Drug Use in Long-Term Care
Transcription
Drug Use in Long-Term Care
ntinuingE 30 Si years nce 198 (Effects on Nutrition & Health Status) Reviewed and Recertified March 2011 by Annette Kobriger, rd, cd, mph, mpa Accredited Continuing Professional Education Course 7950 Jones Branch Drive, 7th Floor, McLean, VA 22107 1-800-866-0919 • www.nutritiondimension.com cation Drug Use in Long-Term Care Co du Quality Drug Use in LTC 5 7950 Jones Branch Drive, 7th Floor, McLean, VA 22107 1-800-866-0919 (US & Canada) • 1-703-854-2531 (overseas) FAX:1-703-854-2531 • e-mail: [email protected] Drug Use in Long-term Care (Effects on Nutrition & Health Status) 2nd Edition • Reviewed & Recertified March 2011 by Annette M. Kobriger, RD, CD, MPH, MPA About the Author: Annette M. Kobriger, RD, CD, MPH, MPA is president of Kobriger Presents, Inc., which provides publications, consultations, and education for health care training. Annette has more than 40 years of active experience as a Registered Dietitian in a variety of settings: public health, prenatal care, pediatric care, education and long-term care. She has demonstrated leadership in these areas through publications, seminars, and program development. While at the Missouri Department of Health, Annette created a network for over 700 health care providers for nutrition education and training. She has appeared on television and radio, and has spoken to over 40 Health Care Associations across the United States. Annette holds a Bachelor’s degree in Food Service Management (Hospital Dietetics) from Penn State, a Master’s in Public Health from the University of Minnesota, and a Master’s in Public Administration from the University of Missouri. Annette completed a dietetic internship at St. Paul-Ramsey Hospital in St. Paul, MN. Important - Read Before Proceeding EXPIRATION DATE: Students of all professions must submit this course for credit no later than December 31, 2016. Credit will not be awarded for this course after that date. Course Code: RD77 This course approved for: RD........................... 16 CPEU DTR........................ 16 CPEU CDM............16 Clock Hours © 2011 OnCourse Learning Corporation No part of this course may be reproduced, duplicated or copied in any way without the written permission of the copyright holder. (See note on Page ii) Drug Use in LTC ii How to Earn Continuing Education Credit 1.Read or watch the course material. Don’t forget to review the course objectives and take note of course tools available to you. The objectives provide specific learning goals and an overview of the course. Read the material in the order presented. If you need help with the material, please e-mail [email protected] with your specific question. 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Drug Use in LTC iii Table of Contents Introduction ................................................................................................................................1 Chapter 1 Responsibility for Food and Drugs in the Elderly............................. Page 3 Chapter 3 The Beers Criteria................................................................................... Page 27 Chapter 2 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9 Regulatory Guidelines........................................................................... Page 15 2006 Medication Survey Guidelines................................................... Page 35 Drugs and How Drugs Work................................................................ Page 67 Drugs and the Elderly............................................................................ Page 81 Food-Drug Interactions........................................................................ Page 101 Additional Food-Drug Interactions................................................... Page 115 Nutritional Supplements and Drug Interactions........................... Page 137 Bibliography .................................................................................................................. Page 153 Appendix A Drugs Commonly Used in TLC........................................................ Page 155 Appendix B Terms to Describe Food-Drug Interactions...................................... Page 162 Final Exam .................................................................................................................. Page 164 Learning Objectives Upon successful completion of this course, the student will be able to: 1. Know how drugs can impact nutritional status in long-term care. 2. Understand impact of drug regulations on drug use in long-term care. 3. Identify food and drug interactions. 4. Identify drug-dietary supplement interactions. 5. Be able to identify drugs to be given with and without food. 6. Know how drug use differs for the elderly. 7. Distinguish which drugs should not be sued with the elderly per the Beers Criteria. 8. Know risks of adverse effects of drug use for the elderly. Drug Use in LTC 1 Introduction Nutrition and pharmacology have a common basis in clinical practice. The com- mon basis is that all therapeutic interventions are based on normal physiology. Like drugs, foods have to be absorbed, distributed to all body cells, then metabolized and excreted. There are more bonds to pharmacology than most nutrition professionals may have realized. The discovery for the commonalities of practice will allow better communication among health professionals. The nutritionist must first learn the language of pharmacology to participate as a full team member with physicians, nurses and pharmacists. This has been a deficit in our educational preparation. Yet the Joint Commission on Accreditation of Health Care Organizations (JCAHO — recently changed to “The Joint Commission” or TJC) and OBRA (shorthand for the health care provisions in the Omnibus Budget Reconciliation Act) expect nutrition professionals to identify, educate and recommend interventions for food-drug interactions. This has always been a question for me: Why does the physician prescribe the drug, the pharmacist dispense the drug, the nurse give the drug, and the nutrition professional have the responsibility for the food-drug interactions? Quality of life is an important issue when there are fewer years left to live. Very strict therapeutic practices in both diets and drugs can cause the last years to be less joyful and functional. Quality of life in both professions calls for communication and the best care available. As a positive approach, this expands our practice into an exciting and new world of discovery. This continuing education program will focus on the elderly in acute care, sub-acute care, and in long-term care. The book will also address younger adults in long- Drug Use in LTC 2 term care due to a devastating illness, mental retardation or mental disease. This has been an extraordinary undertaking. I have been challenged by the volume of literature to process and adapt to the needs of those serving the elderly. My basic philosophy is “Let’s improve the quality of life for the elderly – it’s not too long before we will all get old.” My hope is that your practice will be enriched by what you learn from this publication. I hope your skills improve the quality of life for those you care for in your health care setting. The outcome will be real job satisfaction for you. Maybe some day I will meet you as I conduct seminars around the United States. It will be my great pleasure to meet a health care professional with a sincere desire to improve the last years of the elderly. Drug Use in LTC 3 Chapter One: Responsibility for Food and Drugs in the Elderly “Failing to protect consumers against dangerous interactions of prescription drugs, (is) an exploding health care problem that sends hundreds of thousands of Americans to the hospital each year.” -- US News and World Report Drug errors in the elderly - medical error identified Current concern about drug safety was brought to public attention as the result of two studies on adverse events occurring in hospitals — one in Colorado and Utah, and one in New York. Adverse events occurred in 2.9 percent in the Colorado/Utah study, and 3.7 percent in the New York study. Deaths occurred in 6 percent of the Colorado/ Utah study, and in 13.6 percent of the adverse events in New York. The data was extrapolated to the 33.6 million hospital admissions in the US in 1997, and the headlines warned that between 44,000 and 98,000 Americans could die each year from medical errors committed in US hospitals; a half-million additional patients could be seriously injured. The public was startled by the news, particularly when it was put in comparative terms: more people die from medical errors than from motor vehicle accidents, breast cancer, or AIDS. Costs from medical errors constitute about half of the estimated $17 billion to $29 billion additional cost for healthcare in the US. The elderly are 30 to 40 percent of patients in hospitals, and Medicare accounts for 40 percent of hospital revenues, so the direct costs are borne by us all. Indirect costs are litigation, insurance premium increases (liability coverage for care providers and healthcare facilities) and lost productivity. Consumers with chronic pain and physical disability produce less and pay less in taxes; decreased morale in healthcare providers makes the system work less well. Drug Use in LTC 4 The Institute of Medicine actually believes that the healthcare system in the US is a “non-system.” Medical personnel do have lines of authority or accountability, but employers making group purchases of healthcare insurance have not made quality of care a requirement of purchasing health insurance. They have not demanded value for their health insurance dollars. “Most third party systems provide little incentive for a healthcare organization to improve safety, nor do they recognize and reward safety or quality.” (IOM, 1999) The status quo no longer can be tolerated. Not all errors result in harm, but too many do, and most are probably preventable. The IOM believes the future must shift – from blame to correction of error or design. Blaming does not stop an individual or another person from committing an error in the future. “Whether a person is sick or just trying to stay healthy, they should not have to worry about being harmed by the healthy; they should not have to worry about being harmed by the health system itself. This report is a call to action to make healthcare safer for patients.” (IOM, 1999) The need is the intrinsic motivation of healthcare providers, shaped by professional ethics norms and expectations and accountability. The IOM actually believes that the healthcare system in the US is a non-system. We believe we are safe Safety, defined as freedom from accidental injury, should be the norm. Most consumers believe they are safe when going to the hospital. Licensing and accreditation agencies are believed to offer assurance of the quality of care in the hospital. The public believes providers of care can be punished if they fail to perform adequately. This is often not the case. Three general mechanisms motivate hospitals to promote patient-safety: professionalism, regulation, and market forces. There has been little impact on hospitals to date, despite the efforts of the Joint Commission on Accreditation of Healthcare Organizations (formerly called “JCAHO,” now usually referred to as “TJC” for “The Joint Commission.” Both abbreviations will be used in this course.) Most hospitals are JCAHOaccredited and therefore are not subject to review by state governments for Medicare and Medicaid reimbursement. Only California has passed regulations to have hospitals reduce medical errors, partly by mandating nursingstaff-to-patient ratios. The “root cause” is most likely to be in the design of the system rather than as a result of an error by a single person. Drug Use in LTC 5 We are not safe Voluntary, confidential reporting systems are rarely used. The staff involved may write a report, but problem-solving must include front line staff who know of the details of the error and have the power to make changes. Blame is an important barrier to determining error, and is probably why incidents of error are under-reported. The person who committed the error is under considerable pressure to minimize the event; supervisors can be torn between understanding the pressures involved and wanting to improve the system. Personnel reviewing the event may not have adequate knowledge of the process to understand the potential for error, and without knowledgeable staff input cannot identify systemic problems and differentiate them from individual malperformance. The “root cause” of most errors is most likely the design of the system rather than a mistake made by a single person. Many factors may occur to cause an error: new staff, new equipment, unfamiliar procedures, fatigue, and interruption of a process, unclear assignments, and inaccurate data. Defining quality of care is, and should be, a constant concern. The elderly The elderly are the most common users of drugs: both prescription and over-thecounter drugs. The elderly aged 65 to 69 take an average of 13.6 medications a year; those aged 80 to 84 years take 18.2 medications per year. Eighty percent of physician visits by the elderly result in a new prescription. Medicare provides 50 to 60 percent of the drugs provided to residents in long-term care. Drugs make up about 15 percent of the total state expenditures. States are facing budget crunches; drug use for Medicaid patients is a possible target. In 2002, 25 states listed drug costs as the primary reason for increased Medicaid costs; 32 states implemented cost control systems. The number of drugs used by the elderly increases with admission to the nursing home. In 2001, $42.7 billion was spent on nursing home care. Expenditures are expected to greatly increase in the coming years. Multiple drug use, or polypharmia, is a cause of many adverse drug reactions, resulting in costly hospitalizations and deaths. Current budget projections have Medicare growing at an average of 9 percent each year for the next decade. In 2014, Medicare costs will be half of the Federal budget. The number of those over age 65 will double by 2008. Drugs can cause major problems for residents Drugs can cause a loss of appetite, loss of taste, anorexia, nausea, vomiting and diarrhea – all of which have a negative impact on nutritional status, as well as decrease the effectiveness of nutrients and/or drugs. A major difference between pharmacy and nutrition is that nutrients and energy are essential to life. Drugs are only needed in the absence of health. Nutrients are essential to maintaining life in both health and disease. Drug Use in LTC 6 Many drugs that affect nutritional status are thought to be very safe, such as laxatives, vitamins and analgesics. However, the evidence does not bear out their safety. About 40 percent of drugs used by those over age 65 are over-the-counter preparations, primarily analgesics. This rate is seven times higher than the general adult population. In addition, 40 percent of Americans used unconventional medical therapy in the last year. Adverse drug effects The potential for adverse effects of drugs rises with increased drug use, and the elderly have a three to seven times greater likelihood of experiencing an adverse drug reaction than middle-age adults. Healthcare costs increase due to hospitalizations alone. Data from North America and England shows that 30 percent of admissions of elderly patients to acute care hospitals are due to adverse drug reactions. Adverse drug reactions are the 8th leading cause of death in the elderly. Examples of common side effects of drugs in the elderly include: • Gastrointestinal bleeds or hemorrhages from high doses of non-steroidal antiinflammatory drugs such as Advil or Motrin (Ibuprofen), available as over-thecounter drugs. There are 16,500 deaths each year from the use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), used mostly by the