampinSt. John’s Wort AmoxicillinCephalosporinsFluoroquinolonesTetracyclinesAmiodarone BactrimAntifungal medications FluvastatinFluvoxamineMacrolide antibiotics FlagylTigecyclineNSAIDsSSRIsSNRIs

30. 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

31. High Blood Pressure – Beta Blockers Common BrandsGeneric Toprol-XL, Lopressor Metoprolol TenorminAtenolol CoregCarvedilol ZebetaBisoprolol Normodyne, Trandate Labetalol InderalPropranolol Common Side Effects  Fatigue, depression: usually worse within the first few weeks of taking  Dizziness  Cold hands Can 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

32. High Blood Pressure– ACE Inhibitors Common BrandsGeneric Zestril, PrinivilLisinopril AltaceRamipril VasotecEnalapril CapotenCaptopril AccuprilQuinapril LotensinBenazepril 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  Dizziness Avoid Excess Over the Counter NSAIDs- Motrin, Aleve, Advil, etc.

33. High Blood Pressure– Diuretics (Water Pills) Common Brands Generic Maxzide Hydrochlorothiazide (HCTZ) ThalitoneChlorthalidone DyreniumTriamterene AldactoneSpironolactone LasixFurosemide BumexBumetanide 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  Dizziness NSAIDS may decrease their effectiveness through their actions on the kidney

34. 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!

35. Diabetes - Insulin Type/NamesTips Short-acting Aspart (Novolog) Lispro (Humalog) Regular (Humulin R, Novolin R) Take 15-30 minutes before you eat a meal to avoid low blood sugar Longer-acting Glargine (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

36. Diabetes- Other Drugs DrugCommon Interactions and Side Effects Sulfonylureas Glipizide Glimepiride Glyburide 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)

37. 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

38. 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!

39. Questions