Medications in the Elderly Rolly Kali-Rai

Transcription

1 Medications in the Elderly Rolly Kali-Rai Dr. Hendler: Hello and welcome to KP Healthcast. Today our guest is Rolly Kali-Rai, pharmacist, who has been with KP for 15 years. Rolly has held the position of Drug Education Coordinator and now holds the position of the Inpatient Clinical Supervisor for the Kaiser Permanente Hospital in Fremont, California. Welcome Rolly. Rolly Kali-Rai: Why thanks for having me here. What we re going to be speaking about today is common questions that people have regarding medications, specifically seniors and medication use. Dr. Hendler: Seniors and medication use. What s the difference between prescription drugs and over-the-counter drugs? Rolly Kali-Rai: That s a good question to start out with. There are two types of medications drugs your doctor prescribes for you, called prescription drugs, and those you can get without a doctor s prescription, called over-the-counter drugs. They are often also referred to as OTC drugs. It is important to realize that over-the-counter products, or OTC drugs, include many different substances such as vitamins and minerals, herbal and dietary supplements, laxatives, cold medicines, and antacids. Dr. Hendler: That brings up a question, is the regulation of OTC actual drugs such as laxatives, etcetera, different than it is for herbal medications or the alternative medications? Rolly Kali-Rai: There are actually. The Food and Drug Administration, the FDA, is the governmental body that controls the use of medications and regulates these medications and the sale of such. There are different rules that account for herbal products, or natural products, naturopathic products as they are sometimes referred to, and also vitamin products. They are not held to the same standards of production, use, or actual effectiveness as normal prescription medications, those that you would get from your physician. Dr. Hendler: And the OTC drugs, are they under stricter supervision than the herbal drugs? Rolly Kali-Rai: They are, that s very true. Over-the-counter drugs, it may seem counter-intuitive, but things like cold medicines are actually under higher regulations regarding their purity, their manufacturing, and their actual efficacy or how they work, compared to herbal products or even vitamins and minerals. Page 1

2 Dr. Hendler: So it might be important if you re buying something for your cold to know whether it s an actual OTC medication or an OTC herb because one is held to a much higher standard. Rolly Kali-Rai: Absolutely. What you can do is if you re looking for items that are over-the-counter drugs, other than herbal products or vitamin products, or even vitamin products at some times, look for a symbol that s actually on the bottle label, it s a USP label, it s called United States Pharmacopoeia, and they have some standards as far as the production of the product. Look for that symbol on it as a minimal standard but by all means, check with either your doctor or your pharmacist whenever you purchase anything, whether it be an over-the-counter product or a prescription product. Dr. Hendler: Now after you swallow a pill or a capsule, what happens to the drug inside your body? Rolly Kali-Rai: This is a question I often get asked. Oftentimes I get asked this whenever I go to do any kind of talks, especially with the youngsters. When you swallow a pill or capsule, it moves through the digestive tract to the liver, the place where the body actually processes chemicals. The drug then enters the bloodstream, where it can interact with many body organs. Dr. Hendler: How does the body get rid of these medications? Rolly Kali-Rai: After a medicine has done its job in the body, the drug is broken down through a process called metabolism and this occurs mostly in the liver. Once inactive, a drug enters excretion stage and exits the body in the urine or feces. Dr. Hendler: What do they mean on the label when they talk about the active ingredient? Rolly Kali-Rai: Many medications have many ingredients in them, more than one. An active ingredient is a chemical substance in a medicine that actually works with your body to bring about a relief of your symptom or the condition. Many drugs, such as overthe-counter pain relievers, contain one or more different active relief ingredients. Dr. Hendler: Why would you have anything that was not an active ingredient in a medication? Rolly Kali-Rai: Good question. Well we oftentimes have things that actually hold a medication together or give it taste or consistency. For example, a cough syrup to make it taste better or feel more slippery might have a certain ingredient in it to help with taste or the texture of the product. The same goes with tablets or capsules, oftentimes you have colors or binders added to that specific medication. Dr. Hendler: Does aging affect how a body processes medicines? And I guess this means aging of the body, not aging of the medicine. Page 2