elderly (Dimant, 2002). • Cognitive impairment or sedation as a result of drugs such as antidepressants, anticonvulsants or sedatives, and result in broken bones and hip fractures, which cause functional dependence. • Blurred vision occurs with a commonly used cardiac drug (digoxin). This drug may cause an elderly person to see a halo over lighted objects such as a television or a traffic light. • Depth perception can be a problem with some drugs, and can lead to confusion and an increased risk of falls. There are over 300,000 drugs available for purchase. An adverse drug event can occur with prescribing, dispensing, administering, or monitoring of drug use. Adverse drug events include: allergies, drug interactions, food-drug interactions, sub-therapeutic dose, duplicate dose, and other unexpected or undesirable outcomes. Laboratory values are available to monitor some drug levels. The chart on the next page is available for your clinical assessment. Drug Use in LTC 7 Selected Laboratory Monitoring Values for Drug Use in LTC Generic Name acetaminophen alprazolam amantadine amikacin aminophylline amitriptyline Brand Name Tylenol, etc. Xanax Elavil, etc. (combined w/ nortriptyline) aspirin (other salicylates) atenolol azithromycin bumetanide bupropion Wellbutrin buspirone carbamazepine chlorpromazine ciprofloxacin clonazepam codeine cyclosporine desipramine diazepam digitoxin digoxin diltiazem doxepin ethosuximide flucytosine fluoxetine fluphenazine gentamicin gold salts haloperidol imipramine kanamycin klonopin Tegretol Thorazine Cipro Klonopin Sandimmune Norpramin Valium Crystodigin Lanoxin Cardizem Adapin, Sinequan Zarontin Ancobon Prozac Prolixin Garamycin Auranofin, etc. Haldol Janimine, Tofranil, etc. Kantrex lithium Eskalith, Lithotab Laboratory Value 7200 mcg/ml >350 mg/ml 4-23 mcg/ml 0-5 mcg/ml trough >35 mcg/ml peak 10-20 mcg/ml 120-250 ng/ml 100-250 mcg/ml 1-2 mcg/ml 0.4-0.6 mg/L 40-80 ng/ml 50-100 mg/dl <6 ng/ml (90 min. after 20 mg dose) 6-12 mcg/dl 50-300 ng/ml 0.94-3.4 mcg/ml 50-70 ng/dl >1.1 mcg/ml 100-150 ng/ml 150-300 ng/dl 0.2-1.5 mcg/dl 15-30 ng/ml 0.5-2.0 ng/ml 100-200 ng/ml 100-275 ng/ml 40-100 mcg/ml 50-100 mcg/ml 100-800 ng/ml 5-20 ng/ml 4.0-10 mcg/ml peak <2 mcg/ml trough 1.0-2.0 mcg/ml 5-15 ng/ml 150-300 ng/ml 25-35 mcg/ml 5-70 ng/ml >80 ng/dl 0.6-1.2 mEq/l Comments Toxic concentration w/ possible liver toxicity Toxic level Toxic and potentially fatal Therapeutic level Toxic level Therapeutic level Peak plasma level Peak serum level Therapeutic level Therapeutic level (12 hrs. after dose) Peak plasma level Therapeutic level Therapeutic level Toxic level Therapeutic level Therapeutic level Therapeutic level Therapeutic level Therapeutic level Therapeutic level Toxic level Therapeutic level Drug Use in LTC 8 Selected Laboratory Monitoring Values for Drug Use in LTC, cont. Generic Name lorazepam methotrexate metoprolol nicardipine nifedipine nortriptyline oxazepam phenobarbital phenytoin Brand Name Ativan Mexate Lopressor Procardia Pamelor Serax Luminal, etc. Dilantin prazepam primidone protriptyline risperidone Centrax Mysoline Vivactil Risperdal streptomycin sulfadiazine sulfamethoxazole temazepam theophylline thioridazine thiothixene tobramycin tocainide trazodone valproic acid vancomycin venlafaxine verapamil zinc sulfate Microsulfon Gantanol Restoril Aminophylline, etc. Mellaril Navane Nebcin Tonocard Desyrel Depakene, Depakote Vancocin Effexor Calan Laboratory Value 50-240 ng/ml up to 0.1 mcmol/L 20-200 ng/ml 30-50 ng/mL 25-100 ng/ml 50-150 ng/ml 0.2-1.4 mcg/ml 10-25 mcg/ml Total phenytoin 10-20 mg/ml 50-240 ng/ml 5-12 mcg/ml 70-250 ng/ml 12 ng/ml (w/in 2 hrs. of 1 mg dose) 4-8 mcg/ml peak < 5 mcg/ml trough 40 mcg/ml peak 40 mcg/ml trough 100-120 mcg/ml 90-100 mcg/ml 25 ng/ml (after 24 hrs.) 10-20 mcg/ml 50-300 ng/ml 2-57 ng/ml 4.0-10 mcg/ml (peak) <2 mcg/ml (trough) 5-12 mcg/ml 0.5-2.5 mcg/ml 50-100 mcg/ml 30-40 mcg/ml (peak) 5-10 mcg/ml (trough) 163 ng/ml 50-200 ng/ml 50-150 mcg/dl Comments Therapeutic level Therapeutic level Therapeutic level Therapeutic level Therapeutic level Therapeutic level Therapeutic level Peak plasma level * Therapeutic level Therapeutic level Toxic level Toxic level Therapeutic level Therapeutic level * Therapeutic level Therapeutic level Serum peak level Therapeutic level * Question if valid. Reference: Higbee, Martin, 1996; 1996 Drug Formulary and Therapeutic Information Guide, Lexi-Comp Inc., Hudson, OH. Drug Use in LTC 9 Quality of life issues Drugs often have a negative impact on nutritional status. The drugs may cause loss of appetite, nausea, vomiting, abdominal pain and weight loss. Nutritional management of these diseases can be complicated by the side effects of drugs. Quality of life is a major issue for those with limited years remaining to live. As many elders enter acute, sub-acute or long-term care, their priorities for clinical interventions may change. The elderly may choose less medicine and clinical nutrition for more enjoyment in their later years. In long-term care this is considered their right, as long as they (or their family or holder of a power of attorney) are aware of any consequences that may result. Morley, et al. (1990) summarized this concept: “Aging is not a homogeneous process, nor a disease with a course of action that can be reversed or cured by medications or nutrients. In each person, an inevitable decline in physiological function will occur, which will ultimately affect the well-being of the individual.” Ackerman (1995) wrote: “The average 78-year-old American has a life expectancy of approximately five to six years. Nursing home residents are generally sicker than the average elder, and therefore have a lower life expectancy. Drugs that are used to prevent illness but do not make the patient feel better have increasingly marginal benefit-risk profiles. Further, in the patient with moderate or severe cognitive impairment, prevention of major causes of death, such as stroke or myocardial infarction, becomes increasingly difficult to justify.” Harmful side effects of inappropriate prescribing include falls, fractures, acute confusion, and death. Urinary retention, anorexia, sedation, constipation and urinary incontinence are less dramatic reactions. Even an unneeded iron supplement results in constipation, anorexia and abdominal discomfort (Beers, et al., 1992). About 50 percent of the elderly will spend time in nursing homes. Drug use in long-term care The elderly are frequent users of drugs for many chronic illnesses. In assisted living and long-term care, the elderly tend to be more ill and frail. This chapter will discuss studies done with the elderly in long-term care settings. In a later chapter, Regulations and Guidelines, and the Beers Criteria — a standard used to evaluate safe drug use in the elderly — are presented. The reporting of medical and drug errors is voluntary, so many adverse drug reaction (ADR) events go unreported. Medical errors that are reported are published and available to physicians in: • MedMARx – from the U.S. Pharmacopedia (USP) • Institute for Safe Medication Practices “drug alerts” Drug Use in LTC 10 • Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Two types of drug error are noted in the Beers study: errors of commission (administering of one or more drug causing a toxic reaction), and errors of omission (not prescribing a needed drug, or prescribing an underdose of a needed drug). An example of Type 2 error is to not monitor potassium with large doses of loop diuretics such as Lasix®. The authors noted that attention to a limited number of medications could result in a significant decrease in medication errors. “Many [adverse drug reactions] in elderly patients could be prevented by better prescribing habits. Prescribing should be limited to the drugs whose benefits are felt likely to outweigh the risks.” (Walker and Wynne, 1994) Only a small number of ADR cause serious problems. However, the elderly receive many drugs, so the number of increased adverse drug events is higher. These ADR can end in greater morbidity and mortality, and longer and more frequent hospitalizations. Psychotropic medications can cause 14 percent of hip fractures, according to one study. Dietary supplements are discussed in another chapter. The elderly are at risk for medication adverse events due to: • Age over 85 years. Little research has been conducted on the elderly over age 85 on drug use. • More than six active chronic disease diagnoses. • Low body weight. • Use of nine or more medications. • More than 12 doses of medicine per day. The elderly have physiological changes that can complicate drug use. At times, adverse drug reactions can be interpreted as “just getting old.” This is due to: • Atypical presentation of illness. • Cognitive decline. • Diminished senses: vision, hearing, taste, smell. • Taking drugs with a narrow therapeutic index, i.e., warfarin, digoxin, phenytoin, and hypoglycemic agents. A study by the American Society of Heath-System Pharmacists found Americans are “very concerned” about being given the wrong drug. This group called medicationrelated problems “the nation’s $100 billion disease.”The American Society of Consultant Pharmacists (ASCP) found eight categories to evaluate to consider inappropriate drug use in the elderly. These are causes of preventable error in most cases. Drug Use in LTC 11 This ASCP categories are: 1. Medication needed for an untreated medical problem. No medication is given. This could be an antidepressant for depression, medications for asthma or pain. Depression without treatment is a Quality Indicator reviewed by surveyors as part of the survey in long term care facilities. 2. Improper Medication Selection. The resident has a problem but is given the wrong medication. A resident is given an anti-psychotic medication or an antianxiety medication when the diagnosis is depression. Another example is a resident is given an iron supplement when his vitamin B12 level is abnormal and his serum ferritin level is high. 3. Too little medication. Studies have shown that frequently pain medication is withheld from residents experiencing significant pain. Another example may be a resident receiving too little medication for an elevated blood glucose level. 4. Failure to receive prescribed medication. There may be a PRN order for pain medication but the medication is not given when requested. 5.Too much medication. This is often a problem with residents on digoxin, when they loose weight or become dehydrated. The digoxin is not adjusted and digoxin toxicity develops. 6. Adverse drug reaction. A drug was given to a resident with a known allergy to the drug. The resident has an adverse reaction to the drug not causes by his illness. 7. Drug interaction. A medical problem occurs as a result of a drug, drug, or drug food interaction. A calcium channel blocker (Felodipine) for hypertension is given to a resident with grapefruit juice, a contradicted combination of food and drugs. His blood pressure drops below normal. 8. Medication use with no indication. There is no reason for the patient to take the medication. An example that occurs frequently in long term care is a resident is on a cholesterol lowering medication with a cholesterol level of 167 mg/dL or there is no verification of an elevated cholesterol level anywhere in the resident history (ASCP, 2000). Drug Use in LTC 12 “In addition the cost of care in skilled-nursing facilities is often borne by the government through Medicaid and Medicare and by the insurance industry through Medigap policies, unnecessary prescribing wastes limited resources as well as the limited time available to licensed nursing staff in these facilities. Treating the iatrogenic complications of prescribing further burdens the healthcare system.” (Beers, et al., 1992) Guidelines for Effective Drug Prescribing For nursing home patients, the guiding principle has been to start the dosage of drug low, and to advance the drug slowly if needed. The elderly have physiological factors that cause a decreased tolerance to drugs. • The starting place for the drug dosage is about one-half of the dose given to a middle-aged patient. This is especially true for drugs with a narrow therapeutic margin, such as digoxin and theophylline. This means there is a very small line between drug effectiveness and drug toxicity. Drugs with a narrow therapeutic range need to be monitored carefully by laboratory values or careful clinical observation. • Drugs should not be prescribed for every minor symptom or pain. Options, such as physical therapy, application of heat, or the use of capsaicin (Zostrix®), a topical cream, to treat arthritic pain may be considered. Acetaminophen (Tylenol®), while generally considered a harmless medicine, has caused serious liver problems if taken in doses of 3 to 5 gm/day. The physician should question if treatment is needed. For instance, it may be appropriate to not treat asymptomatic hypertension, diabetes, or urinary tract infections. • Often the side effects of a medication are treated with another drug. For instance, the use of potassium chloride for Lasix. The use of a potassium-sparing diuretic or an angiotensin converting enzyme inhibitor (ACE inhibitor), may be considered in place of a potassium supplement, if the resident/patient needs a drug for hypertension. Examples of ACE inhibitors commonly used are: Lotensin® (benazepril), Capoten® (captopril), Vasotec® (enalapril), Zestril® (lisinopril) and Altace® (ramipril), which increase the blood potassium level. Potassium chloride may not be needed for all those receiving potassium-depleting diuretics. Many elderly have significant renal impairment, and additional potassium could compromise renal status. In other words, potassium chloride should not be added without definite evidence of potassium depletion. Potassium chloride has serious side effects of gastrointestinal irritation and perforation. • Priorities in therapy are set with reasonable treatment goals. As an example, if the goal of therapy is to maintain the blood sugar level, care should be taken not to add another drug that is known to elevate the blood sugar level. Drugs such as Drug Use in LTC 13 Lasix, and Prednisone complicate blood sugar control by raising the blood sugar level. • For the elderly, drug side-effects, interactions, and contraindications need to be carefully reviewed. For example vitamin E ordered for a cardiac condition could interfere with Coumadin ordered to prevent future blood clots. Multivitamin supplements containing vitamins A, E, and K can also decrease the effectiveness of Coumadin. • Monitoring drugs for physiological effectiveness and for toxicity improves resident outcomes. The monitoring of blood sugar levels, potassium, sodium and other blood components insures safe and effective drug levels for residents. These drug levels are often monitored by the nutrition professional. (Please refer to the table of safe drug levels commonly used in long-term care, found earlier in this chapter.) (Ackermann, 1995; Reese, 1997). Remember that drugs can cause illness. Drugs are most often tested on healthy young persons, not on elderly people with multiple health problems — both chronic and acute. Be wary of the effect of new drugs on sick and frail elders. It may take some time before unwarranted outcomes or case reports appear in the literature. In the meantime, residents may suffer from the consequences of the unproven drug. Remember that drugs can cause illness. Summary The elderly in all healthcare settings are at risk for adverse drug reactions. Diet therapy has been modified to increase the quality of life in our elderly. Drug regimes also need to be revised to meet the needs of the elderly. More than five drugs per day increases the risk of negative outcomes. The nutrition professional can work with other members of the healthcare team to make them aware of possible side effects of drugs, and how they impact on nutritional status, appetite, weight loss and patient outcomes. Serious negative effects can occur if the effects