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Prescribed Medications and Otcs: Interactions and Timing Issues

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Prescribed Medications and Otcs: Interactions and Timing Issues In Brief This article describes some common drug-drug interactions between prescrip- tion medications and over-the-counter medications that people with diabetes might encounter. With each interaction listed, there is a description of how to appropriately manage it. Also, proper timing of the medications in relation to food intake is described. The data presented are not all-inclusive but do detail the common medications used in people with diabetes. Prescribed Medications and OTCs: Interactions and Timing Issues An estimated 17 million people in the pertensive agents, and antilipemic United States have diabetes. This is agents. Common OTCs include anal- ~6.2% of the population.1 The majori- gesics, cough and cold products, and Kimberly R. Rhoades, RPh, CDE ty of the premature deaths attributed antacids/laxatives. Drug-drug interac- to diabetes are a result of complica- tions among these classes of medica- tions from the disease.2 Approximately tions, as well as the few drug-disease 73% of adults with diabetes have high interactions possible with these blood pressure or use prescription agents, will be reviewed. medications to help control hyperten- Thousands of drug-drug interac- sion. Adults with diabetes are also two tions have been documented. However, to four times more likely to die from only a small percentage of these are heart disease or to have a stroke than clinically important. To help clinicians are those without diabetes.1 The determine the clinical significance of a macrovascular diseases, such as arte- drug interaction, rating systems have riosclerosis, are one of the many rea- been established. Most rating systems sons for the increased incidence of use a numerical scale. heart disease and stroke. National This article will draw upon the rat- guidelines now suggest more stringent ing scales developed by Facts and blood pressure and cholesterol targets Comparisons4 and Hansten and than in the past. Therefore, people Horn.5 The two scales stratify drug with diabetes are more likely to be interactions by their severity and doc- prescribed multiple medications to umentation of supporting biomedical control these concurrent disease states. literature. Hansten and Horn assess The greater the number of medica- severity and documentation together, tions a person is taking, the greater whereas Facts and Comparisons the risk for drug-drug interactions. assesses each of these individually According to one hospital study,3 first and then assigns a rating. Facts 33% of all adverse drug reactions and Comparisons’ ratings will be (ADRs) were a result of preventable referred to as “significance rating A,” drug interactions. This percentage and the rating provided by Hansten may be even larger if over-the-counter and Horn will be referred to as “sig- (OTC) product use were taken into nificance rating B.” account. Drug interactions between When assessing severity, Facts and common prescription medications and Comparisons labels the interactions as OTCs that a person with diabetes Major, Moderate, or Minor. Major might encounter will be discussed fur- interactions are those in which the ther in this article. Common classes of effect is potentially capable of causing prescription medications used in dia- permanent damage. Moderate interac- betes are antidiabetic agents, antihy- tions are those that may cause deterio- 256 Diabetes Spectrum Volume 15, Number 4, 2002 ration in the clinical status of a to Practice Research From / Boon or Bane? Polypharmacy: patient. Minor interactions are those Table 1. Significance Rating Scales in which the consequences may be 4 5 bothersome but should not signifi- Source A Source B Severity of Support from Assigned Rating Avoidance Risk cantly affect outcomes. Consequences Literature A & B Facts and Comparisons categorizes the documentation in the literature as Major Probable or 1 Avoid Established, Probable, Suspected, Suspected combination Possible, or Unlikely. Established doc- umentation has been proven to occur Moderate Probable or 2 Avoid combination Suspected if possible in well-controlled studies. Probable documentation is very likely to occur Minor Probable 3 Monitor and take but not proven clinically. Suspected or Suspected action if necessary documentation means that it may Major/Moderate Possible 4 No action necessary occur and that there are good data, but that more studies are needed to Minor Unlikely or Possible 5 No interaction confirm. Possible documentation means that it may occur, however severe and has a very high probability interactions among prescription med- there is limited data. Unlikely docu- of occurring. A level 4 or 5 rating is ications dispensed. Unfortunately, this