3 Rolly Kali-Rai: Absolutely, actually both things do. Older medications don t tend to work as well as some do but actually as the body ages its ability to absorb and process foods and drugs does change. As people age, metabolism changes so that older people often process drugs less extensively than they once did. Older people often need smaller doses of medicine per pound of body weight than they once did when they were younger. Dr. Hendler: Do all medicines work the same in all people? Rolly Kali-Rai: Actually, no they do not. Many factors including how people exercise, their habits, diet, and general state of health can influence a person s response to medications. Another key factor is hereditary. Genes can influence the way people respond to many types of medications. Dr. Hendler: How can I remember all the details about a new medicine that a doctor would prescribe for me? Rolly Kali-Rai: Actually, it s very important that whenever you discuss medications with your doctor, or anyone for that matter, it s a good idea to write down your questions ahead of time and to jot down the doctor s answers to those questions. Taking a friend or relative with you to the doctor s appointment also may help you understand what the doctor said and remember what points, when you get home, when oftentimes some other questions do come up. Another thing that s nice to do, if you have a small pocket card that lists all your medications on that. I encourage people to list not only their medications but also what they look like, a general description, if there s a colored tablet, or the size of it, as well as the specific directions for their use and what they re actually taking it for. For example, someone could write down they re taking a medication, say acetaminophen, or Tylenol, for fever as needed. It s a white tablet and they take 500 mg and that would provide the information you would need if somebody would be in need of medical care. Dr. Hendler: How do people who have many different medications remember when to take all those different medications that are prescribed for them? Rolly Kali-Rai: An important thing is to have a list. Keep a checklist of all the prescription and the over-the-counter medications we spoke of earlier. For each medication mark down the amount you take, the time of day you take it, and whether it should be taken with or without food, or any other special instructions, and then store two copies of the list, one on your refrigerator door, or where your medications are stored, and then one in your wallet or purse. And I encourage that you to bring those to your appointments whenever you can. Dr. Hendler: What do you think about those little boxes that have Monday, Tuesday, Wednesday, Thursday, Friday on them and some of them even have Morning and Afternoon? Page 3

4 Rolly Kali-Rai: It think those are great to use. It s very important that you use those appropriately though. Make sure that you can store medications in those pill boxes or reminder boxes. Ask your pharmacist if a medication cannot be stored in that box. And the other thing is when you put those medications in those boxes, make sure you can identify which pill is for what condition so you don t get confused on that. There are many different ways to remember which medications to use and there s special boxes. There are boxes that will actually beep or remind you what time of day to take them, and there s also less techy ways to take your medications with a simple pill box. Whatever way works for you, continue to use that way. Dr. Hendler: When your doctor or your pharmacist is telling you about a new medication, how important is it that they know what other medications you re taking? Rolly Kali-Rai: Actually, it s very important that you let the person who s taking care of you, your doctor or your pharmacist or your nurse, know exactly what medications you re taking. You should always be sure to tell your doctor or pharmacist about any and all medications that you take every day, or even once in a while. That includes over-thecounter products. Untoward effects can occur when a drug interacts or interferes with another or with certain foods. These chemical interactions change the way your body handles one or more of these mediations. Dr. Hendler: Can you actually give us an example of, like maybe two common drugs that somebody would take that would respond badly with each other, or at least make each other behave differently? Rolly Kali-Rai: Yeah, a common example is around this time of year, actually any time of year, in this part of the state, people suffer from allergies and oftentimes people will take a nasal decongestant, they will take an oral decongestant, something like Sudafed, and they ll take pseudoephedrine and they ll notice that their heart s racing or their blood pressure kind of jumps up. That particular medication may not be warranted or may actually be contraindicated if they re taking medication to control their blood pressure or have other conditions, such as urinary retention for a man who has prostate trouble, or a person who is suffering from glaucoma, where you would actually not want to use specific decongestants. That would be a case when it would be absolutely vital that you talk to your doctor before you use it or at least check with the pharmacist at the drug store. Dr. Hendler: Now, let s say that I think I understand my medication but then I leave the doctor s office and realize I either forgot what he said or I forgot to ask something that I just thought of. What can I do at that point? Rolly Kali-Rai: In general what we suggest is if you have any questions regarding your medications, contact your pharmacist. If you have difficulty contacting your pharmacist, your local area pharmacy should be able to help you out. If all else fails, please call your doctor if you have any questions regarding your medications. It s vital that you take your medications correctly and have your questions answered regarding them. Page 4