of drugs on nutritional status and health outcome are not clearly understood by the resident/patient or their guardians. The next chapter will discuss regulatory guidelines to prevent adverse drug reactions. Drug Use in LTC Notes 14 Drug Use in LTC 15 Chapter Two: Regulatory Guidelines “God made wrinkles to show where smiles have been.” -- Barbara Johnson Regulatory guidelines are an attempt by official agencies to prevent adverse drug reactions. These guidelines are used in the survey process to evaluate drug use in longterm care. In Chapter 1, the points of interaction with nutrition and pharmacology were examined. The adverse effects on the elderly of taking multiple drugs were discussed. This chapter will look at general information about drugs and how drugs affect nutritional status. Chapter 5 is more specific to the elderly. The chapter will begin with a review of drug regulations. Pharmacology legislation and regulations Legislation exists on the Federal level and regulations vary with each state. Congressional legislation focuses on what drugs are safe and effective. The Federal Food and Drug Administration (FDA) was created to oversee drug testing and drug marketing. Today there are three classifications of drugs determined by Federal legislation: • controlled substances; • prescription drugs; and • over-the-counter drugs. Controlled substances are, primarily, those drugs that have the potential to cause addiction. They are divided into five types: Schedule I drugs have high potential for abuse, and have no acceptable medical use in the United States. An example would be heroin. Drug Use in LTC 16 Schedule II drugs have a high potential for abuse, but do have accepted medical use. Drugs in this category can lead to severe psychological or physical dependence. Examples include: morphine, Percodan, Percocet, Ritalin. Schedule III drugs have a medical use, and a lesser degree of addiction potential than schedule II drugs. An examples is Empirin with codeine. Schedule IV drugs have lesser potential for abuse than the drugs in schedules I, II, and III. These drugs would lead to less physical and psychological dependence. Examples include: Librium and Serax. Schedule V drugs have the lowest potential for abuse. They are drug combinations containing small amounts of narcotic drugs for coughs and diarrhea. An example would be Lomotil. These drugs have specific reorder points, and these are the drugs nurses must count at the change of shift. Prescription drugs are considered to be of “sufficient danger,” so are prescribed under supervision of a knowledgeable health professional. No prescription for drugs, other than narcotics, was required before 1954. The Durham-Humphrey Amendment in 1951 required medical supervision of drugs that had the potential for medical complications. These drugs require a written prescription by a physician, dentist or nurse practitioner. This is by far the largest drug category. The FDA requires that these drugs be tested for safety and effectiveness before they are marketed. The OBRA regulations (regulations for nursing homes) in 1989, 1990, 1991 and 1997 changed some regulations for Medicare with regard to giving medications in long-term care, especially psychoactive drugs. Brand Names vs. Generic Generic name is the official, common, or public name used to designate an active drug, whether in pure form or in dosage form. Generic names are coined by committees of officially appointed drug experts and are approved by governmental agencies for national and international use, thus they are nonproprietary. Many drug products are marketed only under the generic name of the principal active ingredient. Prescriptions for generic medicines account for an increased number of all new prescriptions written in the United States. The drugs most commonly prescribed by generic name are listed on the next page, ranked in descending order of the number of new prescriptions issued. (Rybacki, 1998) Drug Use in LTC 17 amoxicillin penicillin VK ampicillin tetracycline prednisone erythromycin hydrochlorothiazide acetaminophen/codeine doxycycline phenobarbital Medicare specifies the use of generic drugs. Medicare believes money will be saved with the generic products. A physician may specify a generic drug may not replace a specific registered brand name drug. A generic drug simply does not enjoy the trademark protection of a brand name drug. Generic drugs save money because they are not well advertised, and save the consumer up to 40 percent of the purchase price. The active drug, or amount of drug, is not altered in a generic replacement drug. Fillers may affect the effectiveness of the active drug. This is why physicians may specify “no substitutions.” Another change may be the manufacturing process used to compound the active drug with fillers. According to FDA guidelines, the generic equivalent may (legally) alter the activity of the drug by a maximum of 20 percent. The FDA believes this 20 percent variation is not enough to change “effectiveness or safety” of the drug. Some drugs such as digoxin (Lanoxin) and warfarin (Coumadin), are allowed only a 3.5 percent variation, due to their small margin of safety. A small margin of safety means there is only a small amount of difference between an effective dose of the drug and toxicity. Medication Fillers Added ingredients which may be used as fillers in medications include: lactose tartrazine caffeine dextrose sesame oil starch cornstarch potato starch aspartame citric acid soybean derivative sucrose saccharin wheat flour phenylalanine metabisulfite natural orange flavor sorbitol mannitol sugar benzyl alcohol alcohol olive oil Drug Use in LTC 18 Caution should be the rule when prescribing generics for the elderly. One cost saving measure used by managed care organizations is to use a therapeutic interchange. Therapeutic interchange means switching an ordered drug for one in the same drug classification that is less expensive. An example is an H2 blocker used for stomach acid being switched for the less expensive Cimetidine (Tagamet). Cimetidine has to be given two to three times a day instead of once. While drug cost is saved, more time is needed for nursing to administer the drug. According to Tim Webster, Executive Director of the American Society of Consultant Pharmacists: It’s a real risky business when the therapeutic interchange is economically driven instead of patient-specific and therapeutically driven … The frail elderly are at highest risk for adverse effects unless you pay attention and make sure this patient is the appropriate candidate. This can be a particular concern with a resident stabilized on a drug regimen. The drug changes can result in the loss of disease control in diabetes, or heart disease, with poor resident outcomes. The result of this is that more money is spent on adverse drug events than the drugs themselves (Reese, 1997). A coalition called the Health Alliance for NTI (Narrow Therapeutic Index) Patient Safety is calling attention to drug substitutions for cardiac arrest, stroke, asthma and depression. This group believes substitution (generics) of these drugs can “lead to adverse drug effects.” The group is joined by the American Health Care Association (AHCA) and includes the American Medical Association, the American Academy of Neurology, and the American Psychiatric Association (Reese, 1997). Therapeutic interchange means switching an ordered drug for one in the same drug classification that is less expensive Over-the-counter medications are those medicines the consumer can purchase without a physician’s prescription. The American Medical Association (AMA) estimated that 75 percent of disease symptoms are treated with over-the-counter medications. These medications include pain medication, antihistamines, antacids, laxatives and headache drugs. Over-the-counter medicines were not tested for safety and effectiveness until 1962. Many drugs were removed from the marketplace at that time, since they were neither safe nor effective. Many drugs remain to be tested, to insure all over-the-counter medicines are safe and effective. In recent years, “dietary supplements” have been available as over-the-counter medications. Dietary supplements are discussed in greater depth in a later chapter. Drug Use in LTC 19 The revised OBRA regulations Unnecessary drugs The revised OBRA regulations define an unnecessary drug under F Tag 329. The 22nd revision was issued December 15, 2006. effective on February 18, 2007. The survey or guidelines are clarified in this section. (F329 (Rev. 22, Issued: 12-15-06, Effective/ Implementation: 12-18-06) 483.25(1) Definitions Definitions are provided to clarify terminology related to medications and to the evaluation and treatment of residents. • “Adverse consequence” is an unpleasant symptom or event that is due to or associated with a medication, such as impairment or decline in an individual’s mental or physical condition or functional or psychosocial status. It may include various types of adverse drug reactions and interactions (e.g. medication-medication, medication-food, and medication-disease). NOTE: Adverse drug reaction (ADR) is a form of adverse consequences. It may be either a secondary effect of a medication that is usually undesirable and different from the therapeutic effect of the medication or any response to a medication that is noxious and unintended and occurs in doses for prophylaxis, diagnosis, or treatment. The term “side effect” is often used interchangeably with ADR; however, side effects are but 1 of 5 ADR categories, the other being hypersensitivity; idiosyncratic response, toxic reactions, and adverse medication interactions. A side effect is an expected, well-known reaction that occurs with a predictable frequency and may or may not constitute an adverse consequence. • “Anticholinergic side effect” is an effect of a medication that opposes or inhibits the activity of the parasympathetic (cholinergic) nervous system to the point of causing symptoms such as dry mouth, blurred vision, tachycardia, urinary retention, constipation, confusion, delirium, or hallucinations. • “Behavioral interventions” are individualized non-pharmacological approaches (including direct care and activities) that are provide as part of a supportive physical and psychosocial environment, and are directed toward preventing, relieving, and/or accommodating a resident’s distressed behavior. • “Clinically significant” refers to effects, results, or consequences that materially affect or are likely to affect an individual’s mental, physical, or psychosocial well-being either positively by preventing, stabilizing, or improving a condition or reducing a risk, or negatively by exacerbating, causing, or contributing to a symptom, illness, or decline in status. • “Distressed behavior” is behavior that reflects individual discomfort or emotional strain. It may present as crying, apathetic or withdrawn behavior, or as verbal or physical actions such as: pacing, cursing, hitting, kicking, pushing, scratching, tearing things, or grabbing others. Drug Use in LTC 20 • “Dose” is the total amount/strength/concentration of a medication given at one time or over a period of time. The individual dose is the amount/strength/concentration received at each administration. The amount received over a 24-hour period may be referred to as the daily dose. “Excessive dose” means the total amount of any medication (including duplicate therapy) given at one time or over a period of time that is greater than the amount recommended by the manufacturer’s label, package insert, current standards of practice for a resident’s age and condition, or clinical studies or evidence-based review articles that are published in medical and/or pharmacy journals and that lacks evidence of: -- A review for the continued necessity of the dose; -- Attempts at, or consideration of the possibility of, tapering a medication; and -- A documented clinical rational for the benefit of, or necessity for, the dose or for the use of multiple medications from the same pharmacologi- cal class. • “Duplicate therapy” refers to multiple medications of the same pharmacological class/category or any medication therapy that substantially duplicates a particular effect of another medication that the individual is taking. • “Duration” is the total length of time the medication is being received. “Excessive Duration” means the medication is administered beyond the manufacturer’s recommended time frames or facility-established stop order policies, beyond the length of time advised by current standards of practice, clinical practice guidelines, clinical studies or evidence-based review articles and/or without either evidence of additional therapeutic benefit for the resident or clinical evidence that would warrant the continued use of the medication. • “Extrapyramidal symptoms (EPS)” are neurological side effects that can occur at any time from the first few days of treatment to years later. EPS includes various syndromes such as: -- Akathisia, which refers to a distressing feeling of internal restlessness that may appear as constant motion, the inability to sit still, fidgeting, pacing, or rocking. -- Medication-induced Parkinsonism, which refers to a syndrome of Parkinson-like symptoms, including tremors, shuffling gait, slowness of movement, expressionless face, drooling, postural unsteadiness and rigidity of muscles in the limbs, neck, and trunk. -- Dystonia, which refers to an acute, painful, spastic contraction of muscle groups (commonly the neck, eyes and trunk) that often occurs soon after initiating treatment and is more common in younger people. • “Gradual Dose Reduction (GDR)” is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued. Drug Use in LTC 21 • “Indications for use” is the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident’s condition and therapeutic goals and is consistent with manufacturer’s recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review articles that are published in medical and/or pharmacy journals. • “Insomnia” is the inability to sleep characterized by difficulty falling asleep, difficulty staying asleep, early waking, or non-restorative sleep, which may result in impaired physical, social, or cognitive function. • “Medication Regimen Review” (MRR) is a thorough evaluation of the medication regimen by a pharmacist with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication. The review includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities in collaboration with other members of the interdisciplinary team. • “Monitoring” is the ongoing collection and analysis of information (such as observations and diagnostic test results and comparison to baseline data in order to: -- Ascertain the individual’s response to treatment and care, including progress or lack of progress toward a therapeutic goal: -- Detect any complications or adverse consequences of the condition or of the treatment; and -- Support decisions about modifying discontinuing, or continuing any interventions. • “Neuroleptic Malignant Syndrome” (NMS) is a syndrome related to the use of medications, mainly antipsychotics, that typically presents with a sudden onset of diffuse muscle rigidity, high fever, labile blood pressure, tremor, and notable cognitive dysfunction. It is potentially fatal if not treated immediately, including stopping the offending medications. • “Non-pharmacological interventions” refers to approaches to care that do not involve medications, generally directed towards stabilizing or improving a resident’s mental physical or psychosocial well-being. • “Psychopharmacological medication” is any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders. • “Serotonin Syndrome” is a potentially serious clinical condition resulting from overstimulation of serotonin receptors. It is commonly related to the use of multiple serotonin-stimulating medications (e.g. SSRIs, SNRIs, triptans, certain antibiotics). Symptoms may include restlessness, hallucinations, confusion, loss