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Aging In America_2015_Rx
This document discusses the risks of combining herbal supplements and conventional medications, especially in geriatric patients. It notes a lack of regulation and standardization of herbal products that can lead to interactions and adverse effects when taken with prescription drugs. Clinical evidence shows some herbal supplements like St. John's Wort, garlic, and ginger can interact with anti-coagulant medications by interfering with metabolic enzymes or platelet function. The presentation emphasizes the importance of discussing all medications and supplements with a pharmacist to help prevent potential harmful interactions and adverse outcomes.
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Aging In America_2015_Rx
- 1. Herbals, Drugs andAging…. Are these compatible?Are these compatible? 2015 CPS
- 2. I do nothave a vested interest or an affiliation with any corporation or organization offering financial support or grant monies for this seminar. I do not have an affiliation with any organization whose philosophy could potentially bias this presentation. Speaker Disclosure
- 3. Speaker Background Norm Tomaka –Pharmacist – Consultant Pharmacist – Licensed Health Care Risk ManagerLicensed Health Care Risk Manager – Affiliation -Consultant Pharmacy Services -Outpatient /Ambulatory Healthcare Facilities
- 4. Objectives • Become familiarwith the risks to patient safety when combining conventional medication therapy with alternative products (nutraceuticals) • Evaluate the lack of standardization and regulation of herbals and other nutraceuticals • Gain an understanding of the complex interactions presented by drug therapy and nutraceuticals in geriatric patients • Review herbal-medication anti-coagulants interactions supported by clinical evidence
- 5. Medication Safety • Misuseof “over-the counter” (OTC) products has lead to increased hospitalizations • Ask your pharmacist before adding ANY herbal, OTC or vitamin https://www.ismp.org/tools/use-medicine-safely-campaign/Americas_Medicine_Cabinet_11.pdf
- 6. Unintentional medication misuse can leadto patient harm and additional health care costs CDC Grand Rounds: Prescription Drug Overdoses- U.S. Epidemic. Jan 13, 2012 pp. 10-13. http://www.cdc.gov/mmwr/pdf/wk/mm6101.pdf
- 7. Medication “Balance” • Desiredeffects • Standard vs Individualized dosing – Weight – Age – Other medications – Race – Health Condition • Side effects – Not always desirable • Start low, go slow… Homeostasis
- 8. Are consumers/patients accurately informedabout the “alternative products” they’re purchasing? Poll
- 9. Patient visit Ambulatory Medical Clinic December 2014 Patient requestedto bring in all “medications” from home
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- 13. Can I takeherbal supplements if I am taking other medicines? “A key concern for older adults is whether an herb will interact with prescription medications- resulting in adverse effects.” Sunny Linnebur, PharmD, FCCP, BCPS, CGP Associate Professor University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences University of Colorado Anschutz Medical Camp http://www.healthinaging.org/resources/resource:herbal-remedies-ask-the-experts/
- 14. The New YorkState attorney general’s office accused four national retailers of selling dietary supplements that were fraudulent and in many cases contaminated with unlisted ingredients - 02/03/2015, page A1 of the New York Times™, NY edition with the headline: 4 Retailers Told to Stop Selling Supplements What’s in those supplements? http://well.blogs.nytimes.com/2015/02/03/sidebar-whats-in-those-supplements/?ref=todayspaper&_r=0
- 15. 2015 Class actionlawsuit* over ‘herbal’ supplements Investigators analysis found French bean, asparagus, pea, wild carrot, rice, wheat/grass, and daisy, in addition to the herbal supplements Gingko Biloba, St. John’s Wort, ginseng, garlic, echinacea, and saw palmetto *John Hollis is lead plaintiff in a class action lawsuit filed against Walgreens by Bailey & Glasser LLP in Washington, D.C. Hollis claims the Walgreens brand Ginkgo Biloba he purchased for years was composed of rice and other substitutes not Ginkgo Biloba. www.baileyandglasser.com
- 16. “Some of thesubstituted fillers and contaminants are allergens posing considerable health risks that should have been disclosed to consumers,” the attorneys stated. “These supplements are expensive, and consumers should have confidence that they are buying something beneficial, not worthless products that might actually contain allergens and other contaminants.” http://drugtopics.modernmedicine.com/drug-topics/news/walgreens-facing-class-action-lawsuit-over-herbal-supplements?page=0,0
- 17. Pharmacist as aresource Are patients and caregivers asking important questions? http://www.rc-hr.com/pharmacy/ Donna Apostal, RPh
- 18. Definitions • Complementary andalternative medicine (CAM) o “A group of diverse medical practices and products that are not presently considered to be part of conventional medicine” o Ranges from medicinal herbs to acupuncture to massage • Dietary supplement o “Any product (besides tobacco) that contains a vitamin, mineral, herb, or amino acid and that is intended as a supplement to the normal diet” • Nutraceutical o “Food, or parts of food, that provide medical or health benefits, including the prevention and treatment of disease” o More recent, general term Pharmacy and Therapeutics, vol. 35, no. 8, pp. 461–468, 2010.
