Practical Issues for Dietitians

SUPPLEMENTAL SLIDES

Presented by

David B. Goldwater R.PhClinical Consultant Pharmacist

March 31, 2011

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CONTENTS

MEGACE-ES ADVERSE EFFECTS

PROGRAF

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MEGACE & ADRENAL MEGACE & ADRENAL INSUFFICIENCYINSUFFICIENCY

Source: Am J Geriatr Pharmacother 2008; 6:167–172

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MEGACE & ADRENAL MEGACE & ADRENAL INSUFFICIENCYINSUFFICIENCYSource: Am J Geriatr Pharmacother 2008; 6:167–172

FOCUS OF CONCERNFOCUS OF CONCERN Malnourished older patients who are given Megestrol

acetate could be at risk for adrenal insufficiency. It might be difficult to detect because the signs and

symptoms are subtle.

CASE STUDYCASE STUDY In Kansas City, Missouri, an 80-yearold woman with

Dyspnea was being treated for major depression with psychotic features. Her physical functioning had declined.

Because she was losing weight, Megestrol Because she was losing weight, Megestrol acetate was prescribed to stimulate her acetate was prescribed to stimulate her appetiteappetite.

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DURING HOSPITALIZATIONDURING HOSPITALIZATION

Her Dyspnea worsened. She was transferred to the intensive-care unit, where she was intubated. Her blood pressure dropped.

After infectious, cardiac, and neurological causes of hypotension were ruled out, a a cosyntropin stimulation test, was performed to cosyntropin stimulation test, was performed to exclude adrenal insufficiency.exclude adrenal insufficiency.

IT INDICATED A SUBOPTIMAL RESPONSE.IT INDICATED A SUBOPTIMAL RESPONSE.

The medication was discontinued, and steroid replacement was initiated.

Blood pressure returned to normal, and the patient slowly improved.

She was weaned from the ventilator several weeks later.

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OUTCOMEOUTCOME

Two months later, her respiratory function Two months later, her respiratory function improved, and improved, and cosyntropin stimulationcosyntropin stimulation test test findings were findings were normal.normal.

Chronically ill, malnourished Chronically ill, malnourished elderlyelderly patients patients with adrenal insufficiencywith adrenal insufficiency may experience may experience depression and reduced appetite, depression and reduced appetite, making the making the diagnosis difficultdiagnosis difficult..

In this case, adrenal insufficiency was In this case, adrenal insufficiency was not not suspected at firstsuspected at first because the presentation because the presentation was unusual,was unusual,

The patientThe patient’’s clinical history was complicated s clinical history was complicated by other illnesses, and she by other illnesses, and she had NOT been had NOT been using Megestrol for a long timeusing Megestrol for a long time..

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MEGACE-ESMEGACE-ESCONCLUSION/ CONCLUSION/

RECOMMENDATIONRECOMMENDATION

For patients who need more than 12 For patients who need more than 12 weeks of treatment with Megestrolweeks of treatment with Megestrol……... ...

Free cortisol levels should be checked at Free cortisol levels should be checked at 12 weeks and biweekly thereafter.12 weeks and biweekly thereafter.

THE RESEARCHERS RECOMMEND:THE RESEARCHERS RECOMMEND: During periods of illnessDuring periods of illness( in patients receiving ( in patients receiving

Megestrol)Megestrol)………….... Consider Consider EMPIRICAL THERAPYEMPIRICAL THERAPY with stress with stress

doses of corticosteroidsdoses of corticosteroids Do not D/C Megace abruptly. Always taper Do not D/C Megace abruptly. Always taper

gradually gradually GO BACK TO

SLIDE # 66

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Implications for Drug Implications for Drug AbuseAbuse

An Interesting Drug-An Interesting Drug-Alcohol InteractionAlcohol Interaction

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An Interesting Drug-Alcohol An Interesting Drug-Alcohol Interaction **Implications for Drug Interaction **Implications for Drug

Abuse**Abuse**

Published in Journal Watch General Medicine January 31, 1992Published in Journal Watch General Medicine January 31, 1992Citations:Citations: DiPadova C et al. Comparison with other H2-receptor antagonists. JAMA 1992 Jan 1 267 83-86DiPadova C et al. Comparison with other H2-receptor antagonists. JAMA 1992 Jan 1 267 83-86

A study measuring the effects of A study measuring the effects of Ranitidine Ranitidine (Zantac(Zantac®®) and ) and CimetidineCimetidine (Tagamet(Tagamet®®) on the ) on the bioavailability of bioavailability of ethanolethanol suggests that drinking with suggests that drinking with these drugs is NOT a wise choice these drugs is NOT a wise choice becausebecause………………..

RANITIDINE AND CIMETIDINE INCREASE RANITIDINE AND CIMETIDINE INCREASE BLOOD ALCOHOL LEVELS.BLOOD ALCOHOL LEVELS.