of coordination, fast heart beat, rapid changes in blood pressure, increased body temperature, overactive reflexes, nausea, vomiting, and diarrhea. • “Tardive dyskinesia” refers to abnormal, recurrent, involuntary movements that may be irreversible and typically present as lateral movements of the tongue or Drug Use in LTC 22 jaw, tongue thrusting, chewing, frequent blinking, brow arching, grimacing, and lip smacking, although the trunk or other parts of the body may also be affected. Orders from multiple prescribers can increase the resident’s chances of receiving unnecessary medications. Many residents receive orders for medications from several practitioners, for exam, attending and on-call physicians, consultants, and nurse practitioner(s). It is important that the facility clearly identify who is responsible for prescribing and identifying the indications for use of medication(s), for providing and administering the medication(s) and monitoring the resident for the effects and potential adverse consequence of the medication regimen. This is also important when care is delivered or ordered by diverse sources such as consultants, providers, or suppliers (e.g. hospice or dialysis programs). The facility’s pharmacist is a valuable source of information about medications. Listings or descriptions of most significant risks, recommended doses, medication interactions, cautions, etc., can be found in widely available standard references, and computer software and systems that provide up-to-date information. It is important to note that some of the medication information found in many of these references is not specific to older adults or institutionalized individuals. Clinical standards of practice and clinical guidelines established by professional groups are useful to guide clinicians. Some of the recognized clinical resources available for understanding the overall treatment and management of medical problems, symptoms and medication consequences and precautions include those listed below: Valuable Resources • American Geriatric Society: www.americangeriatrics.org www.geriatricsatyourfingertips.org • American Medical Director Association www.amda.com • American Psychiatric Association www.psych.org • American Society of Consultant Pharmacists www.ASCP.com • Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov • American Association for Geriatric Psychiatry www.aagp.org • US Dept of Health & Human Services (National Inst. of Mental Health) www.nimh.nih.gov Drug Use in LTC 23 Although these guidelines generally emphasize the older adult resident, adverse consequences can occur in anyone at any age; therefore, these requirements apply to residents of all ages. Resident Choice A resident and/or representative(s) has the right to be informed about the resident’s condition; treatment options, relative risks and benefits of treatment, required monitoring , expected outcomes of the treatment; and has the right to refuse care and treatment. If a resident refuses treatment, the facility staff and physician should inform the resident about the risks related to the refusal, and discuss appropriate alternatives such as offering the medication at another time or in another dosage form, or offer an alternative medication non-pharmacological approach, if available. Advance Directives A resident may have written or verbal directions related to treatment choices (or a decision has been made by the resident’s surrogate or representative) in accordance with state law. An advance directive is a means for the resident to communicate his or her wishes, which may include withdrawing or withholding medications. Whether or not a resident has an advanced directive, the facility is responsible for giving treatment, support, and other care that is consistent with the resident’s condition and applicable care instructions. NOTE: Choosing not to be resuscitated — reflected in a “Do Not Resuscitate” (DNR) order — indicates that the resident should not be resuscitated if respirations and/ or cardiac function cease. A DNR order by itself dose not indicate that the resident has declined other appropriate treatment and services. Examples of tools that may be used by facility staff, practitioners, or consultants to determine baseline status as well as to monitor for effectiveness and potential adverse consequences may include, but are not limited to those listed in the following chart. Drug Use in LTC 24 Useful Tools to Determine Baseline Status Common Conditions/ Symptoms Diabetes Alzheimer’s Disease/ Dementia Functional Decline Delirium Bipolar disorder Pain Examples of Tools Potential Applications Blood gluDiabnoses cose, Hemo- diabetes and globin A1c determine diabetic control Source/Reference www.endocrineweb.com/diabetes/ diagnosis.html www.diabetes.org/home.isp www.diabetes.niddk.nih.gov/ www.diabetestoolbox.com/HbA1c.asp Mini Mental Determine Status Exam degree of cog(MMSE) nitive impairment www.emedicine.com/med/topic3358.htm www.fpnotebook.com/NEU75.htm Instrumental Assess funcActivities of tional capabiliDaily Living ties (IADL) www.cdc.gov/nchs/datawh/nchsdefs/iadl.htm www.fpnotebook.com/GER3.htm Resident Assessment Instrument (RAI) Assess aspects of nursing home resident’s behavior and function Functional Alzheimer’s Screening Test (FAST) Assess level of function in individuals with dementia Confusion Assessment Method (CAM) Screen for cognitive impairment and delirium Mania Rating Assess severScale ity of mania List of pain scales Assess pain characteristics (e.g. intensity, impact, timing) www.apadiv20.phhp.ufl.edu.fries.htm www.careplans.com/pages/library/ RAI_ user_.pdf http://geriatrics.uthsca.edu/educational/ med_students/fastscale_admin.htm www.hartfordign.org/publications/trythis/ issue13.pdf http://elderlife.med.yale.edu/pdf/ The%20 Confusion%20Assessment%20 Methold.pdf www.psychiatryinpractice. com/ AssessmentToolsdefault. aspx?11=3&12+ 3&13=&13= www.brainexplorer.org/factsheets/ Psychiatry%20Rating%20Scales.pdf www.chcr.brown.edu/pcoc/Physical.htm Drug Use in LTC 25 Useful Tools to Determine Baseline Status, cont. Common Conditions/ Symptoms Examples of Tools Potential Applications Geriatric Depression Scale Screen or monitor individuals at risk for depression www.assessmentpsychology.com/geriatricscales.htm www.hartfordign.org/publications/trythis/issue04.pdf www.merck.com/mrkshared/mmg/ tables/33t4.jsp Cornell Depression in Dementia Scale Screen or monitor for depression in individuals with cognitive impairment www.emoryhealthcare.org/departmentsfugua/ CornellScale.pdf Abnormal movements Abnormal Involuntary Movement Scales (AIMS) Assess presence and severity of involuntary movements that may be due to disease or medications www.carepaths.com/pages/Instruments_ AIMS.asp www.mhsip.org/library/pdfFiles/abnormalinvoluntarymovementscale.pdf Behavioral Symptoms assocated with Dementia Neuropsychiatric InventoryNursing Home Version (NPI-NH) Screen or monitor for behavior associated with dementia (e.g. hallucinations, agitation or anxiety) www.alzheimer-insights.com/insights/vol2no3/vol2no3.htm Behavioral Pathology in Alzheimer Disease Rating Scale (Behave AD) Provide a global rating of non-cognitive symptoms. www.researchinstituteonaging.org/assessment.htm www.geriatrictimes.com/g010533.html Depression Source/Reference Drug Use in LTC Notes 26 Drug Use in LTC 27 Chapter Three: The Beers Criteria “Life is just a bowl of cherries... it’s the pits.” The Beers Criteria -- D. Whiting The Beers Criteria, discussed in Chapter 1, have been developed to guide clinical practice for the elderly patient. Although “these criteria are not meant to regulate practice in a manner to which they supersede the clinical judgment and assessment of the physician or the practitioner” (Fick, 2003), they are of considerable value, and have become the standard of practice. The criteria were updated in 2003 to keep current with new drugs and new information learned over the past 10 years. They identify 48 medications and 20 disease conditions where specific drugs may cause harm in those over 65 years of age. The new criteria are expected to reduce drug costs by preventing adverse drug events. The criteria are also available to include in drug formularies to make unsafe drugs unavailable to those prescribing medications. The medications can also be excluded from formularies developed by insurance companies, and from the new Medicare prescription plan. The availability of criteria to judge unsafe medications is a standard to use in research to develop information on appropriate drug use in the elderly (Fick, 2003; Pronsky, 2004; Dimant, 2002). The Beers Criteria list specific drugs contraindicated with diagnoses of disease categories, as discussed below. Drug Use in LTC 28 1. Heart failure The drug dispoyramide (Norpace® and Norpace CR®) is not recommended for heart failure in the elderly. These drugs cause a negative inotrope effect on the heart muscle. A negative inotrope effect weakens the contraction of the heart. This action increases the risk of heart failure. The drug causes hypokalemia and cardiac risks. A lower dose of this drug is recommended for a person under 110 pounds. Severity risk: High. Drugs with a high sodium content are: (sodium and sodium salts [alginate bicarbonate, biphosphate, citrate, phosphate, salicylate, and sulfate]). These drugs can cause a risk of heart failure due to their high sodium content. The high sodium content causes fluid retention, which can worsen or cause heart failure. Sodium bicarbonate contains 90 mg sodium in 325 mg tablet, and 973 mg sodium in a teaspoon of powdered sodium bicarbonate. Severity Risk: High. Symptoms of heart failure include: edema with shortness of breath, confusion, weakness and fatigue. 2. Hypertension Pseudoephedrine, diet pills and amphetamines are drugs contraindicated with hypertension. These drugs cause an increase in blood pressure. In addition, these drugs can cause tachycardia, and anorexia as a result of central nervous system (CNS) stimulation. Severity Risk: High. Diet pills of concern may include: amphetamine (Adderall®); dextroamphetamine (Dexadrine®); diethypropion (Tenuate®); as examples. Methyphenidate (Ritalin®) and Permolile (Cylert®) are considered CNS stimulants, and are used at times in the elderly to stimulate the CNS in those who are unresponsive to their environment. Severity Risk: High. 3. Gastric or duodenal ulcers Gastric or duodenal ulcers can be caused or made worse by the use of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) such as ibuprofen or Advil, or aspirin doses over 325 mg used for pain relief. NSAIDs that are not Cox-II inhibitors destroy the protective mucus in the gastrointestinal tract that protects from bleeding. These drugs also increase the risk of severe gastrointestinal bleeding in the elderly. Cox-II inhibitors are excluded. Severity Risk: High. Drug Use in LTC 29 4. Seizures or epilepsy Contraindicated the use of clozapine (Clozaril®), chlorpromazine (Thorazine®), thioridazine (Mellaril®), and thiothixene (Navane®). These drugs lower the seizure threshold and make seizures more likely to occur. Seizures may occur for the first time in residents with dementia as their cognitive loss progresses. Severity Risk: High. 5. Blood clotting disorders Residents requiring anticoagulant therapy are at risk for bleeding when these drugs are used: Aspirin, NSAIDs, dipyridamole (Persantin®), ticlopidine (Ticlid®), and clopidogrel (Plavix®). Severity Risk: High. In long-term care, it is not uncommon to have residents on warfarin (Coumadin) therapy and aspirin and Plavix. The nutrition professional may note bleeding by noting a drop in the hemoglobin level. 6. Bladder flow obstruction Bladder flow obstruction in residents may be made worse by the use of the following drugs: anticholinergics and antihistamines, gastrointestinal antispasmodics, muscle relaxants, oxybutynin (Ditropan®), flavoxate (Urispas®), anticholinergics, antidepressants, decongestants, and tolterodine (Detrol®). These drugs increase urine retention and decrease urine flow. Some of the drugs in this group are used for incontinence in the elderly. At times, these drugs may cause urinary tract infections due to urinary retention. Severity Risk: High. 7. Stress incontinence Stress incontinence (urine released when a cough or sneeze occurs) may be caused by drugs in this category. The drugs increase urine flow and may cause or increase incontinence: A-Blockers (Doxazosin,® Prazosin,® and Terazosin®), anticholinergics, tricyclic antidepressants (imipramine hydrochloride, doxepin hydrochloride, and amitriptyline hydrochloride), and long-acting benzodiazepines. Note alpha-blockers such as Cardura® are used for hypertension. Severity Risk: High. 8. Arrhythmias Arrhythmias may be affected by the use of these anti-depressants: Tricyclic antidepressants (impiramine hydrochloride, doxepin hydrochloride, and amitriptyline hydrochloride). These drugs may alter the QT interval, increase arrhythmias and cause a decline in cardiac activity. Severity Risk: High. Drug Use in LTC 30 9. Insomnia Residents with insomnia should avoid decongestants, theophylline, methyphenidate, amphetamines and monoamine oxidase inhibitors (MAOI). These drugs cause central nervous system stimulation and interfere with sleep. Severity Risk: High. 10. Parkinson’s disease Parkinson’s disease is affected by the following drugs: Metoclopramide (Reglan®), conventional antipsychotics, and tacrine (Cognex®). These drugs affect the neurotransmitters dopamine and acethylcholine. Dopamine is decreased in Parkinson’s disease and acethylcholine is increased. These drugs increase the affect of acethylcholine while decreasing dopamine, and worsen the disease. Severity Risk: High. 11. Cognitive impairment Cognitive impairment in residents is negatively influenced by the use of these drugs: Barbiturates, anticholinergics, antispasmodics, and muscle relaxants. Also, CNS stimulants: dextroamphetamine, amphetamine (Adderall), methylphenidate (Ritalin), methamphetamine (Desoxyn®), and pemolin. These drugs alter the central nervous system and can decrease cognitive function. Severity Risk: High. 12. Depression Depression is worsened or caused by the use of these drugs: Long-term benzodiazepine use. Sympatholytic agents: methyldopa (Aldomet®), resperine, and guanethidine (Ismelin®). Severity Risk: High. 13. Anorexia and malnutrition Anorexia and malnutrition are caused by the use of these drugs: CNS stimulants dextroamphetamine, amphetamine (Adderall), methylphenidate (Ritalin), methamphetamine (Desoxyn), pemolin, and fluoxetine (Prozac®). These drugs may depress the appetite. Prozac and other seritonin uptake inhibitors (SSRI) may initially cause weight loss; however, long-term use may cause weight gain. Severity Risk: High. 14. Syncope or falls Syncope or falls can result from the use of these drugs: Short- to intermediate-acting benzodiazepine and tricyclic antidepressants (imipramine hydrochloride, doxepin hydrochloride, and amitriptyline hydrochloride). Many of these drugs are older anti-de- Drug Use in LTC 31 pressant agents. Psychomotor function is affected and results in falls. These falls increase the risk of a hip fracture. Severity Risk: High. 15. Siadh/Hyponatremia Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) and hyponatremia may be caused by the following drugs: SSRI: fluoxetine (Prozac), citalopram (Celax®), fluvoxamine (Luvox®), paroxetine (Paxil®), and sertraline (Zoloft®). Severity Risk: Low. 16. Seizure disorder Seizure disorders may be increased with the use of the antidepressant Wellbutrin®. Severity Risk: High. 17. Obesity Obesity risk is increased with the anti-psychotic drug Zyprexa®. Also noted is that Zyprexa increases the risk of Type 2 Diabetes. Severity Risk: Low. 18. COPD COPD is made worse by the use of the adverse central nervous system effects of these drugs: Long-acting benzodiazepines: chlordiazepoxide (Librium®), chlordiazepoxide-amitriptyline (Limbitrol®), clidinium-chlordiazepoxide (Librax®), diazepam (Valium®), quazepam (Doral®), halazepam (Paxipam®), and chlorazepate (Tranxene®). Beta-blockers: propranolol. The drugs may depress the respiratory tract and worsen the disease. The symptoms of worsening respiratory depression are: increased cough, shortness of breath, tightness in chest, wheezing, and increase in sputum production. Severity Risk: High. 19. Chronic constipation Chronic constipation may worsen with the use of these drugs: Calcium channel blockers, anticholinergics, and tricyclic antidepressant (imipramine hydrochloride, doxeppin hydrochloride, and amitriptyline hydrochloride). Severity Risk: Low. The survey guidelines have more completely described some of the negative effects of individual drugs and drug categories. Drug UseDrugs in LTC Are Potentially 32 Diagnosis in Which Certain Contraindicated 2003 Criteria for Potentially Inappropriate Medication Use in Older Adults: Considering Diagnoses or Conditons Disease or Condition Severity Rating Notes Drug Concern Heart Failure Disopyramide (Norpace, Norpace CR) and high sodium content drugs (sodium and sodium salts [alginate bicarbonate, biphosphate, citrate, phosphate, salicylate, and sulfate]). Negative inotropic effect. Potential to promote fluid retention and exacerbation of heart failure. High Drugs weaken cardiac contraction and increases risk of heart failure. The drugs with the high sodium content cause fluid retention and can increase the risk of heart failure. Symptoms of cardiac failure potential adverse effects: • Edema with weight gain • Shortness of breath • Confusion • Weakness and fatigue • Disorientation Hypertension Phenylpropanolamine hydrochloride (removed from the market in 2001), pseudoephedrine; diet pills and amphetamines. May produce elevation of blood pressure secondary to sympathomimetic activity. High These medicines can increase blood pressure. Gastric or duodenal ulcers NSAIDs and aspirin (>325 mg) (Cox II Inhibitors excluded) Ketorolac (Toradol) May exacerbate existing ulcers or produce new/additional ulcers. High Cox II inhibitors are not included in the exclusion of NSAIDs. These medicines can cause additional ulcers, dyspepsia, abdominal pain, gastrointestinal bleeding, or vomiting. Seuzures or epilepsy Clozapine (Clozaril), chlorpromazine (Thorazine), thioridazine (Mellaril), and thiothixene (Navane) May lower seizure thresholds. High These drugs lower the seizure threshold and increase the risk of a seizure. May prolong clotting time and elevate INR values or inhibit platelet aggregation, resulting in an increased potential for bleeding. High These drugs increase the risk of bleeding. Aspirin, NSAIDs, dipyridamole Blood clotting (Persantin), ticlopidine (Ticlid), disorders or receiving antico- and clopidogrel (Plavix) agulant therapy Bladder outflow obstruction Anticholinergics and antihistamines, gastrointestinal antispasmodics, muscle relaxants, oxybutynin (Ditropan), flavoxate (Urispas), anticholinergics, antidepressants, decongestants, and tolterodine (Detrol) May decrease urinary flow, leading to urinary retention. High Narcotic drugs, barbiturate drugs, and all beta blockers except propranolol (Inderal) Increases risk of urinary retention, and decreased urine flow. Stress incontinence A-Blockers (Doxazosin, Prazosin, and Terazosin), anticholinergics, tricyclic antidepressants (imipramine hydrochloride, doxepin hydrochloride, and amitriptyline hydrochloride), and long-acting benzodiazepines. May produce polyuria and worsening of incontinence. High The drugs increase urine production and may worsen incontinence. Arrhythmias Tricyclic antidepressants (impiramine hydrochloride, doxepin hydrochloride, and amitriptyline hydrochloride) Concern due to proarrhythmic effects and ability to produce QT interval changes. High These drugs may increase arrhythmias and worsen cardiac activity. DrugDrugs Use in LTC 33 Diagnosis in Which Certain Are Potentially Contraindicated, cont. 2003 Criteria for Potentially Inappropriate Medication Use in Older Adults: Considering Diagnoses or Conditons Disease or Condition Severity Rating Notes Drug Concern Insomnia Decongestants, theophylline (Theodur), methylphenidate (Ritalin), MAOIs, and amphetamines. Concern due to CNS stimulant effects. High Desipramine (Pertofrane, Norpramin), Selective Serotonin Uptake Inhibitors, Beta-agonists have been removed from this list. The drugs may worsen insomnia. Parkinson’s Disease Metoclopramide (Reglan), conventional antipsychotics, and tacrine (Cognex) Concern due to their antidopaminergic / cholinergic effects. High These drugs are a risk for worsening the Parkinson’s disease due to alteration in the activity of dopamine and/or acethylcholine. Cognitive impairment Barbiturates, anticholinergics, antispasmodics, and muscle relaxants. CNS stimulants: dextroAmphetamine (Adderall), methylphenidate (Ritalin), methamphetamine (Desoxyn), and pemolin Concern due to CNS-altering effects. High These drugs can alter central nervous system action and worsen cognitive status. Depression Long-term benzodiazepine use. Sympatholytic agents: methyldopa (Aldomet), resperine, and guanethidine (Ismelin) May produce or exacerbate depression. High Drugs may cause or worsen depression Anorexia and malnutrition CNS stimulants DextroAmphetamine (Adderall), methylphenidate (Ritalin), methamphetamine (Desoxyn), pemolin, and fluoxetine (Prozac) Concern due to appetitesuppressing effects. High May affect a decrease in appetite. Short- to intermediate-acting benzodiazepine and tricyclic antidepressants (imipramine hydrochloride, doxepin hydrochloride, and amitriptyline hydrochloride) May produce ataxia, impaired psychomotor function, syncope, and additional falls. High Drugs increase the risk of falls by impairing psychomotor function. Low Drug may cause syndrome of inappropriate anti-diuretic hormone secretion causing hyponatremia. Syncope or falls SIADH / Hypo- SSRIs: fluoxetine (Prozac), citalopram natremia (Celax), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft) May exacerbate or cause SIADH. Seizure disorder Bupropion (Wellbutrin) May lower seizure threshold. High Obesity Olanzapine (Zyprexa) May stimulate appetite and increase weight gain. Low Drug may increase appetite, weight gain, and may increase risk of diabetes type 2. COPD Long-acting benzodiazepines: chlordiazepoxide (Librium), chlordiazepoxideamitriptyline (Limbitrol), clidiniumchlordiazepoxide (Librax), diazepam (Valium), quazepam (Doral), halazepam (Paxipam), and chlorazepate (Tranxene). Beta-blockers: propranolol. CNS adverse effects. May induce respiratory depression. May exacerbate or cause respiratory depression. High Can cause respiratory depression and central nervous system effects worsening disease: • Increased cough • Shortness of breath • Tightness in chest • Wheezing • Increase in sputum production Chronic constipation Calcium channel blockers, anticholinergics, and tricyclic antidepressant (imipramine hydrochloride, doxeppin hydrochloride, and amitriptyline hydrochloride) May exacerbate constipation. Low Increase the risk of constipation. Drug Use in LTC Notes 34 Drug Use in LTC 35 Chapter Four: 2006 Medication Survey Guidelines “A man is not idle because he is absorbed in thought. There is a visible labor and there is an invisible labor.” ~ Victor Hugo (This chapter includes the latest survey guidelines (from Dec. 15, 2006; implemented Jan. 15, 2007). These guidelines came from the Centers for Medicare & Medicaid Services, Revised Long-Term Care Facility Resident Assessment Instrument User’s Manual, Version 2.0, (Dec. 2002, revised March 2007). On average, senior citizens spend about $3 billion a year on prescription medications. In addition to prescription medicines, the elderly take approximately 40 percent of the over-the-counter medicine. In addition, 40 percent of the elderly over age 65 have taken a nutrition supplement in the last year. The supplements most likely to be taken were not vitamins or minerals, but herbal supplements. The most common supplements taken were: • Ginkgo biloba • St. John’s Wort • Saw palmetto • Ginseng • Yohimbe • Senna, cascara The potential for adverse effects of drugs rises with increased drug use, and the elderly have a three- to seven-times greater likelihood of experiencing an adverse drug reaction than middle-age adults. Health care costs increase due to hospitalizations alone. Data from North America and England shows that 30 percent of admissions of elderly patients to acute care hospitals are due to adverse drug reactions. Drug Use in LTC 36 Costs include $37.6 billion to $50 billion for adverse events, and between $17 and $29 billion for preventable adverse events. Health care costs count for 50 percent of these costs (Brown, 2004). Examples of common side effects of drugs in the elderly include:gastrointestinal bleeds or hemorrhages from high doses of non-steroidal anti-inflammatory drugs (NSAID) such as ibuprofen, available as over-the-counter drugs. There are 16,500 deaths each year from the use of NSAID, used mostly by the elderly (Dimant, 2002). Adverse drug events in nursing homes The average long-term care resident receives six medications daily, on average; some may use up to 10 or more drugs. A drug may be given one to four times a day, thus increasing the risk of adverse drug events. Drugs provoke multiple adverse events in long-term care, many of which can be prevented, according to Gurwitz (2000). An important study was conducted in 18 nursing homes in Massachusetts over a one-year period, involved 2,916 nursing home residents, totaling28,839 patient-months of care. About 80 percent of the residents were women, averaging about 84 years old. Reports of adverse medication events were obtained from two sources: self-reporting, and reviews of resident records conducted by a specially trained nurse and pharmacist from the study team. An incident was judged to be an “adverse drug event,” or a “potential adverse event,” by the agreement of two independent physicians. A potential adverse event was an adverse drug event caught and corrected in advance. The drug events were also classified by severity and preventability. During the study, 546 adverse drug events occurred, or 1.89 adverse events per 100 resident-months. There were also 188 potential adverse drug events. One adverse drug event resulted in death, 31 were life-threatening, 206 were serious, and 308 were significant. The study showed 51 percent of the adverse drug events were avoidable. Antibiotic drugs were responsible for 36 percent of adverse events and 5 percent of preventable drug events. Psychoactive drugs were commonly used: antidepressants were used by 36 percent of residents, anti-anxiety/hypnotic drugs by 24 percent of residents, and antipsychotic drugs by 17 percent of residents. The average long-term care resident receives six medications daily, on average, some may use up to 10 or more drugs. While these two groups were associated with numerous events, almost 80 percent of drug events were associated with the use of the anticoagulant warfarin, commonly prescribed in long-term care to prevent clotting. Bleeding is a serious adverse effect. The relevant measurement is Internationalized Normalized Ratio — a standardized measure of the clotting ability of the blood, expressed as prothrombin time (PT) or clotting response time. An INR of 1.0 is normal; an INR of 2.0 indicates double the normal PT. Drug Use in LTC 37 The mean INR in the study was 6.1, with a range of 4.0 to 15.6. The values were also kept at less than 1.5 for several weeks of treatment in some residents. The ideal INR is considered to be 2 to 3 (to prevent clotting in less-active residents). Those residents with a high INR were subject to bleeding, and those with a low INR were receiving no therapeutic benefit from the warfarin, and were thus subject to a heart attack or stroke. Bleeding was responsible for 14 percent of the adverse events, with only 6 percent of these events believed to be preventable. The use of neuropsychiatric drugs was associated with the majority of the adverse outcomes, resulting in delirium, oversedation, confusion, falls and hallucinations. Falls occurred in 20 percent of the residents with only 4 percent considered non-preventable. Gastrointestinal effects of medications caused 12 percent of adverse drug reactions. The adverse drug events were caused in the Ordering stage 68 percent of the time, and in the Monitoring stage 70 percent of the time; 0.7 percent of errors occurred in the transcription of drugs, and 0.5 percent in the dispensing of drugs. In the Ordering stage, the most common error was giving a geriatric patient an excessive dose of medication, but 22 percent of errors were due to ordering a drug that would cause a known reaction with a drug already prescribed. The third most common error in prescription of drugs in this study was ordering of the wrong drug for the patient. Most drug monitoring errors by physicians tended to involve not ordering laboratory monitoring for drug levels on a timely basis. The most common examples of failure to monitor involved warfarin and digoxin, used to regulate heart activity. If these findings hold true for nursing homes across the country, 24 adverse drug events should be identified in every nursing home and eight potentially avoidable drug reactions should occur in a year: Dimant (2000) summarized: …350,000 adverse drug events — more than half of which are preventable — occur each year in the 1.55 million residents of US nursing homes. There are almost 20,000 fatal or life-threatening adverse drug events per year, of which 80 percent are preventable. Adverse drug interactions The list of the Top 10 dangerous drug interactions in long-term care was determined by 500 geriatric pharmacists and a survey taken at the American Medical Directors Association (AMDA) meeting in March of 2001. This was a project of the Multidisciplinary Medication Management Project (M3 Project). The Top 10 are: 1. Warfarin (Coumadin®) – NSAID. Common drugs interacting with warfarin are Aleve®, Daypro®, Dolobid®, ibuprofen, Motrin®, naproxen, Oruidis®, and Voltaren®. This combination of drugs can result in serious gastrointestinal bleeding. NSAID decrease the ability of platelets to clot. The PT and INR must be checked weekly if these drugs are used together. The resident must be monitored for signs of bleeding, such as: Drug Use in LTC 38 • bruises; • coffee ground-like substance coughed up by resident; • nose or gums bleeding; • blood in urine; and/or • black or tarry stools. 2. Warfarin – Sulfa. This drug interaction also increases the risk of bleeding. The reason suggested for the increased risk of bleeding is due to a decrease in vitamin K synthesis in the colon. The antibiotic destroys the production of vitamin K flora. Sulfa drugs include Bactrim®, Septra®, sulfamethoxazole and trimethoprim. Monitoring of INR levels is suggested every other day if this combination of drugs is used together. Symptoms of active bleeding should be monitored. 3. Warfarin and Macrolides used in combination. Macrolide antibiotics include: azithromycin, Biaxin®, clarithromycin, E-Mycin®, Ery-Tab®, Erythrocin®, erythromycin/sulfisoxazole, and Zithromax®. The mechanism for causing gastrointestinal bleeding is the same as for sulfa drugs. Monitoring is also the same as for sulfa drugs. 4. Warfarin and quinolone used in combination. The quinolones are a family of broad-spectrum antibiotics. Quinolone drugs include: Cipro®, Floxin®, Levaquin®, Maxaquin®, Noroxin®, and Tequin®. This combination of drugs can cause bleeding by the same mechanism as sulfa drugs. Monitoring should be the same as for sulfa drugs. 5. Warfarin and Phenytoin (Dilantin®) can potentiate the effects of either drug. Dilantin levels should be obtained prior to beginning warfarin. The INR levels for warfarin should be kept at lower therapeutic levels. Signs and symptoms of bleeding should be monitored, as well as Dilantin and INR levels. 