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 Objectives

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 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 Vitamins and Supplements

• Apple Cider Vinegar • Glucosamine/Chondroitin • Baby Aspirin • Iron • Biotin • Melatonin • Calcium • Vitamin B • Coenzyme Q10 • Vitamin C • Fish Oil/Krill Oil • Vitamin D • Flaxseed • Vitamin E Apple Cider Vinegar

Apple Cider Vinegar Uses Cholesterol^ Diabetes^ Digestion^ Urinary Tract Infections^

Dosage Diabetes: 30 grams daily Other dosages unknown

Side Effects Low potassium, weaken bones, throat irritation

Drug Interactions Amaryl (glimepiride), Micronase (glyburide), insulin, Glucophage (Moderate) (metformin), Actos (pioglitazome), Lanoxin (digoxin), Hydrodiuril (hydrochlorothiazide), Thalitone (chlorthalidone), Lasix (furosemide)

*Likely Effective **Possibly Effective ^Insufficient Evidence Baby Aspirin

Baby Aspirin Uses Heart protection Pain Fever reducer Dosage Heart protection: typically 81 mg daily Pain/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

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

Calcium Uses Calcium deficiency Osteoporosis prevention* Cancer prevention^ Dosage Dietary Reference Intake: Females 19-50 years: 1000 mg elemental calcium >51 years: 1200 mg elemental calcium Males 19-70 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) *Likely Effective **Possibly Effective ^Insufficient Evidence 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 daily Blood Pressure: 120 to 200 mg twice daily Migraines: 100 mg three times daily

Side Effects Nausea, vomiting diarrhea, appetite suppression, and heartburn Drug Interactions Increased concentrations of vitamin A, C, K, and E; blood pressure (Moderate) medications; chemotherapy medications; warfarin *Likely Effective **Possibly Effective ^Insufficient Evidence Fish Oil

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

Glucosamine Chondroitin Uses Knee Pain^ Osteoarthritis** Osteoarthritis^ Dosage 500 mg three times daily alone or in 400 mg three times daily alone or combination with chondroitin in combination with glucosamine Side Effects Gas, bloating, and cramps Nausea, diarrhea, constipation, swelling , and hair loss Drug Major: Coumadin (warfarin) Moderate: Coumadin (warfarin) Interactions Moderate: Chemotherapeutic agents Minor: Amaryl (glimepiride), Micronase (glyburide), insulin, Glucophage (metformin), Actos (pioglitazome), Tylenol (acetaminophen) Disease Asthma, diabetes, cholesterol, blood Asthma, prostate cancer Interactions pressure Warnings/ Shellfish allergy -- Precautions Stop use 2 weeks prior to surgery Iron

Iron Uses Anemia ACE 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

*Likely Effective **Possibly Effective ^Insufficient Evidence 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 Drowsiness, headache, dizziness

Drug Interactions Coumadin (warfarin)

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

*Likely Effective **Possibly Effective ^Insufficient Evidence Vitamin B Complex

Vitamin B5 Vitamin B6 Vitamin B12 Uses Vitamin B5 Blood pressure ** Vitamin B12 Deficiency Deficiency Kidney Stones ** 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 Well tolerated appetite, headache, feeling tired

Drug No known drug Cordarone (amiodarone), Vasotec No known drug Interactions interactions (enalapril), Zestril (lisinopril), interactions Diovan (valsartan), Cozaar (losartan), Cardizem (diltiazem), Norvasc (amlodipine), Hydrodiuril (hydrochlorothiazide), phenobarbital, phenytoin

*Likely Effective **Possibly Effective ^Insufficient Evidence 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

*Likely Effective **Possibly Effective ^Insufficient Evidence Vitamin D

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

Vitamin E Uses Vitamin E Deficiency Cardiovascular 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

*Likely Effective **Possibly Effective ^Insufficient Evidence Over-the-Counter Medications

Cough and Allergy Pain Cold

Heartburn and Diarrhea and sour stomach Constipation Over-the-Counter Medications