- 19. Epidemiology • 36% to62% of the adult by population use at least one form of alternative/nutraceutical “treatment” • 76% physicians and pharmacists surveyed said that they were “poorly informed” about herbal medicines Natural Medicines Comprehensive Database: Unbiased, Scientific Clinical Information on Complementary, Alternative, and Integrative Therapies. Pharmacy and Therapeutics, vol. 35, no. 8, pp. 461–468, 2010.
- 20. Case: Medications Sertraline 50mg 1 tablet by mouth at bedtime Quetiapine 25 mg 1 tablet by mouth at 8AM, 2PM, and 10 PM Trazodone 50 mg 1 tablet by mouth at 6AM and 2PM Trazodone 100 mg 1 tablet by mouth at bedtime Spironolactone 25 mg 1 tablet by mouth daily Furosemide 20 mg 1 tablet by mouth daily Acetaminophen 325 mg 1 to 2 tablets every 8 hours as needed for pain (must ask for) Docusate-Senna 50-8.6 mg 1 tablet by mouth twice daily for laxative Guaifenesin 100 mg/5 mL, 10 ml by mouth every 4 hours as needed for phlegm Ipratropium-Albuterol 0.5-2.5 mg/3 mL inhale 1 vial via nebulizer every 6 hours as needed for cough or shortness of breath Florastor™ 250 mg 1 capsule by mouth twice daily Ultimate Probiotic Critical Care™ 1 capsule by mouth daily Vitamin B-12 1,000 mcg/mL 1 mL by mouth daily Vitamin B complex 1 tablet by mouth daily
- 21. L-Taurine 850 mg6 capsules 1 time daily 1 hour before or after food or other supplements Coenzyme Q10 75 mg 1 capsule by mouth daily Prosta-Glan™ Dietary Supplement 3 capsules by mouth twice daily with meals GC-MSM 3550 (glucosamine, chondroitin, hyaluronic acid) 4 tablets by mouth daily Nattokinase with Vitamin E 3 capsules by mouth twice daily Phosphatidylserin E complex 1,000 mg 1 tablet by mouth daily Bladder Control Advantage™ 1 capsule by mouth twice daily 100% Protein Powder Mix 1 scoop with 8 oz and drink by mouth daily Mega EPA Omega-3 EPA and DHA 2,126 mg 1 softgel by mouth daily Bruise Free™ 3 capsules by mouth daily Twilight-Time™ dietary supplement 1-2 capsules by mouth at bedtime for sleep Acetyl L-Carnitine 500 mg 1 capsule by mouth twice daily between meals Same Case: Nutraceuticals
- 22. Physiologic Effects ofAging ● Alters pharmacokinetics ■ GI Absorption, distribution, metabolism, elimination of medications ■ Muscle mass, kidney function, bone mineral density Hajjar ER, Gray SL, Guay DR, Starner CI, Handler SM, Hanlon JT. Chapter 11. Geriatrics. In: Talbert RL, DiPiro JT, Matzke GR, by mouthsey LM, Wells BG, Yee GC, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York: McGraw-Hill; 2011.