6. ACE Inhibitors can increase serum potassium levels by decreasing aldosterone levels and decreasing potassium excretion. ACE (angiotensin converting enzyme) Inhibitors include: Accupril®, Altace®, Capoten®, Enalapril®, Lisinopril®, Lotensin®, Monopril®, Prinivil®, Quinapril®, Vasotec® and Zestril®. Potassium supplements include: K+Care®, K-Dur®, Klor-Con®, K-Phos®, MicroK®, as examples. A potassium level should be determined before initiating ACE Inhibitors. Potassium levels over 5.0 mg/dL should be carefully monitored for EKG changes and changes in renal function. Potassium levels must be monitored when taking ACE Inhibitors with potassium supplements. 7. ACE Inhibitors and spironolactone (Aldactone®) used in combination can also elevate potassium levels. The combination may raise K levels. Same monitoring levels should be in place as in number 6, above. 8. Digoxin (Lanoxin®) and amiodarone (Cordarone®) may cause digoxin toxicity. Digoxin levels should be determined prior to prescribing amiodarone. The digoxin dose should be decreased by one-half and digoxin levels monitored for several weeks. Monitor resident for symptoms of digoxin toxicity: Drug Use in LTC • Nausea • abdominal pain • mental changes • vertigo • anorexia 39 • fatigue • restlessness • blurred vision • diarrhea 9. Digoxin and verapamil (Calan®, Isoptin®, and Verelan®) used in combination. This combination of drugs may result in digoxin toxicity. The heart rate and EKG-PR interval should be monitored. Signs of digoxin toxicity should be monitored as listed in number 8, above. 10. Theophylline and quinolones used in combination can cause theophylline toxicity. Quinolones are listed in number 4. Theophylline drugs include: aminophylline, Slo-bid®, Slo-Phyllin®, Theo-IL®, Theo-Dur®, and Theolair®. The quinolone drugs inhibit theophylline metabolism, and thereby increase theophylline levels to toxic levels. Alternative theophylline drugs that may be safer to use with quinolone are: gatifloxacin, levofloxacin, moxifloxacin or trovafloxacin, which do not seem to interfere with metabolism of theophylline. Theophylline levels should be kept at 5 to 15 mcg/ml. In addition to laboratory levels, symptoms of theophylline toxicity should be monitored. These ten drug combinations can cause danger to residents. Careful monitoring of these drug combinations is recommended for resident safety (Brown, 2004). According to Wayne K. Anderson, Dean of the State University of New York School of Pharmacy, “Statistically, if you take six different drugs, you have an 80 percent chance of at least one drug-drug interaction.” Remember that drugs can cause illness. Drugs are most often tested in healthy young persons, and not in the elderly with multiple health problems – both chronic and acute. Be wary of the effect of new drugs on sick and frail elders. It may take some time before unwarranted outcomes or case reports appear in the literature. In the meantime, residents may suffer from the consequences of the unproven drug. The elderly in all health care settings are at risk for adverse drug reactions. Drug regimes also need to be revised to meet the needs of the elderly. More than five drugs per day increases the risk of negative outcomes. Remember that drugs can cause illness. Quality of life issues Quality of life is a major issue for those with limited years remaining to live. As many elders enter acute, sub-acute or long-term care, their priorities for clinical interven- Drug Use in LTC 40 tions may change. The elderly may choose less medicine and clinical nutrition for more enjoyment in their later years. In long-term care this is considered their right, as long as they (or their family or power of attorney) are aware of any consequences that may result. The harmful side effects of inappropriate prescribing include falls, fractures, acute confusion, and death. Urinary retention, anorexia, sedation, constipation and urinary incontinence are less dramatic reactions. Even an unneeded iron supplement results in constipation, anorexia, abdominal discomfort and the need for a laxative (Beers, et al., 1992). Drug errors A meta-review of 10 studies reported since 1994 and 2001 on adverse drug events in hospitals by Kanjanarat, et al. (2003), evaluated drugs, drug classifications, and adverse outcomes from drugs. The study also looked at preventable drug errors. The authors of this study reasoned that, if they could identify the most common drugs and classifications of drugs involved in adverse events, a focus on these drugs or drug classifications would reduce drug errors. Qualitative analysis found cardiovascular drugs were the most common drugs causing adverse drug reactions. The classification of drugs most often involved was antihypertensive — such as beta-blockers, ACE Inhibitors and nitrates. The second category of drugs most likely to result in adverse drug effects was the psychoactive drugs — including sedatives, hypnotics, antidepressants and antipsychotic, especially benzodiazepines. The next-most-common category of drugs was pain medications – such as opioids, and NSAID. Commonly used for arthritis pain, NSAID cause gastric ulcers and bleeding. Anticoagulants were the next category of concern, followed by antibiotics — especially penicillin and cephalosporin. Anti-infective drugs were believed to be the most easily prevented adverse reaction, if a known allergy exists. The next most easily prevented drug reactions involved the cardiovascular drugs, then psychoactive drugs, and finally the analgesics. The study involved 111,700 patients from various countries around the world. The same types of error were commonly reported in multiple countries. The following tables list, alphabetically, examples of some categories of medications that have the potential to cause clinically significant adverse consequences that may have limited indications for use, require specific monitoring, and which warrant careful consideration of relative risks and benefit. Inclusion of a medication in this table does not imply that it is contraindicated for every resident. Medications are identified by generic rather than trade names. Drug Use in LTC 41 NOTE: These tables are based on review of a variety of pharmaceutical references. It does not include all categories of medications or all medications within a category, and does not address all issues or considerations related to medication use, such as dosages. Medications other than those listed in this table may present significant issues related to indications, dosage, duration, monitoring, or potential for clinically significant adverse consequences. Since medication issues continue to evolve and new medications are being approved regularly, it is important to refer to a current authoritative source for detailed medication information such as indications and precautions, dosage, monitoring or adverse consequences. The listed doses for psychopharmacological medications are applicable to older individuals. The facility is encouraged to initiate therapy with lower doses and, when necessary, only gradually increase doses. The facility may exceed these doses if it provides evidence to show why higher doses were necessary to maintain or improve the resident’s function and quality of life. Drug Use in LTC 42 Medication Issues of Particular Relevance MEDICATION ANALGESICS • e.g. Acetaminophen ISSUES AND CONCERNS DOSAGE/ADVERSE CONSEQUENCE • Daily doses greater than 4 gm/day from all sources (alone or as part of combination products) may increase risk of liver toxicity. MONITORING • For doses greater than the maximum recommended daily dose, documented assessment should reflect periodic monitoring of liver function and indicate that benefits outweigh risks. NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAID) Non-selective NSAID • aspirin • diclofenac • diflunisal • ibuprofen • indomethacin • ketorolac • meclofenamate • naproxen • piroxicam • salicylates • tolmetin CYCLOOXYGENASE-II (COX-2) INHIBITORS • celecoxib OPIOID ANALGESICS Short-acting, e.g. • Codeine • Fentanyl • Hydrocodone • Hydromorphone • Meperidine • Morphine • Oxycodone NSAID, including COX-2 inhibitors, should be reserved for symptoms and/or inflammatory conditions for which lower risk analgesics (e.g., acetaminophen) have either failed or are not clinically indicated. EXCEPTION: Use of low-dose aspirin (81-325 mg) as prophylactic treatment for cardiovascular events such as myocardial infarction or stroke may be appropriate. INTERACTIONS • Aspirin may increase the adverse effects of COX-2 inhibitors on the gastrointestinal (GI) tract. • Some NSAIDS (e.g. ibuprofen) may reduce the cardioprotective effect of aspirin MONITORING • Monitoring closely for bleeding when ASA>325 mg/day is being used with another NSAID or when NSAIDs are used with other platelet inhibitors or anticoagulants (See 42 CFR 483.60 (c) F428 for Table of Common Medication-Medication Interactions in Long Term Care) ADVERSE CONSEQUENCES • May cause gastrointestinal (GI) bleeding in anyone with a prior history of, or with increased risk for, GI bleeding. Compared to nonselective NSAID, COX-2 inhibitors may reduce-but do not eliminate-risk of gastrointestinal bleeding. • May cause bleeding to anyone who is receiving warfarin, heparin, other anticoagulants, or platelet inhibitors (e.g. ticlopidine, clopidogrel, and dipyridamole). • Any NSAID may cause or worsen renal failure, increase blood pressure, or exacerbate heart failure. • Prolonged use of indomethacin, piroxicam, tolmetin, and meclofenamate should be avoided because of central nervous system side effects, e.g. dizziness somnolence, confusion. INDICATIONS • The initiation of longer-acting opioid analgesics is not recommended unless shorter-acting opioids have been tried unsuccessfully, or titration of shorter-acting doses has established a clear daily dose of opioid analgesic that can be provided by using a long-acting form. • Meperidine is not an effective oral analgesic in doses commonly used in older individuals. continued on following page Drug Use in LTC 43 Medication Issues of Particular Relevance, cont. OPIOID ANALGESICS Long-acting, e.g. • fentanyl, transdermal • methadone • morphine, sustained-release • oxycodone, sustained-release PENTAZOCINE PROPOXYPHENE e.g. • Darvon • Darvocet (and related compounds) ANTIBIOTICS PARENTERAL VANCOMYCIN AND AMINOGLYCOSIDES, e.g. • Amikacin • Gentamycin/ gentamicin • Tobramycin ADVERSE CONSEQUENCES • May cause constipation, nausea, vomiting, sedation, lethargy, weak- ness, confusion, dysphoria, physical and psychological dependency, hallucinations and unintended respiratory depression, especially in individuals with compromised pulmonary function. These can lead to other adverse consequences such as falls. • Meperidine use (oral or injectable) may cause confusion, respiratory depression even with therapeutic analgesic doses • Active metabolite of meperidine (normeperidine) accumulates with repeated use and has been associated with seizures. INDICATIONS • Limited effectiveness because it is a partial opiate agonist-antagonist; is not recommended for use in older individuals ADVERSE CONSEQUENCES • This opioid analgesic causes central nervous system side effects (including confusion and hallucinations) more commonly than other opioid analgesics. • May cause dizziness, lightheadedness, euphoria, sedation, hypotension, tachycardia, syncope. INDICATIONS • Offers few analgesic advantages over acetaminophen, yet has the adverse effects, including addiction risk of other opioid medications; is not recommended for use in older individuals ADVERSE CONSEQUENCES • May cause hypotension and central nervous system effects (e.g. confusion, drowsiness, dizziness) that can lead to other adverse consequences such as falls INDICATIONS • Use of all antibiotics should be limited to confirmed or suspected bacterial infection. ADVERSE CONSEQUENCES • Any antibiotic may cause diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions • Antibiotics are non-selective and may result in the eradication of beneficial microorganisms and the emergence of undesired ones, causing secondary infections such as oral thrush, colitis, and vaginitis. MONITORING • Use must be accompanied by monitoring of renal function tests (which should be compared with the baseline) and by serum medication concentrations. • Serious adverse consequences may occur insidiously if adequate monitoring does not occur EXCEPTION: Single-dose administration prophylaxis. ADVERSE CONSEQUENCES • May cause or worsen hearing loss and renal failure. continued on following page Drug Use in LTC 44 Medication Issues of Particular Relevance, cont. NITROFURANTOIN INDICATIONS • It is not the anti-infective/antibiotic of choice for treatment of acute urinary tract infection or prophylaxis in individuals with impaired renal function (CrCl<60 ml/min) because of ineffectiveness and the high risk of serious adverse consequences. ADVERSE CONSEQUENCES • May cause pulmonary fibrosis (e.g. symptoms including dyspnea, cough) and peripheral neuropathy. FLUOROQUINOLONES, e.g. • Ciprofloxacin • Levofloxacin • Moxifloxacin • Ofloxacin INDICATIONS • Use should be avoided in individuals with prolonged QT intervals or who are receiving antiarrhythmic agents in class Ia (e.g. procainamide), class Ic (e.g. flecainide) or class III (e.g. amiodarone). ANTICOAGULANTS, e.g. • warfarin MONITORING • Use must be monitored by Prothrombin Time (T/International Normal- ization Ratio (INR), with frequency determined by clinical circum- stances, duration of use, and stability of monitoring results. ADVERSE CONSEQUENCES • May cause prolonged QT interval. • May increase risk of hypo- or hyperglycemia in individuals aged 65 or older, and in individuals with diabetes mellitus, renal insufficiency (Cr Cl<60 ml/min) or those receiving other glucose-altering medications. • May increase risk of acute tendonitis. ADVERSE CONSEQUENCES • Multiple medication interactions exist (See 42 CFR 483.60(c) F428 for table of Common Medication-Medication Interactions in Long Term Care) which may: - Significantly increase PT/INR results to levels associated with life- threatening bleeding, or - Decrease PT/INR results to ineffective levels, or - Increase or decrease the serum concentration of the interacting medication. ANTICONVULSANTS,e.g. • carbamazepine • Gabapentin • lamotrigine • levetiracetam • oxcarbazepine • phenobarbital • phenytoin • primidone • valproic acid INDICATIONS • In addition to seizures, may also be used to treat other disorders, such as bipolar disorder, schizoaffective disorder, chronic neuropathic pain, and for prophylaxis of migraine headaches. • Need for indefinite continuation should be based on confirmation of the condition (for example, distinguish epilepsy from isolated seizure due to medical cause or distinguish migraine from other causes of head - aches) and its potential causes (medications, electrolyte imbalance, hypocalcemia, etc.) DURATION • If used to manage behavior, stabilize mood, or treat a psychiatric disorder, refer to Section V – Tapering of a Medication Dose/Gradual Dose Reduction (GDR) in the guidance. MONITORING • Serum medication concentration monitoring is not required or available for all anticonvulsants. Only the following anticonvulsants should be monitored with periodic serum concentrations: Phenytoin, phenobar- bital, primidone, divalproex sodium (as valproic acid), and carbamazepine. continued on following page Drug Use in LTC 45 Medication Issues of Particular Relevance, cont. ANTICONVULSANTS,cont’d • Serum medication concentrations may help identify toxicity, but signifi- cant signs and symptoms of toxicity can occur even at normal or low serum concentrations. • When anticonvulsants are used for conditions other than seizure disorders (e.g. as mood stabilizers), the same concerns exist regarding the need for monitoring for effectiveness and side effects; but evaluation of symptoms-not serum concentrations-should be used to adjust doses. High or toxic serum concentrations should, however, be evaluated and considered for dosage adjustments. • Symptom control for seizures or behavior can occur with subtherapeutic serum medication concentrations. ADVERSE