5 Dr. Hendler: Now some medications are to be taken on an empty stomach and some are to be taken with meals. What s that all about? Rolly Kali-Rai: Well, taking some medications with food can actually help the drug to be absorbed by the body, although certain foods actually slow down absorption. Foods can also sometimes prevent stomach upset, a common side effect that occurs when a drug irritates the stomach s lining. Taking medicine with a full glass of water can also reduce the chance of getting an upset stomach because the water helps the medicine dissolve faster. Dr. Hendler: So then should all medicines be taken with food? Rolly Kali-Rai: Um, no. It s very important to read the labels on all medications. When you receive your prescription bottle there will be numerous labels on the bottle that will tell you exactly how to take your medication. Both prescription and over-the-counter drugs will have those labels or markings on them. Food can interact with some medicines, affecting the way they act in the body. These types of medications should be taken with a full glass of water, not milk or juice, to prevent them from being lodged in your throat or esophagus. Other medications will actually interact with certain types of food. For example, there may be antibiotics, a common antibiotic, tetracycline, you wouldn t want to take with any kind of dairy product or vitamin or mineral supplement at the same time because, chemically, the two entities, the calcium or the iron, will actually bind to the antibiotic and render it ineffective. The best thing is when in doubt, please check with your pharmacist or your doctor regarding your medications, whether to take them with our without food. Dr. Hendler: That reminds me of a patient I once had who was on Coumadin and her PT levels were basically stable and normal but every once in a while would go way below threshold, and it was finally figured out that when kale was on sale she would buy a lot of it and eat it with the vitamin K. Rolly Kali-Rai: That s a wonderful example. Warfarin, or Coumadin, is an anticoagulant that interacts, actually the way it works, its beneficial effects, is only interacting with a certain part of the body, a chemical reaction that has to do with blood clotting. And that particular thing it affects is vitamin K. Kale is very rich. It s a green leafy vegetable that s very rich in vitamin K and taking extra amounts of kale or vitamin K actually affects how well the Coumadin or the warfarin would work. So that s a classic example of what can happen, a significant interaction between a drug and food. Dr. Hendler: It was good that somebody thought to take the history. Now what are drug interactions? Rolly Kali-Rai: Drug interactions occur when a medicine interacts chemically with another drug or with certain foods. These interactions change the way your body handles Page 5

6 one or both medicines and this can change the effectiveness of either that or the other drug. Dr. Hendler: Now let s talk about side effects. What are side effects? Rolly Kali-Rai: Side effects, there s actually two things, side effects are unwanted or unexpected symptoms or feelings that occur when you take medicines. Sometimes, however, we do use medications for side effects. Side effects can be relatively minor, such as a headache or dry mouth or drowsiness and they also can be life threatening, such as severe bleeding or irreversible damage to the liver or kidneys. Stomach upset, including diarrhea or constipation, is a common side effect to many, many medications. Often this side effect can be lessened by taking certain drugs with meals. However, again, check with your doctor, nurse, or pharmacist concerning taking your medications with food or not. A common medication we actually use for its side effect is Benadryl, or the antihistamine diphenhydramine. Many times in the hospital we will use diphenhydramine as something to help people sleep, and there we are specifically using a medication traditionally used for allergies to help people sleep. We re using it for its side effect. Dr. Hendler: That makes sense. Now. I often have to make the difference, the point, the difference between what side effects are and what risks are. And this for example, when I start people on methotrexate, there are some very rare but serious complications and people, often thinking in terms of side effects, believe that if they take the drug, then these bad things will happen to them. But I like to explain to them that s it s more like, if you cross the street you won t necessarily get hit by a car, you probably won t get hit by a car at all, but every once in a while somebody who crosses the street gets hit by a car and not side effects but risks are of that nature where a side effect I believe means that it happens almost all the time and it s a minor thing, whereas a risk would be a more serious thing that doesn t happen at all, except when it does. Rolly Kali-Rai: That s common. Oftentimes if you actually ask for the package insert of the drug, which you should feel free to ask for if you visit your pharmacy, it gives you specific details regarding side effects and will actually categorize them by risk, or the likelihood that they will happen. Some side effects are very common, side effects such as dizziness, drowsiness, or headache, nausea, or vomiting are common in almost every single medication we know of. And then there s more specific side effects that are relatively rare. Oftentimes rare side effects also tend to be more severe. Any questions that you have regarding the side effects at all, whether how severe they are or their rarity or frequency of occurrence, please check with your doctor and pharmacist. Dr. Hendler: Well, at least it s nice that the more serious ones are the more rare ones. Rolly Kali-Rai: That is nice. Dr. Hendler: What are some of the ways to avoid side effects? Page 6

