Community TouchPoint · Apple Cider Vinegar Uses Cholesterol^ Diabetes^ Digestion^ Urinary Tract Infections^ Dosage Diabetes: 30 grams daily Other dosages unknown Side Effects Low

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^DigestionÛrinary 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 Însufficient 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


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


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)


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


Increased concentrations of vitamin A, C, K, and E; blood pressure medications; chemotherapy medications; warfarin


Fish Oil

Fish Oil Krill Oil

Uses CholesterolHeart Disease*

CholesterolÔsteoarthritis^

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)


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


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


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


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)


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


Vitamin B Complex


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


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)


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


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


Cough and Cold Medication Examples


Allergy Medications


• 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


Allergy Medication Examples


Pain Medications


• 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


Pain Medication Examples



Heartburn and Sour Stomach Medications


• 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

Heartburn and Sour Stomach Medication Examples


Diarrhea and Constipation Medications


• 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


Diarrhea and Constipation Medication Examples


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

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

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

Medication Disposal

• Needles and other sharps:

Medication Safety

• 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

[email protected]

317-497-6330

Documents

Community TouchPoint · Apple Cider Vinegar Uses Cholesterol^ Diabetes^ Digestion^ Urinary Tract Infections^ Dosage Diabetes: 30 grams daily Other dosages unknown Side Effects Low