CONSEQUENCES • May cause liver dysfunction, blood dyscrasias, and serious skin rashes requiring discontinuation of treatment. • May cause nausea/vomiting, dizziness, ataxia, somnolence/lethargy, incoordination, blurred or double vision, restlessness, toxic encephalopa thy, anorexia, headaches. These effects can increase the risk for falls. ANTIDEPRESSANTS (All antidepressant classes): • alpha-adrenoceptor antagonists, e.g. Mirtazapine • Dopamine-reuptake blocking compounds, e.g.Bupropion • Monoamine oxidase inhibitors (MAOI) • Serotonin (5-HT 2) antagonists, e.g. Nefazodone,Trazodone • Selective serotonin-norepineph- rine reuptake inhibitors (SNRI), e.g.fluoxetine, venlafaxine • Selective serotonin reuptake inhibitors (SSRI), e.g. citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline • Tricyclic (TCA) and related compounds INDICATIONS • Agents usually classified as “antidepressants” are prescribed for conditions other than depression including anxiety disorders, post-traumatic stress disorder, obsessive compulsive disorder insomnia, neuropathic pain (e.g., diabetic peripheral neuropathy), migraine headaches, urinary incontinence, and others. DOSAGE • Use of 2 or more antidepressants simultaneously may increase risk of side effects; in such cases there should be documentation of expected benefits that outweigh associated risks and monitoring for any increase in side effects. DURATION • Duration should be in accordance with pertinent literature, including clinical practical guidelines. • Prior to discontinuation, many antidepressants may need a gradual dose reduction or tapering to avoid a withdrawal syndrome (e.g. SSRI, TCA). • If used to manage behavior, stabilize mood, or treat a psychiatric disorder, refer to Section V-Tapering a Medication Dose/Gradual Dose Reduction (GDR) in the guidance. MONITORING • All residents being treated for depression with any antidepressant should be monitored closely for worsening of depression and/or suicidal behavior or thinking, especially during initiation of therapy and during any change in dosage. INTERACTIONS/ADVERSE CONSEQUENCES • May cause dizziness, nausea, diarrhea, anxiety, nervousness, insomnia, somnolence, weight gain, anorexia, or increased appetite. Many of these effects can increase the risk for falls. • Bupropion may increase seizure risk and be associated with seizures in susceptible individuals. • SSRI in combination with other medications affecting serotonin (e.g. tramadol, St. John’s Wort, linezolid, other SSRI) may increase the risk for serotonin syndrome and seizures. continued on following page Drug Use in LTC 46 Medication Issues of Particular Relevance, cont. MONOAMINE OXIDASE INHIBITORS (MAOI), e.g. • Isocarboxazid • phenelzine • tranylcypromine INDICATIONS/CONTRAINDICATIONS • Should not be administered to anyone with a confirmed or suspected cerebrovascular defect or to anyone with confirmed cardiovascular disease or hypertension. • Should not be used in the presence of pheochromocytoma. • MAOI are rarely utilized due to their potential interactions with tyramine or tryptophan-containing foods, other medications, and their profound effect on blood pressure. ADVERSE CONSEQUENCES • MAY CAUSE HYPERTENSIVE CRISIS IF COMBINED WITH CERTAIN FOODS, CHEESE, WINE. EXCEPTION: Monoamine oxidase inhibitors such as selegiline (MAO-B inhibitors) utilized for Parkinson’s Disease, unless used in doses greater than 10 mg per day. INTERACTIONS • Should not be administered together or in rapid succession with other MAO inhibitors (tricyclic antidepressants, bupropion, SSRI, buspirone, sympathomimetics, meperidine, triptans, and other medications that affect serotonin or norepinephrine. TRICYCLIC ANTIDEPRESSANTS (TCA), e.g. • amitriptyline • amoxapine • doxepin • combination products, e.g. - Amitriptyline & chlordiazepoxide - Amitriptyline & perphenazine INDICATIONS • Because of strong anticholinergic and sedating properties, TCAs and combination products are rarely the medication of choice in older individuals. EXCEPTION: Use of TCA may be appropriate if: - The resident is being treated for neurogenic pain (e.g. trigeminal neuralgia, peripheral neuropathy), based on documented evidence to support the diagnosis; and - Relative benefits outweigh the risks and other safer agents, including nonpharmacologic therapies which are not indicated or have failed. ADVERSE CONSEQUENCES • Compared to other categories of antidepressants, TCAs cause significant anticholinergic side effects and sedation (nortriptyline and desipramine are less problematic). ANTIDIABETIC MEDICATIONS Insulin and oral hypoglycemics, e.g. • acarbose • acetohexamide • chlorpropamide • glimepiride • glipizide • glyburide • metformin • repaglinide • rosiglitazone • tolazamide • tolbutamide MONITORING • Use of anti-diabetic medications should include monitoring (for example, periodic blood sugars) for effectiveness based on desired goals for that individual and to identify complications of treatment such as hypo- glycemia, impaired renal function. NOTE: Continued or long-term need for sliding scale insulin for non- emergency coverage may indicate inadequate blood sugar control. • Residents on rosiglitazone should be monitored for visual deterioration due to new onset and/or worsening of macular edema in diabetic patients. continued on following page Drug Use in LTC 47 Medication Issues of Particular Relevance, cont. ANTIDIABETIC MEDICATIONS, cont’d Combination products, e.g. • rosiglitazone/metformin • glyburide/metformin • pioglitazone/metformin ANTIDIABETIC MEDICATIONS • chlorpropamide • glyburide ANTIFUNGALS Imidazoles for systemic use, e.g. • fluconazole • itraconazole • ketoconazole ADVERSE CONSEQUENCES • Metformin has been associated with the development of lactic acidosis (a potentially life threatening metabolic disorder), which is more likely to occur in individuals with: - Serum creatinine ≥1.5 mg/dL in males or ≥1.4 mg/dL in females. - Abnormal creatinine clearance from any cause, including shock, acute myocardial infarction, or septicemia. - Age ≥80 years unless measurement of creatinine clearance verifies normal renal function. - Radiologic studies in which intravascular iodinated contrast materials are given. - Congestive heart failure requiring pharmacological management. - Acute or chronic metabolic acidosis with or without coma (including diabetic ketoacidosis). • Rosiglitazone and pioglitazone have been associated with edema and weight gain; therefore, their use should be avoided in residents with Stage III or Stage IV heart disease. • Sulfonylureas can cause the syndrome of inappropriate antidiuretic hormone (SIADH) and result in hyponatremia. INDICATIONS • Chlorpropamide and glyburide are not considered hypoglycemic agents of choice in older individuals because of the long half-life and/or duration of action and increased risk of hypoglycemia. ADVERSE CONSEQUENCES • May cause prolonged and serious hypoglycemia (with symptoms including tachycardia, palpitations, irritability, headache, hypothermia, visual disturbances, lethargy, confusion, seizures, and/or coma). INDICATIONS • Should be used in lowest possible dose for shortest possible duration, especially in anyone receiving other medications known to interact with these medications. INTERACTIONS/ADVERSE CONSEQUENCES • Interaction with warfarin can cause markedly elevated PT/INR, increasing bleeding risk. • Multiple potentially significant medication interactions may occur, for example: - These medications when administered concurrently may increase the effect or toxicity of phenytoin, theophylline, sulfonylureas (hypoglycemics). - Other medications such as rifampin and cimetidine may decrease the effect of these antifungals. • May cause hepatotoxicity, headaches, GI distress. MONITORING • Enhanced monitoring may be required to identify and minimize adverse consequences when these antifungals are given with the following: - warfarin (PT/INR) - Phenytoin (serum phenytoin levels). - Theophylline (serum theophylline levels). - Sulfonylureas (fasting blood glucose). continued on following page Drug Use in LTC 48 Medication Issues of Particular Relevance, cont. ANTIMANIC MEDICATIONS Lithium ANTIPARKINSON MEDICATIONS All classes, e.g. Catechol-0-Methyl Transferase (COMT) Inhibitors, e.g. • entacapone Dopamine agonists, e.g. • bromocriptine • ropinirole • pramipexole MAO inhibitors, e.g. • selegiline Others, e.g. • amantadine Various dopaminergic combinations, e.g. • carbidopa/levodopa • carbidopa/levodopa/ entacapone ANTIPSYCHOTIC MEDICATIONS All classes First generation (conventional) agents, e.g. • chlorpromazine • fluphenazine • haloperidol • loxapine • mesoridazine • molindone • perphenazine • promazine • thioridazine • trifluoperazine • triflupromazine INDICATIONS • Should generally not be given to individuals with significant renal or cardiovascular disease, severe debilitation, dehydration, or sodium depletion. MONITORING • Toxic levels are very close to therapeutic levels. Serum lithium concentra- tion should be monitored periodically, and dosage adjusted accordingly. INTERACTIONS/ADVERSE CONSEQUENCES • May cause potentially dangerous sodium imbalance. • Adverse consequences may occur at relatively low serum concentrations (1-1.5 mEq/L). • Serum lithium concentration levels can be affected by many other medications, e.g. thiazide diuretics, ACE inhibitors, NSAIDs. ADVERSE CONSEQUENCES • May cause significant confusion, restlessness, delirium, dyskinesia, nausea, dizziness, hallucinations, agitation. • Increased risk of postural hypotension and falls, especially anti- hypertensive medications. INDICATIONS • An antipsychotic medication should be used only for the following conditions/diagnoses as documented in the record and as meets the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Training Revision (DSM-IV TR) or subsequent editions) - Schizophrenia - Schizo-affective disorder - Delusional disorder - Mood disorders (e.g. mania, bipolar disorder, depression with psychotic features, and treatment refractory major depression) - Schizophreniform disorder - Psychosis NOS - Atypical psychosis - Brief psychotic disorder - Dementing illnesses with associated behavioral symptoms continued on following page Drug Use in LTC 49 Medication Issues of Particular Relevance, cont. ANTIPSYCHOTIC MEDICATIONS cont’d Second generation (atypical) agents, e.g. • aripiprazole • clozapine • olanzapine • quetiapine • risperidone • ziprasidone - Medical illnesses or delirium with manic or psychotic symptoms and/or treatment-related psychosis or mania (e.g. thyrotoxicosis, neoplasms, high-dose steroids) • In addition, the use of an antipsychotic must meet the criteria and applicable, additional requirements listed below. 1. Criteria: • Since diagnoses alone do not warrant the use of antipsychotic medica- tions, the clinical condition must also meet at least one of the following criteria (A or B or C): A: The symptoms are identified as being due to mania or psychosis (such as: auditory, visual, or other hallucinations; delusions (such as paranoia or grandiosity); OR B: The behavioral symptoms present a danger to the resident or to others; OR C: The symptoms are significant enough that the resident is experienc- ing one or more of the following: inconsolable or persistent distress (e.g. fear, a continuously yelling, screaming, distress, associated with end-of-life, or crying); a significant decline in function; and/or substantial difficulty receiving needed care (e.g. not eating resulting in weight loss, fear and not bathing, leading to skin breakdown or infection). 2. Additional Requirements: • Acute Psychiatric Situations When an antipsychotic medication is being initiated or used to treat an acute psychiatric emergency (i.e. recent or abrupt onset or exacerbation of symptoms) related to one or more of the aforementioned conditions/ diagnoses, that use must meet one of the above criteria and all of the following additional requirements: A. The acute treatment period is limited to seven days or less; and B. A clinician in conjunction with the interdisciplinary team must evaluate and document the situation within 7 days. To identify and address any contributing and underlying causes of the acute psychiatric condition and verify the continuing need for antipsychotic medication; and C. Pertinent non-pharmacological interventions must be attempted, unless contraindicated and documented following the resolution on the acute psychiatric situation. • Enduring Psychiatric Conditions Antipsychotic medications may be used to treat an enduring (i.e. non- acute, chronic, or prolonged) condition, if the clinical condition/ diagnosis meets the criteria in #1 above. In addition, before initiating or increasing an antipsychotic medication for enduring conditions, the target behavior must be clearly and specifically identified and monitored objectively and qualitatively, in order to ensure the behavioral symptoms are: A. Not due to a medical condition or problem e.g. headache or joint pain, fluid or electrolyte imbalance, pneumonia, hypoxia, unrecognized hearing or visual impairment) that can be expected to improve or resolve as the underlying condition is treated; B. Persistent or likely to reoccur without continued treatment; continued on following page Drug Use in LTC 50 Medication Issues of Particular Relevance, cont. ANTIPSYCHOTIC MEDICATIONS cont’d C. Not sufficiently relieved by non-pharmacological interventions; D. Not due to environmental stressors (e.g. alteration in the resident’s customary location or daily routine, unfamiliar care provider, hunger or thirst, excessive noise for that individual inadequate or inappropri- ate staff response, physical barriers) that can be addressed to improve the psychotic symptoms or maintain safety; and E. Not due to psychological stressors (e.g. loneliness, taunting, abuse), or anxiety or fear stemming from misunderstanding related to his or her cognitive impairment (e.g. the mistaken belief that this is not where he/she lives or inability to find his or her clothes or glasses) that can be expected to improve or resolve as the situation is addressed • After initiating or increasing the dose of an antipsychotic medication, the behavioral symptoms must be reevaluated periodically to determine the effectiveness of the antipsychotic and the potential for reducing or discontinuing the dose. EXCEPTION: When antipsychotic medications are used for behavioral disturbances related to Tourette’s disorder, or for non-psychiatric indications such as movement disorders associated with Huntington’s disease, hiccups, nausea and vomiting associated with cancer or cancer chemotherapy, or adjunctive therapy at end of life. INADEQUATE INDICATIONS: • In many situations, antipsychotic medications are not indicated. They should not be used if the only indication is one or more of the following 1) wandering; 2) poor self-care; 3) restlessness; 4) impaired memory; 5) mild anxiety; 6) insomnia; 7) unsociability; 8) inattention or indifference to surroundings; 9) fidgeting; 10) nervousness; 11) uncooperativeness; or 12) verbal expressions or behavior that are not due to the conditions listed under “Indications” and do not represent a danger to the resident or others. DOSAGE • Doses for acute indications (for example, delirium) may differ from those used for long-term treatment, but should be the lowest possible to achieve the desired therapeutic effects. Daily Dose Thresholds for Antipsychotic Medications Used to Manage Behavioral Symptoms Related to Dementing Illnesses GENERIC MEDICATION DOSAGE • First Generation chlorpromazine 75 mg fluphenazine 4 mg haloperidol 2 mg loxapine 10 mg molindone 10 mg perphenazine 8 mg pimozide * prochloroperazine * thioridazine 75 mg thiothixene 7 mg trifluoperazine 8 mg continued on following page Drug Use in LTC 51 Medication Issues of Particular Relevance, cont. ANTIPSYCHOTIC MEDICATIONS cont’d • Second Generation aripiprazole 10 mg clozapine 50 mg olanzapine 7.5 mg quetiapine 150 mg risperidone 2 mg ziprasidone (not customarily used in treating behavioral