7 Rolly Kali-Rai: Well, always inform your doctor or pharmacist about the medications you are already taking, again including herbal products and over-the-counter products. Tell your doctor, nurse, or pharmacist about past problems you have had with medications, such as rashes, indigestion, dizziness, or not feeling hungry. Some other tips are, ask whether the drug may interact with other foods or over-the-counter drugs or supplements that you are taking; read the prescription label on the container carefully and follow directions; and make sure you understand when to take the medication, how to take it each time. Other tips to avoid side effects include, if you experience side effects, write them down so you can report them to your doctor accurately, so you keep note of them. Call your doctor right away if you have any problems with your medicines or if you re worried that the medicine might be doing more harm than good. He or she may be able to change your medicine to another one that will work just as well. And also, don t mix alcohol and medicines unless your doctor or pharmacist says that it s okay to do so. Some medicines may not work as well or may make you quite ill if taken with alcohol. Dr. Hendler: Thanks. What s the grapefruit juice effect that I ve heard people talk about? Rolly Kali-Rai: Actually, this was very, very interesting. It came about, about five or six years ago that it became known that taking certain medications with a glass of grapefruit juice can lead to higher levels of medicine in the blood and that can cause significant health problems. Scientists originally discovered that grapefruit juice effect by luck, after giving volunteers grapefruit juice to mask the taste of a certain medication. Researchers now know that grapefruit juice blunts the effects of an enzyme that has to do with the metabolism of drugs in the liver and that oftentimes occurs with medications that are commonly used to treat heart conditions. My standard recommendation is not to take a medication with grapefruit juice or to drink grapefruit juice at all, if you take medications at all, unless you check with your physician or your pharmacist first. Dr. Hendler: That s very interesting. So you re saying that this enzyme is in grapefruit but it s not in orange juice or lemonade, or any of those other similar ones? Rolly Kali-Rai: What actually happens is the grapefruit juice interacts with a certain enzyme in the liver that causes it not to metabolize the drugs as well as it would if you did not drink the grapefruit juice, and it is specific to grapefruit juice. Dr. Hendler: Okay, if I feel better, then can I stop taking the medicine that my doctor prescribed for me? Rolly Kali-Rai: Unfortunately, no. Don t stop taking a prescription drug unless your doctor says it is okay for you to do so, even if you are feeling better. Also, never share your prescription drugs with another person. Many times individuals, specifically with antibiotics, will stop taking their course of antibiotics the minute they start feeling better. However, what happens is you develop what we call a subclinical infection where the bacteria kind of hides out for a few days and then can come back even worse or develop drug resistance. Page 7