- 23. Effects of Agingon Metabolism http://jap.physiology.org/content/95/6/2598 Aging and Human Temperature Regulation W. Larry Kenney , Thayne A. Munce Journal of Applied Physiology Published 1 December 2003 Vol. 95 no. 6, 2598-2603 DOI: 10.1152/japplphysiol.00202.2003
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- 25. Natural Medicines and…. PlateletAggregation Name Potential Drug Interactions/Comments Andrographis Anticoagulants, antiplatelets, antihypertensive drugs, immunosuppressants1,2 Black tea (Contains caffeine) Anticoagulants, antiplatelets, benzodiazepines, beta- adrenergic agonists, diuretics, warfarin1,2 Boldo Warfarin1,2 Chamomile Warfarin (interferes with metabolizing enzymes)3,4 Chondroitin Warfarin1,2 Coenzyme Q10 Warfarin (alters gut vitamin K synthesis or contains vitamin K)3,4 Cranberry Warfarin (interferes with coagulation cascade and metabolizing enzymes)3,4 Danshen Warfarin1,2 Dong quai Warfarin1,2 Fenugreek Warfarin1,2 Fish oil (High doses) Garlic Warfarin (interferes with metabolizing enzymes and platelet function)1,2,3,4
- 26. Natural Medicines and….. PlateletAggregation Ginger Warfarin (interferes with platelet function)1,2,3,4 Ginkgo biloba Warfarin (interferes with metabolizing enzymes)3,4 Ginseng Warfarin (interferes with metabolizing enzymes and platelet function)3,4 Glucosamine Warfarin1,2 Grapefruit Warfarin (interferes with metabolizing enzymes)3,4 Green tea Warfarin (alters gut vitamin K synthesis or contains vitamin K)3,4 Guarana (Contains caffeine) Horse chestnut Nattokinase Policosanol Resveratrol Saw palmetto St. John’s Wort Warfarin (interferes with metabolizing enzymes)3,4 Vitamin E (High doses)
- 27. Poll Which of thefollowing is correctly matched with its “pharmacological” activity? a. Glucosamine Antiplatelet activity b. Coenzyme Q10 Decreased blood pressure c. Green tea Antiplatelet activity d. St. John’s wort Serotonergic activity e. All of the above
- 28. Answer Which of thefollowing is correctly matched with its pharmacological activity? a. Glucosamine Antiplatelet activity b. Coenzyme Q10 Decreased blood pressure c. Green tea Antiplatelet activity d. St. John’s wort Serotonergic activity e.e. All of the aboveAll of the above
- 29. • The useof dietary supplements is extensive and growing o Global nutraceutical market is estimated as $117 billion • Dietary supplements are not without adverse effects o Those at highest risk include older adults and all patients perioperatively • All caregivers should play an active role in recognizing potentially harmful from dietary supplements • Examples of outcomes through interventions include: o Reduce adverse drug event (e.g. hypoglycemic episode, falls) o Prevent medication-nutraceutical interaction o Reduce hospital readmissions
- 30. Talk with YourPharmacist • Pharmacy technicians verbally offer the opportunity to talk to the pharmacist (FL Law) – Prepare questions ahead of interaction • Side effects? • Is the dose appropriate for condition treated? • Will this prescription mix with other products? • Does the medication have the by potential to affect behavior? -Know what you are signing if you decline consultation
- 31. Prescription Medications • Is thisyour medicine? • Check your address and date of birth; do you match the information on the prescription? • At the pharmacy- ask to open the bag and compare the name on the receipt with the name on the prescription label
- 32. Talk with YOURPharmacist • Improve medication management – for every $1 spent on Rx medication, there is $4 decrease in hospital costs. – for every $3 spent on asthma medication, there is a $17 decrease in emergency room spending. Source: NACDS Practice Memo. It’s time to talk about value. Available online at: http://www.practicememo.com/Archives/html/2006/Nov06.html
- 33. Pharmacists improving medication use…advancingpatient care Just ASK your pharmacist
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- 37. Additional References 1) TOPHerbals (2015, March 3) Retrieved from http://top-herbals.com 2) Institute for Safe Medication Practices, “America’s Medicine Cabinet” presentation. (Accessed 2014, Dec. 10) www.ismp.org 3) Healthy.Net (2015, March 2) Retrieved from www.healthy.net 4) Natural Medicines Comprehensive Database: Unbiased, Scientific Clinical Information on Complementary, Alternative, and Integrative Therapies. The Perioperative Use of Natural Medicines. (Referenced 2015, February 12-14) http://naturaldatabase.therapeuticresearch.com/ce/ceCourse.aspx?s=ND&cs=UFL&pc=12-102&cec=1&pm=5#references 5) Health in Aging.Org “Herbal Remedies Topic Review” ( 2015, February 13) http://www.healthinaging.org/resources/resource:herbal-remedies-ask-the-experts 6) Natural Standard: The Authority on Integrative Medicine. https://naturalmedicines.therapeuticresearch.com/ 7) Ge B, Zhang Z, Zuo Z. Updates on the clinical evidenced herb-warfarin interactions. Evid Based Complement Alternat Med. 2014: 957362 8) Heck AM, DeWitt BA, Lukes AL. Potential interactions between alternative therapies and warfarin. Am J Health Syst Pharm. 