Community TouchPoint

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1 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

2 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

3 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

4 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

5 Apple Cider Vinegar Uses Dosage Side Effects Drug Interactions (Moderate) Apple Cider Vinegar Cholesterol^ Diabetes^ Digestion^ Urinary Tract Infections^ Diabetes: 30 grams daily Other dosages unknown Low potassium, weaken bones, throat irritation Amaryl (glimepiride), Micronase (glyburide), insulin, Glucophage (metformin), Actos (pioglitazome), Lanoxin (digoxin), Hydrodiuril (hydrochlorothiazide), Thalitone (chlorthalidone), Lasix (furosemide) *Likely Effective **Possibly Effective ^Insufficient Evidence

6 Baby Aspirin Uses Dosage Baby Aspirin Heart protection Pain Fever reducer Heart protection: typically 81 mg daily Pain/Fever reducer: 325 to 650 mg every 4 hours, max 3.9 g per day Side Effects Drug Interactions Clinical Pearls *Likely Effective Bleeding, ringing in the ears, stomach ulcer NSAIDs (ibuprofen/naproxen), Coumadin (warfarin), heparin, Lovenox (enoxaparin), Plavix (clopidogrel), Brilinta (ticagrelor), Ticlid (ticlopidine), Xarelto (rivaroxaban), Pradaxa (dabigatran), Eliquis (apixaban), depression medications, methotrexate Recommend talking to your doctor before starting to take aspirin every day **Possibly Effective ^Insufficient Evidence

7 Biotin Uses Biotin 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 *Likely Effective Antibiotics, Accutane (isotrentinoin), Carbatrol (carbamazepine), phenobarbital, Dilantin (phenytoin), Mysoline (primidone) may all decrease the amount of biotin in the body **Possibly Effective ^Insufficient Evidence

8 Calcium Uses Dosage Side Effects Drug Interactions *Likely Effective Calcium Calcium deficiency Osteoporosis prevention* Cancer prevention^ Dietary Reference Intake: Females years: 1000 mg elemental calcium >51 years: 1200 mg elemental calcium Males years: 1000 mg elemental calcium >70 years: 1200 mg elemental calcium Constipation, gas Vibramycin (doxycycline), Minocin (minocycline), Achromycin (tetracycline), Cipro (ciprofloxacin), Levaquin (levofloxacin), Avelox (moxifloxacin), levothyroxine, Fosamax (alendronate) Actonel (risedronate), Boniva (ibandronate) **Possibly Effective ^Insufficient Evidence

9 Coenzyme Q10 Uses Dosage Side Effects Drug Interactions (Moderate) *Likely Effective Coenzyme Q10 Blood Pressure** Coenzyme Q10 deficiency* Congestive Heart Failure** Muscle soreness as a result of Cholesterol-Lowering Therapy^ Migraines** Nerve Damage related to Diabetes** 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 Nausea, vomiting diarrhea, appetite suppression, and heartburn Increased concentrations of vitamin A, C, K, and E; blood pressure medications; chemotherapy medications; warfarin **Possibly Effective ^Insufficient Evidence

10 Fish Oil Uses Fish Oil Cholesterol Heart Disease* Krill Oil Cholesterol^ Osteoarthritis^ Dosage 2 grams twice daily Cholesterol: 1 to 3 grams daily Osteoarthritis: 300 mg daily Side Effects Drug Interactions Clinical Pearl *Likely Effective Fishy burp, bad breath, heartburn, nausea, diarrhea, and rash Moderate: Blood pressure medications, birth control, Alli (orlistat) Minor: Plavix (clopidogrel), Lovenox (enoxaparin), Coumadin (warfarin) Fishy burp, bad breath, heartburn, nausea, and diarrhea Moderate: Plavix (clopidogrel), Lovenox (enoxaparin), Coumadin (warfarin), Amaryl (glimepiride), Micronase (glyburide), insulin, Glucophage (metformin), Actos (pioglitazome) Minor: Alli (orlistat) Can avoid a majority of the side effects by freezing capsules (except Lovaza which should not be frozen) **Possibly Effective ^Insufficient Evidence

11 Flaxseed Flaxseed Uses Cholesterol ** Diabetes** High Blood Pressure^ Dosage Side Effects Drug Interactions (Moderate) Clinical Pearls Cholesterol: 40 to 50 grams per day Diabetes: 600 mg three times daily Bloating, flatulence, abdominal pain, diarrhea, constipation, heartburn, and nausea 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) Do not consume raw or unripe flaxseed that has not been baked *Likely Effective **Possibly Effective ^Insufficient Evidence