8 Dr. Hendler: And I believe that with blood pressure medicine, very often, you not only don t feel better but sometimes you may even feel slightly worse. Rolly Kali-Rai: Absolutely. That s the case until your body becomes accustomed to you now having a normal, or lower blood pressure. So do continue taking your medication until your physician tells you not to. Dr. Hendler: What is the best place to store medications? Rolly Kali-Rai: Great question. Contrary to belief, it s not the medicine cabinet. Be sure to ask your doctor or pharmacist and read the medications label to determine exactly how it s to be stored. For example, some medicines must be stored in the refrigerator and they will be marked as such. Again, contrary to what many people think, your bathroom medicine cabinet is not a good place to store medications, due to the moist, warm conditions that can cause drugs to break down more quickly and the medication cabinet often being in the restroom or the bathroom. Keep medicines in their original containers. Never put more than one kind of medicine in the same container, and make sure it s the most recent container. That will help you when you go in for a refill. Dr. Hendler: Oh, I have a lot of cleaning up to do then. Rolly Kali-Rai: We all do. Dr. Hendler: Where do scientists get ideas for new drugs? Rolly Kali-Rai: Well, it s actually a tedious process. Researchers usually do years of experiments in the laboratory on animals before they can even consider an experimental medication on people. Much of this basic research occurs at universities and medical centers across the country and is often funded by the National Institute of Health. The NIH actually, for short, is also a wonderful place to get more information regarding medication use, whether you re a senior listening to this program, a young woman with children, a young man or elderly man, a wonderful place to go is the NIH. Dr. Hendler: And that would be just NIH.gov, I believe. Rolly Kali-Rai: That s correct. Dr. Hendler: Where do drugs come from? I think they come from the jungle mostly, don t they? Rolly Kali-Rai: Actually, it s true. Many of the medications that come out, it s kind of funny, many times people ask me or tell me that they prefer holistic medications or natural medications. When you look at the basic chemical research on where medications actually do come from, the vast majority of them actually do come out of the jungle or Page 8

9 actually our vastly depleted rain forests. Many, many medications are rooted from plants and herbal products. Dr. Hendler: Um, something that s very recent in my field, well very recent meaning like five years, not very recent, but rather than having drugs which were based on ancient chemicals found in plants, they re now having companies like Genentech make bioengineered drugs, which are extremely effective, although I can t say that any of those are pills. Those seem to me that they re always injected. Rolly Kali-Rai: Most medications you re talking about are injectables and it is definitely a new area. Biotechnology is definitely the new area for medication research as well as medication development and we re looking to see some very exciting new breakthroughs for treatment and medications and they do tend to be injections. Dr. Hendler: Quite expensive too. Rolly Kali-Rai: They do. Dr. Hendler: How can doctors be sure that new drugs work as they should? Rolly Kali-Rai: We touched on that a little bit before. The FDA, or the Food and Drug Administration, is the federal agency responsible for making sure that foods, cosmetics, and drugs are safe and that also medicine devices are safe and effective. The FDA requires that new drugs be tested in clinical trials before they are actually put on the market. And also continual surveillance is done. Sometimes medications are put on the market, we feel that they re safe, the FDA gives them their blessing. They re on the market for three to four years, and then they get to be used in more people than they were in the original studies and then information comes to light regarding their true safety and that s when the FDA can step in and actually recall medications, or pull them off the market. Dr. Hendler: Right, what was that one very recently that was the selective non-steroidal anti-inflammatory, was it Vioxx? Rolly Kali-Rai: It was Vioxx. Dr. Hendler: Yeah. And it was leading to a little increase in heart disease, I believe. Rolly Kali-Rai: We actually were seeing increases in heart disease and it was interesting, Kaiser Permanente had a role in that. We were able to share with the FDA and other governmental agencies our own internal data regarding the risk of heart attack and cardiovascular incidents in patients that were also on Vioxx. Dr. Hendler: Are researchers working on developing new medicines for diseases of aging? Page 9