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An Interesting Drug-Alcohol An Interesting Drug-Alcohol Interaction **Implications for Drug Interaction **Implications for Drug Abuse**Abuse**

Researchers tested the blood alcohol Researchers tested the blood alcohol levels of 20 healthy male volunteers levels of 20 healthy male volunteers (mean age, 35)(mean age, 35)

During a baseline period and after a During a baseline period and after a one-week course of EITHER one-week course of EITHER RanitidineRanitidine (300 mg/d), (300 mg/d), CimetidineCimetidine (1000 mg/d) or (1000 mg/d) or Famotidine Famotidine (Pepcid)(Pepcid)

Before each test, the subjects received Before each test, the subjects received OralOral or or intravenousintravenous alcohol alcohol equivalent equivalent to:to: 1 beer or 1 glass of wine.

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RESULTSRESULTS

In subjects given alcohol In subjects given alcohol intravenouslyintravenously, none of the three , none of the three drugs significantly increased alcohol drugs significantly increased alcohol bioavailability. bioavailability.

Among subjects taking alcohol Among subjects taking alcohol ORALLYORALLY, , bioavailability increased bioavailability increased significantlysignificantly with with Ranitidine Ranitidine and and Cimetidine Cimetidine

……..but NOTNOT with Famotidine.Famotidine.

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RESULTSRESULTS

The authors speculate that The authors speculate that RanitidineRanitidine and and CimetidineCimetidine affected affected the the absorption of oral doses because absorption of oral doses because they INHIBIT gastric alcohol they INHIBIT gastric alcohol dehydrogenase activitydehydrogenase activity. .

HoweverHowever…………. . FamotidineFamotidine (Pepcid(Pepcid®®)) has NO effect on this enzyme! has NO effect on this enzyme!

DonDon’’t confuse with t confuse with PrilosecPrilosec®® (omeprazole which is a PPI and not (omeprazole which is a PPI and not an H2 Blockeran H2 Blocker))

In patients with regular but moderate In patients with regular but moderate alcohol use, alcohol use, FamotidineFamotidine (Pepcid(Pepcid®®) ) may be a preferable H2- blockermay be a preferable H2- blocker

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ABUSE POTENTIAL FOR THIS ABUSE POTENTIAL FOR THIS INTERACTION:INTERACTION:

This study indicates the need for This study indicates the need for extreme caution when drinking extreme caution when drinking alcohol with alcohol with CimetidineCimetidine or or RanitidineRanitidine, , particularly particularly before before drivingdriving!!

As recreational drinking is an As recreational drinking is an ORAL event ORAL event ………………………………..

This interaction may be This interaction may be intentional in people who want to intentional in people who want to get inebriated on get inebriated on fewerfewer drinks! drinks!

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…….Timing is Everything!.Timing is Everything!

Prograf® (tacrolimus):Prograf® (tacrolimus):

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Prograf® (tacrolimus): Prograf® (tacrolimus): INDICATIONINDICATION

TacrolimusTacrolimus is an is an immunosuppressive immunosuppressive agentagent derived from the fungus derived from the fungus Streptomyces tsukubaensis.Streptomyces tsukubaensis.

Originally found in a soil sample taken Originally found in a soil sample taken from the base of Mt. Tsukuba in Japan.from the base of Mt. Tsukuba in Japan.

Tacrolimus has been studied in patients Tacrolimus has been studied in patients receiving receiving heart, kidney, liver, lung, heart, kidney, liver, lung, pancreas, small bowel, or bone marrow pancreas, small bowel, or bone marrow transplants.

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Prograf® (tacrolimus)Prograf® (tacrolimus)

Effective in Effective in graft rejectiongraft rejection prophylaxisprophylaxis and in the and in the management management of of acute and steroid-acute and steroid- or or cyclosporine-resistantcyclosporine-resistant transplant transplant rejection. rejection.

Tacrolimus is an alternative to Tacrolimus is an alternative to cyclosporine immunosuppression and cyclosporine immunosuppression and is10—100 times more potent than is10—100 times more potent than cyclosporinecyclosporine

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Prograf® (tacrolimus)Prograf® (tacrolimus)

Administer at approximately Administer at approximately the the same time each day.same time each day.

REASONREASON If given WITH FOOD or WITHIN 1 If given WITH FOOD or WITHIN 1

HOUR OF A MEAL, especially high-HOUR OF A MEAL, especially high-fat meals, fat meals, results in results in significantly significantly decreased absorption.decreased absorption.

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Goals for Scheduling this drug Goals for Scheduling this drug in relationship to mealsin relationship to meals

Consistency is important TO MINIMIZE ANY Variations in bioavailability.

Administer consistently with OR without food.

Ask resident what time of day they have been taking this drug at home in relationship to meals times and what type of meal.

If possible attempt to accommodate the same schedule.