Cough and Cold Medications The Do’s The Don’ts Possible Side Effects • Drink lots of fluids • Caution with • Increased risk of side • Rest combination products effects • Saline nasal spray • Diphenhydramine • Confusion, blurred • Throat lozenges • Chlorpheniramine vision, constipation, (caution with sugar • Caution with problems urinating, content) dextromethorphan dry mouth and cough syrups • Drowsiness and (sugar and alcohol dizziness content) • Increased blood • Nasal decongestants pressure, headache, and pseudoephedrine trouble sleeping, hallucinations Over-the-Counter Medications

Cough and Cold Medication Examples Over-the-Counter Medications

Allergy Medications The Do’s The Don’ts Possible Side Effects • Loratadine • Diphenhydramine • Confusion • Fexofenadine • Chlorpheniramine • Blurred vision • Cetirizine • Dimenhydrinate • Constipation • Limit exposure to • Clemastine • Problems urinating pollen • Nasal • Dry mouth decongestants and • Light-headedness pseudoephedrine • Increased blood pressure, headache, trouble sleeping, hallucinations Over-the-Counter Medications

Allergy Medication Examples Over-the-Counter Medications

Pain Medications The Do’s The Don’ts Possible Side Effects • See your doctor for • Use high doses • Stomach bleeding severe pain or mild • Long-term use and ulcers with pain lasting more without a doctor’s long-term use than 2 week approval • Internal bleeding if • Only use for short- • Take more than using other blood term 3000 mg per day of thinners • Participate in acetaminophen • Fluid retention regular physical • Take an NSAID on an • Increased blood activity empty stomach pressure • RICE: Rest, ice, • Drink alcohol while • Kidney damage compression, taking these • Liver damage elevation medications Over-the-Counter Medications

Pain Medication Examples Over-the-Counter Medications

Heartburn and Sour Stomach Medications The Do’s The Don’ts Possible Side Effects • Avoid foods that • Take an OTC PPI for • Increased risk of worsen symptoms more than 14 days or fractures, low • Do not eat within 2-3 more than 3 courses in magnesium and hours of bedtime a year without doctor’s infections • Elevate the head of approval your bed • Use a PPI to treat • Only prevent • Take OTC antacids for symptoms symptoms mild symptoms • Take high doses of H2- • May cause confusion • Take OTC H2-blocker blockers for moderate • Take high doses of symptoms antacids for more than • Take OTC PPI for a 2 weeks short, 14-day course to prevent symptoms Over-the-Counter Medications

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

Diarrhea and Constipation Medications The Do’s The Don’ts Possible Side Effects • Drink plenty of fluids • Take antidiarrheal if • Fluid loss and • Talk to a doctor you experience dehydration about all blood in the stool or • Electrolyte constipation fever imbalance • See a doctor for • Take laxatives • Constipation diarrhea lasting without a doctor’s • Aspiration with more than 2 days approval mineral oil • Eat adequate • Diarrhea amounts of fiber in • Mask the symptoms the diet or of internal bleeding supplement fiber or psyllium Over-the-Counter Medications

Diarrhea and Constipation Medication Examples Medication Storage 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 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 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 Beers List Examples

Disease Drug Advice Reasoning

Heart Failure NSAIDs, Actos, Avoid Increases fluid Avandia retention History of Falls Lunesta, Ambien, Avoid unless Increased risk of Xanax, SSRIs safer alternative dizziness, not available fainting and additional falls Chronic Detrol, Avoid unless no Worsen Constipation oxybutynin, other constipation Verapamil, alternatives amitriptyline Insomnia Sudafed, Avoid Act as a Adderall, Ritalin stimulant Beers List Examples

Drug Advice Reasoning

Doxazosin, Prazosin, Avoid using for blood Risk of dizziness upon Terazosin pressure control standing and fainting

Nitrofurantoin Avoid for reduced kidney Does not get into the function urine and will not fight infection

Amitriptyline, Imipramine, Avoid Many side effects, risk of Clomipramine dizziness, drowsiness

Lunesta, Ambien Avoid use longer than 90 Increased risk of falls, days fractures and delirium

Ibuprofen, Meloxicam, Avoid chronic use unless Increase risk of GI bleed Sulindac, etc. no other alternative and ulcers 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 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