10 Rolly Kali-Rai: Yes they are. With the advent of biotechnology now, the conditions have been taking off. Hundreds of new medications are in development for diseases of aging, specifically new drugs for heart disease, stroke, cancer, Alzheimer s disease, diabetes, and osteoporosis. Dr. Hendler: Have scientists come up with, I m sure they haven t come up with a cure for Alzheimer s disease, but have they come up with any treatments that are more effective than placebo for Alzheimer s? Rolly Kali-Rai: They have some medications out now for Alzheimer s disease, which is a dreadful disease that is quite rampant at this point. As scientists learn more about human biology, they discover how to identify and attack the root causes of many more health problems, including Alzheimer s disease. A few medications are on the market now that actually help reduce the progression or the deterioration of people that s associated with Alzheimer s disease. Dr. Hendler: What is pharmacogenetics research? Rolly Kali-Rai: It is a big word, that s for sure. Pharmacogenetics research is something we eluded to earlier in the program and what that is, is looking specifically at one s genes, hereditary, and how they affect the use of medications in different individuals. As we know, as individuals, the metabolism specifically in each individual is different. So many different medications, although it is the same medicine, work differently in different individuals. And there is specific research into that area right now, to kind of custom-make medications for different types of people or classes of people based on their genetic background. Dr. Hendler: Are there any drugs that are actually like that now? Rolly Kali-Rai: We don t have anything specific to that. Just a few days ago though, there was a specific test that was marketed. We mentioned a drug called warfarin, or Coumadin, earlier in the program and less than a week ago there was actually a lab that received approval by the FDA to look at a specific genetic marker in the metabolism or breakdown of warfarin to see if patients would be at higher risk for deleterious effects related to that, if they were more likely to bleed if they were given this drug. Hopefully having that test available, along with having warfarin around, you would be able to adjust the dose more appropriately tailor it or custom it to individuals. I think that s really where most research is going right now. So the key word of the day is pharmacogenetics research. Dr. Hendler: Do you have any last thoughts that you d like to tell our audience? Rolly Kali-Rai: I do have a few. I think the main thing to do is to develop a healthy relationship with your pharmacist, as well as your physician. Please make sure to keep a list of your medications and on that list of your medications have the name of your medication, the dose, the amount of tablets you take, any kind of visual que regarding Page 10

11 how that medication looks, and why you re taking that medication listed. Have two copies of that piece of paper, bring one with you in your wallet or purse each time you visit your physician and have the other copy somewhere at home; the refrigerator is a good place to keep it. Heaven forbid that something deleterious happen and you need emergency help, oftentimes paramedics will look a piece of paper that has that information. Having it on your refrigerator, if there s loved ones at home, to be able to hand that to them, so if you would come into one of our hospitals or wherever you go to receive care, someone will have at least a good medical history regarding the medications you re taking. Another point to remember is that over-the-counter products that includes herbal products, things that do not require a prescription from your doctor, vitamins, cough and cold supplements, are also medications and no medications are truly safe. All medications have side effects and do interact with other medications. It is important that whenever you take an herbal product, an over-the-counter product, or even a prescription product, you let your physician or pharmacist know so they can check for drug interactions and monitor you. And the last thing is be your own health steward. Write down what effects you have from medications. If you develop a rash when taking amoxicillin, please write that down. Let your provider and pharmacist know and be aware of that and put that information down on your card. After all, nobody knows us more than ourselves. Dr. Hendler: I think that our members here at Kaiser are lucky because our pharmacy keeps records of the medications, which link right into the medical record, along with the allergies, so for many of them, although it s very good if they also take responsibility themselves, for many of our patients, we are able to know when they come in what medications they re taking and their allergies. Rolly Kali-Rai: Absolutely. If you are fortunate enough to be one of our members and if you do fall ill and you visit one of our facilities, we have that information for you. We have it actually linked all the way from Fresno through our Sacramento/Roseville area if you re in Northern California, and for Southern California also in the Southern California region, so that information is available for your physician or your care provider, basically at the tip of their fingers. They need to log on and the information is right there for them, including your allergies and pretty soon all the electronic medical chart will be on the record also. Dr. Hendler: And I see on your notes here that you have the two good references, the and the and then if you re a Kaiser member you can go to kp.org, where we also have drug information on line. Rolly Kali-Rai: I think those are the three wonderful sites that, oftentimes, I direct people to. The FDA.gov website is also a wonderful site. It has specific sections just for children and for consumers and it also gives you frequent updates, daily updates regarding medication safety. Dr. Hendler: Well Rolly, I d like to thank you for coming out here and giving us this interview. Page 11

12 Rolly Kali-Rai: Well thank you. Thank you for the opportunity. Dr. Hendler: KP Healthcast is created by the people at Kaiser Permanent in Fremont, Hayward, and Union City California. These podcasts are for general information only. They are not intended to be used as a substitute for medical advice given to you by your personal physician. If you or your family member have any of the conditions that we discuss in our podcasts, we encourage you to discuss your individual case with your personal physician. Every case is different and your physician is in the best position to know what s best for you. You can find this and all of our other podcasts on our home page at You can us at [email protected]. We d love to hear from you. Check our home page regularly for new topics and, as usual, be on the lookout for new ways to THRIVE. Page 12