12 Glucosamine/Chondroitin Uses Dosage Glucosamine Knee Pain^ Osteoarthritis^ 500 mg three times daily alone or in combination with chondroitin Chondroitin Osteoarthritis** 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 Disease Interactions Warnings/ Precautions Major: Coumadin (warfarin) Moderate: Chemotherapeutic agents Minor: Amaryl (glimepiride), Micronase (glyburide), insulin, Glucophage (metformin), Actos (pioglitazome), Tylenol (acetaminophen) Asthma, diabetes, cholesterol, blood pressure Shellfish allergy Stop use 2 weeks prior to surgery Moderate: Coumadin (warfarin) Asthma, prostate cancer --

13 Iron Uses Dosage Side Effects Drug Interactions Clinical Pearl *Likely Effective Iron Anemia ACE Inhibitor associated cough** Heart Failure** 150 to 200 mg of elemental iron daily in divided doses Upset stomach, constipation, nausea, and vomiting 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) 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 **Possibly Effective ^Insufficient Evidence

14 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 Drug Interactions Drowsiness, headache, dizziness Coumadin (warfarin) *Likely Effective **Possibly Effective ^Insufficient Evidence

15 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 Disease interactions No known drug interactions Vibramycin (doxycycline), Minocin (minocycline), Achromycin (tetracycline) Alcohol, Catapres (clonidine), Questran (cholestyramine), Colestid (colestipol), Zocor (simvastatin), Lipitor (atorvastatin), Crestor (rosuvastatin), Mevacor (lovastatin), Pravachol (pravastatin) Gout, diabetes *Likely Effective **Possibly Effective ^Insufficient Evidence

16 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 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 *Likely Effective **Possibly Effective ^Insufficient Evidence

17 Vitamin C Vitamin C (Ascorbic Acid) Uses Dosage Side Effects Drug Interactions Clinical Pearl Iron Absorption* Common Cold** Common Cold: 600 to 1000 mg daily Nausea, vomiting, heartburn Moderate: chemotherapy medications, estrogens, Zocor (simvastatin), Lipitor (atorvastatin), Crestor (rosuvastatin), Mevacor (lovastatin), Pravachol (pravastatin), niacin, HIV medications, Coumadin (warfarin) Taking more than 2 grams per day can increase your risk of kidney stone formation *Likely Effective **Possibly Effective ^Insufficient Evidence

18 Vitamin D Uses Dosage Side Effects Drug Interactions *Likely Effective Vitamin D Vitamin D deficiency Bone softening Osteoporosis* Fall prevention* Cancer prevention** Cognitive function^ High blood pressure^ High cholesterol^ Diabetes^ Vitamin D deficiency: 800 to 1000 units daily Fall prevention: 400 to 1000 units daily Vitamin D intoxication Antacids containing aluminum, Alli (orlistat) **Possibly Effective ^Insufficient Evidence

19 Vitamin E Uses Dosage Side Effects Drug Interactions Vitamin E Vitamin E Deficiency Cardiovascular Disease (found to be ineffective) Diabetes ^ 22 IU (15 mg) per day Nausea, diarrhea, cramps, fatigue, weakness, and headache 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

20 Over-the-Counter Medications Cough and Cold Allergy Pain Heartburn and sour stomach Diarrhea and Constipation

21 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

22 Over-the-Counter Medications Cough and Cold Medication Examples

23 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

24 Over-the-Counter Medications Allergy Medication Examples

25 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

26 Over-the-Counter Medications Pain Medication Examples

27 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

28 Over-the-Counter Medications Heartburn and Sour Stomach Medication Examples

29 Over-the-Counter Medications 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 experience blood 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

30 Over-the-Counter Medications Diarrhea and Constipation Medication Examples

31 Medication Storage

32 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

33 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

34 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

35 Medication Disposal

36 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

37 Medication Disposal Needles and other sharps:

38 Medication Safety

39 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

40 Beers List Examples Disease Drug Advice Reasoning Heart Failure NSAIDs, Actos, Avandia Avoid Increases fluid retention History of Falls Lunesta, Ambien, Xanax, SSRIs Avoid unless 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

41 Beers List Examples Drug Advice Reasoning Doxazosin, Prazosin, Terazosin Nitrofurantoin Avoid using for blood pressure control Avoid for reduced kidney function Risk of dizziness upon standing and fainting 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 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

42 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

43 Disclaimer: Always talk to your doctor before starting or stopping any medication, vitamins or supplements. Contact information: Cassie Spray, PharmD County Line Medical Pavilion

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