mentation means the interaction is considered mild and of low probabili- screening process is not available when doubtful because there is no good evi- ty. Table 1 outlines the stratification OTCs are purchased. Labeling regula- dence supporting it. and the assigned numerical rating. tions for OTCs require the manufactur- Finally, a numerical rating of 1 to 5 The majority of pharmacies through- ers to list potential interactions with is assigned. A level 1 rating is most out the country screen for drug-drug medications and disease states. Table 2. Prescription Drug and OTC Interactions Prescription Drug OTC Significance Rating Description and A4 B5 Management Antihypertensive Agents ACE INHIBITORS Benazepril (Lotensin), captopril Antacids (aluminum 5 Not rated Antacids may reduce the absorption and (Capoten),* enalapril (Vasotec), hydroxide, magne- effectiveness of captopril. Separate the fosinopril (Monopril), lisinopril sium hydroxide) administration of each by 2 hours. (Prinivil, Zestril), ramipril (Altace), quinapril (Accupril) Benazepril, captopril, enalapril, Capsaicin 5 Not rated Capsaicin may exacerbate the ACE fosinopril, lisinopril, ramipril, inhibitor–related cough. Case reports have quinapril occurred with topical application as well as inhaled capsaicin. Benazepril, captopril, enalapril, Salicylates (aspirin, 43High-dose salicylates inhibit prostacyclin fosinopril, lisinopril, moexipril bismuth subsalicy- synthesis, which may decrease the hypoten- (Univasc), ramipril, quinapril, late, magnesium sali- sive and vasodilator effects of ACE inhib- trandolapril (Tarka) cylate, sodium salicy- itors. Monitor blood pressure and either late) reduce the dosage of aspirin or change to an alternative agent. ␤-BLOCKERS Acebutolol (Sectral), atenolol Aluminum salts (alu- 34Reduced absorption and delayed gastric (Tenormin), betaxolol (Kerlone), minum carbonate, emptying may alter the effect of ␤-blockers. bisoprolol (Zebeta), carteolol aluminum hydroxide, Separate the administration of each by 2 (Cartrol), metoprolol (Lopressor, aluminum phosphate, hours. Toprol), nadolol (Corgard), pen- attapulgite, kaolin, butolol (Levatol), pindolol magaldrate) (Visken), propranolol (Inderal), timolol (Blocadren), sotalol (Betapace) Acebutolol, atenolol, betaxolol, Calcium salts (calci- 43Calcium salts may impair the absorption of bisoprolol, carteolol, metoprolol, um carbonate, calci- ␤-blockers. Monitor for signs of decreased nadolol, penbutolol, pindolol, um citrate, calcium efficacy and adjust dosage if necessary. propranolol, timolol, sotalol gluconate, calcium lactate, dibasic calci- Continued on p. 258 um phosphate) 257 Diabetes Spectrum Volume 15, Number 4, 2002 Table 2. Prescription Drug and OTC Interactions, Cont. Prescription Drug OTC Significance Rating Description and A4 B5 Management ␤-BLOCKERS cont. Acebutolol, atenolol, betaxolol, Cimetidine 24Cimetidine may reduce hepatic clearance of bisoprolol, carteolol, metoprolol, ␤-blockers creating an increased effect. nadolol, penbutolol, pindolol, Monitor for signs of toxicity and adjust propranolol, timolol, sotalol dosage if necessary or change to alternative histamine2-blocker. Acebutolol, atenolol, betaxolol, NSAIDs (ibuprofen, 23NSAIDs may decrease the antihypertensive bisoprolol, carteolol, metoprolol, indomethacin, effect of ␤-blockers by inhibiting prosta- nadolol, penbutolol, pindolol, naproxen, piroxicam) glandin synthesis. Monitor blood pressure and propranolol, timolol adjust ␤-blocker dosage if necessary. Acebutolol, atenolol, betaxolol, Salicylates (aspirin, 44High-dose salicylates may alter the effect of bisoprolol, carteolol, metoprolol, bismuth subsalicylate, ␤-blockers by inhibition of prostaglandins. nadolol, penbutolol, pindolol, magnesium salicylate, Monitor blood pressure and adjust dosage if propranolol, timolol sodium salicylate) necessary or change to alternative agent. CALCIUM-CHANNEL BLOCKERS Diltiazem (Cardizem, Cartia XL, Calcium salts (calci- 23When large doses of calcium salts are given, a Dilacor, Tiazac), nifedipine um carbonate, calci- reduction of the hypotensive effects of calci- (Adalat, Procardia), nisoldipine um citrate, calcium um-channel blockers may be seen. Monitor (Sular), verapamil (Calan, gluconate, calcium vital signs and adjust dosages if necessary. Covera, Isoptin, Verelan) lactate, dibasic calci- um phosphate) Diltiazem, nifedipine, nisoldipine, Histamine2 antago- 23Cimetidine may increase the plasma concen- verapamil nists (cimetidine, ran- tration of calcium-channel blockers, creating itidine, famotidine) an increase in hypotensive effects. Monitor blood pressure and adjust dosage if necessary or change to alternative agent. LOOP DIURETICS Bumetanide (Bumex), ethacrynic NSAIDs (diclofenac, 33NSAIDs may decrease the effectiveness of acid (Edecrin), furosemide ibuprofen, indometh- loop diuretics. Monitor
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