2000 Jul 1;57(13):1221-7. 9) Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health-Care Professionals, The Pharmaceutical Press, London 1996, p.283. 10) Hajjar ER, Gray SL, Guay DR, Starner CI, Handler SM, Hanlon JT. Chapter 11. Geriatrics. In: Talbert RL, DiPiro JT, Matzke GR, Posey LM, Wells BG, Yee GC, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York: McGraw-Hill; 2011 11) Rozenfeld V, Crain JL, Callahan AK. Possible augmentation of warfarin effect by glucosamine-chondroitin. Am J Health Syst Pharm. 2004 Feb 1;61(3):306-7. 12) Cooper K1, Squires H, Carroll C, Papaioannou D, et al. Chemoprevention of colorectal cancer: systematic review and economic evaluation. Health Technol Assess. 2010 Jun;14(32):1-206. doi: 10.3310/hta14320. 13) C. L. Ventola, “Current issues regarding complementary and alternative medicine (CAM) in the United States—part 1: the widespread use of CAM and the need for better-informed health care professionals to provide patient counseling,” Pharmacy and Therapeutics, vol. 35, no. 8, pp. 461–468, 2010. 14) SecondsCount.Org, SCAI™ ‘My Med Minder” Dose Chart Template. http://www.secondscount.org/heart-resources/heart- resources-detail-2/secondscounts-med-minder#.VQBKENLF_WJ
- 38. Herbals, Drugs andAging…. Are these compatible?Are these compatible? Questions? 2015 CPS
Editor's Notes
- #7 Read slide
- #20 In a recent survey in which more than 80% of the 164 resby mouthndents were general practice physicians (the remainder were mostly pharmacists), 76% said that they were “by mouthorly informed” about herbal medicines and 46.6% said that their own knowledge on this topic was “very by mouthor” or “quite by mouthor.”
- #23 Pharmacokinetics → what the body does to the drug Older adults — Caution should be exercised in the use of herbs in older adults due to by mouthssible decreased renal and hepatic clearance of herb and drug metabolites. Additionally, for older individuals taking multiple medications, there is a greater by mouthtential for herb-drug interactions
- #26 Risk: bleeding Combined use of these herbals may have anticoagulant or antiplatelet activity and might enhance therapeutic effects of anticoagulants/antiplatelets and increase the risk of bleeding Andrographis Common cold, Pharyngotonsillitis, Ulcerative colitis Black tea (Contains caffeine) Mental alertness, atherosclerosis, hyby mouthtension, kidney stones, MI, osteoby mouthrosis, ovarian cancer, Parkinson’s Saw palmetto Benign prostatic hyperplasia (BPH)
- #27 Risk: bleeding Combined use of these herbals may have anticoagulant or antiplatelet activity and might enhance therapeutic effects of anticoagulants/antiplatelets and increase the risk of bleeding Andrographis Common cold, Pharyngotonsillitis, Ulcerative colitis Black tea (Contains caffeine) Mental alertness, atherosclerosis, hyby mouthtension, kidney stones, MI, osteoby mouthrosis, ovarian cancer, Parkinson’s Saw palmetto Benign prostatic hyperplasia (BPH)
- #30 The use of natural medicines in North America is extensive. Many patients do not consider these products to be drugs or medication and often do not disclose their use to health providers. As a result there is a risk that patients may take these products without their health care provider's knowledge. Many natural medicines have pharmacological effects that have the potential to interfere with many disease states. Therefore, assessment of natural medicine use is an important aspect of MTM. Patients should be asked specifically about their use of herbs, vitamins, minerals, or other natural or alternative products. Every patient should be considered individually and risks and benefits should be weighed
- #32 Ask for information about your medicines in terms you can understand—both when your medicines are prescribed and when you receive them. Read the label before you leave the pharmacy with your prescription; be sure you have the right medicine, know the right dose to use, and know how to use it. What is the medicine for? How am I supby mouthsed to take it, and for how long? What side effects are likely? What do I do if they occur? Is this medicine safe to take with other medicines or dietary supplements I am taking? What food, drink, or activities should I avoid while taking this medicine? If you have bought the medicine before, make sure that this medicine has the same shape, color, size, and packaging. Anything different? Ask your pharmacist. Do they offer you the opby mouthrtunity to talk to the pharmacist? Know what you are signing. You may be signing a statement that says you didn’t want to talk to a pharmacist.
- #33 Rxs may be expensive, but consider the cost to the benefits value. When taken correctly, medications can lead to better disease state management and better quality of everyday life. If you need help paying for prescriptions, ask your pharmacist or doctor for government and pharmaceutical sources. Source: National Association of Chain Drug Stores. http://www.nacds.org/
- #34 Any questions?