symptoms) References: Katz IR (2004). Optimizing atypical antipsychotic treatment strategies in the elderly. Journ Am Ger Soc, 52, pp. 272-277. Schneider LS. (2005) Risk of death with atypical antipsychotic drug treatment for dementia. Meta-analysis of randomized placebo controlled trials. JAMA, 294, pp. 1934-943. Saltz BL, Woerner MG, Robinson DG, Kane JM (2000). Side effects of antipsychotic drugs; Avoiding and minimizing their impact in elderly patients. Postgraduate Medicine, 107, pp. 169-178. DURATION • If used to manage behavior, stabilize mood, or treat a psychiatric disorder, refer to Section V-Tapering of a Medication Dose/Gradual Dose Reduction (GDR) in the guidance. MONITORING /ADVERSE CONSEQUENCES • The facility assures that residents are being adequately monitored for adverse consequences such as: - Anticholinergic effects - Increase in total cholesterol and - Triglycerides - Akathisia - Parkinsonism - Neuroleptic malignant syndrome (NMS) - Blood sugar elevation (including diabetes mellitus) - Cardiac arrhythmias - Orthostatic hypotension - Death secondary to heart-related events (e.g. heart failure, sudden death) - Cerebrovascular event (e.g. stroke, transient ischemic attack (TIA) in older individuals with dementia - Tardive dyskinesia - Excessive sedation - Falls - Lethargy. • When antipsychotics are used without monitoring they may be consid- ered unnecessary medications because of inadequate monitoring. ANXIOLYTICS All anxiolytics Benzodiazepines, short-acting, e.g. • alprazolam • estazolam • lorazepam • oxazepam • temazepam INDICATIONS • ANXIOLYTIC MEDICATIONS SHOULD ONLY BE USED WHEN: Use is for one of the following indications as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Training revision (DSM-IV TR) or subsequent editions: a. Generalized anxiety disorder b. Panic disorder c. Symptomatic anxiety that occurs in residents with another diagnosed psychiatric disorder. continued on following page Drug Use in LTC 52 Medication Issues of Particular Relevance, cont. ANXIOLYTICS, cont’d Benzodiazepines, Long-acting, e.g. • chlordiazepoxide • clonazepam • clorazepate • diazepam • flurazepam • quazepam Buspirone Other antidepressants except bupropion d. Sleep disorders (see sedatives/hypnotics) e. Acute alcohol or benzodiazepine withdrawal. f. Significant anxiety in response to a situational trigger g. Delirium, dementia, and other cognitive disorders with associated behaviors that: √ Are quantitatively and objectively documented. √ Are persistent. √ Are not due to preventable or correctable reasons; and √ Constitute clinically significant distress or dysfunction to the resident or represent a danger to the resident or others • Evidence exists that other possible reasons for the individual’s distress have been considered; and • Use results in maintenance or improvement in the individual’s mental, physical, or psychosocial wellbeing (e.g. as reflected on the MDS or other assessment tools); or • There are clinical situations that warrant the use of these medications such as: - A long-acting benzodiazepine is being used to withdraw a resident from a short-acting benzodiazepine. - Used for neuromuscular syndromes (e.g., cerebral palsy, tardive dyskinesia, restless leg syndrome, or seizure disorders). - Symptom relief in end of life situations. DOSAGE • Dosage is less than or equal to the following listed total daily doses unless higher doses (as evidenced by the resident’s response and/or the resident’s clinical record) are necessary to maintain or improve the resident’s function. Total Daily Dose Thresholds for Anxiolytic Medications Generic Medication Dosage flurazepam chlordiazepoxide clorazepate diazepam clonazepam quazepam estazolam alprazolam oxazepam lorazepam 5 mg 20 mg 15 mg 5 mg 1.5 mg 7.5 mg 0.5 mg 0.75 mg 30 mg 2 mg Duration • If used to manage behavior, stabilize mood, or treat a psychiatric disorder, refer to Section V-Tapering of a Medication Dose/Gradual Dose Reduction (GDR) in the guidance. ADVERSE CONSEQUENCES • May increase risk of confusion, sedation, and falls continued on following page Drug Use in LTC 53 Medication Issues of Particular Relevance, cont. DIPHENHYDRAMINE AND HYDROXYZINE INDICATIONS • Highly addictive and sedating medication; not indicated for use in older individuals. DOSAGE/DURATION • Those who have used meprobamate for prolonged periods may be physically and/or psychologically dependent and may need to be withdrawn slowly. CARDIOVASCULAR MEDICATIONS INCLUDING ANTIHYPERTENSIVE All antiarrhythmics AMIODARONE ADVERSE CONSEQUENCES • Cardiac antiarrhythmics can have serious adverse effects in older individuals, including impaired mental function, falls, appetite, behavior, and heart function. INDICATIONS • Only approved indication for use is to treat documented life-threatening recurrent ventricular arrhythmias that do not respond to other antiarrhythmics agents or when alternative agents are not tolerated. • Common off-label use to treat atrial fibrillation; however, literature suggests that in many higher risk individuals, alternative approaches to managing atrial fibrillation (rate control and anticoagulation) are equally effective and less toxic* * Goldschlager N, Epstein AE, Naccarelli G, Olshansky B, Singh B (2000). Practical guidelines for clinicians who treat patients with amiodarone. Archives of Internal Medicine, 160, pp. 1741-1748. * Denus S, Sanoski CA, Carlson J, Opolski G, Spindler SA (2005). Rate vs rhythm control in patients with atrial fibrillation: A meta-analysis. Archives of Internal Medicine, 165, pp. 258-262. DOSAGE/MONITORING • It is critical to carefully consider risks and benefits to use the lowest possible dose for the shortest possible duration to closely monitor individuals receiving long-term amiodarone, and to seek and identify adverse consequences. INTERACTIONS/ADVERSE CONSEQUENCES • May cause potentially fatal toxicities, including pulmonary toxicity (hypersensitivity pneumonitis or interstitial/alveolar pneumonitis) and hepatic injury. May cause hypothyroidism, exacerbate existing arrhyth- mia, and worsen heart failure. Can also impair mental function and behavior. • May cause clinically significant medication interactions; for example, with digoxin and warfarin. • Toxicity increases with higher doses and longer duration of use. DISOPYRAMIDE ADVERSE CONSEQUENCES • Disopyramide has potent negative inotropic effects (decreased force of heart contraction), which may induce heart failure in older individuals, and is also strongly anticholinergic. continued on following page Drug Use in LTC 54 Medication Issues of Particular Relevance, cont. ANTIHYPERTENSIVES DOSAGE/MONITORING • Doses of individual antihypertensives may require modification in order to achieve desired effects while minimizing adverse consequences, especially when multiple antihypertensives are prescribed simultaneously. • When discontinuing some antihypertensives (e.g. clonidine, beta blockers), gradual tapering may be required to avoid adverse consequences caused by abrupt cessation. INTERACTIONS/ADVERSE CONSEQUENCES • May cause dizziness, postural hypotension, fatigue, and an increased risk for falls. • Many other medications may interact with antihypertensives to potentiate their effect (e.g. levodopa, nitrates). ALPHA BLOCKERS, e.g. • alfuzosin • doxazosin • prazosin • tansulosin • terazosin ADVERSE CONSEQUENCES • Doxazosin, prazosin, and terazosin can cause significant hypotension and syncope during the first few doses. Therefore, these medications should be initiated at bedtime with a slow titration of dose. • Prazosin can cause more CNS side effects and generally should be avoided in older individuals. ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS, e.g. • benazepril • captopril • enalapril • fosinopril • lisinopril • ramipril MONITORING • Monitoring of serum potassium is necessary especially in individuals receiving ACE inhibitors with potassium, or potassium sparing diuretics ANGIOTENSIN II RECEPTOR BLOCKERS, e.g. • candesartan • eprosartan • irbesartan • losartan • olmesartan • valsartan BETA ADRENERGIC BLOCKERS, e.g. Nonselective, e.g. • propranolol Cardioselective, e.g. • atenolol • esmolol • metoprolol • nadolol • timolol ADVERSE CONSEQUENCES • May cause angioedema (signs and symptoms of immediate hyper- sensitivity), chronic persistent nonproductive cough, or may worsen renal failure • Potential for life-threatening elevation of serum potassium concentrations when used in combination with potassium supplements potassium- sparing diuretics including spironolactone. ADVERSE CONSEQUENCES • May cause or exacerbate: - Bradycardia, especially in individuals receiving other medications that affect cardiac conduction (e.g. calcium channel blockers); - Dizziness, fatigue; depression, bronchospasm (especially, but not exclusively, propranolol); or - Cardiac decompensation that may require adjusting dose in residents with acute heart failure. • May mask tachycardia associated with symptomatic hypoglycemia. • May have increased effect or may accumulate in individuals with hepatic impairment. continued on following page Drug Use in LTC 55 Medication Issues of Particular Relevance, cont. CALCIUM CHANNEL BLOCKERS, e.g. • nifedipine • isradipine • amlodipine • nisoldipine • diltiazem • verapamil METHYLDOPA Including combination products such as methyldopa/hydrochlorothiazide DIGOXIN DIURETICS, e.g. • Bumetanide • ethacrynic acid • furosemide • hydrochloro-thiazide • metolazone • spironolactone • torsemide • triamterene NITRATES, e.g. • isosorbide mononitrate • isosorbide dinitrate • nitroglycerin ADVERSE CONSEQUENCES • May cause clinically significant constipation • May cause peripheral edema. • Some agents may cause generalized aching, headache, muscle pain. • Short-acting/immediate-release nifedipine increases the risk of cardiac complications and should not be used. INDICATIONS: • Alternate treatments for hypertension are preferred. ADVERSE CONSEQUENCES • May cause bradycardia and excessive sedation; may exacerbate depression in older individuals. INDICATIONS • Digoxin is indicated only for the following diagnoses: congestive heart failure, atrial fibrillation, paroxysmal supraventricular tachycardia, or atrial flutter. • Should be used with caution in individuals with impaired renal function. DOSAGE • Daily doses in older individuals should ordinarily not exceed 0.125 mg/day except when used to control atrial arrhythmia and ventricular rate. MONITORING • Must be used cautiously in individuals with renal failure or fluid and electrolyte imbalance, with close monitoring for adverse consequences and monitoring, as indicated of both renal function and serum medica- tion concentration (‘digoxin level’). • Adverse consequences may occur even with therapeutic serum concentration, especially in older individuals. INTERACTIONS/ADVERSE CONSEQUENCES • May interact with many other medications, possibly resulting in digoxin toxicity or elevated serum concentration of other medications. • May cause significant bradycardia, especially when used in individuals taking other medications affecting cardiac conduction • Toxicity may cause fatigue, nausea, vomiting, anorexia, delirium, cardiac arrhythmia. ADVERSE CONSEQUENCES • May cause fluid and electrolyte imbalance (hypo/hypernatremia , dehydration, etc.), hypotension; may precipitate or exacerbate urinary incontinence, falls. ADVERSE CONSEQUENCES • May cause headaches, dizziness, lightheadedness, faintness, or symptomatic orthostatic hypotension, especially when initially started or when taken in combination with antihypertensive medications continued on following page Drug Use in LTC 56 Medication Issues of Particular Relevance, cont. CHOLESTEROL -LOWERING MEDICATIONS HMG-COA Reductase Inhibitors (‘statins”) e.g. • atorvastatin • fluvastatin • lovastatin • pravastatin • rosuvastatin • simvastatin CHOLESTYRAMINE FIBRATES, e.g. • fenofibrate • clofibrate NIACIN COGNITIVE ENHANCERS Cholinesterase inhibitors, e.g. • donepezil • galantamine • rivastigmine NMDA RECEPTORS ANTAGONIST, e.g. • Memantine MONITORING • Liver function monitoring should be performed consistent with manufacturer’s recommendations, generally accepted as: - Prior to initiation of therapy, at 12 weeks, following both initiation of therapy and any increase in dose, and periodically (e.g., semiannually) thereafter. ADVERSE CONSEQUENCES • May impair liver function; liver function tests should be monitored as indicated above. • May cause muscle pain, myopathy, and rhabdomyolysis (breakdown of skeletal muscle) that can precipitate kidney failure especially in combination with other cholesterol-lowering medications. INTERACTIONS • May reduce the absorption of other medications being taken concurrently. Other medications, including diuretics, beta-blockers, corticosteroids, thyroid hormones, digoxin, valproic acid, NSAIDs, sulfonylureas, and warfarin should be administered 1 hour before or 4 hours after cholestyramine administration to avoid this interaction. ADVERSE CONSEQUENCES • May cause constipation, dyspepsia, nausea, or vomiting, abdominal pain. MONITORING: • Fenofibrate and clofibrate require regular monitoring of liver tests as well as evaluating the complete blood count (CBC) prior to and after initiation. MONITORING • Monitoring glucose and liver function tests regularly. ADVERSE CONSEQUENCES • Interfaces with glucose control and an aggravate diabetes. • Can exacerbate active gallbladder disease and gout. • Flushing is common. INDICATIONS • As the underlying disorder progresses into the advanced stages, the continued use of the medication should be reevaluated. ADVERSE CONSEQUENCES • Affect cardiac conduction, especially in individuals who already have a cardiac conduction disorder or who are taking other medications that affect heart • May cause insomnia, dizziness, nausea, vomiting, diarrhea, anorexia, and weight loss • Should be used with caution in individuals with severe asthma or obstructive pulmonary disease INDICATIONS • As the underlying disorder progresses into advanced stages, the continued use of the medication should be reevaluated. ADVERSE CONSEQUENCES • May cause restlessness, distress, dizziness, somnolence, hypertension, headaches, hallucinations, or increased confusion. INDICATIONS/DURATION continued on following page Drug Use in LTC 57 Medication Issues of Particular Relevance, cont. COUGH, COLD & ALLERGY MEDICATIONS All cough, cold allergy medications ANTIHISTAMINE H-1 BLOCKERS, e.g. • chlorpheniramine • cyproheptadine • eiphenhydramine • hydroxyzine • meclizine • promethazine • Should be used only for a limited duration (less than 14 days) unless there is documented evidence of enduring symptoms that cannot otherwise be alleviated and for which a cause cannot be identified and corrected. INDICATIONS • H-1 blocker antihistamines have strong anticholinergic properties and are not considered medications of choice in older individuals. • If appropriate and effective, topical instead of oral diphenhydramine should be considered for allergic reactions involving the skin. DOSAGE/DURATION • Should be used in the smallest possible dosage for the shortest possible duration, especially in individuals who are susceptible to anticholinergic side effects or who are receiving other medications with anticholinergic properties (see Table II) ADVERSE CONSEQUENCES • May cause excessive sedation, confusion, cognitive impairment, distress, dry mouth, constipation, urinary retention. These may lead to other adverse consequences such as falls. ORAL DECONGESTANTS, e.g. • Pseudoephedrine GASTROINTESTINAL MEDICATIONS Phenothiazine-related antiemetics, e.g. • Prochlorperazine • Promethazine TRIMETHOBENZAMIDE ADVERSE CONSEQUENCES • May cause dizziness, nervousness, insomnia, palpitations, urinary retention, elevated blood pressure. • Should be used with caution in individuals who have insomnia or hypertension. INDICATIONS • Use with caution in individuals with Parkinson’s disease, narrow-angle glaucoma, BPH, seizure disorder. ADVERSE CONSEQUENCES • May cause sedation, dizziness, drowsiness, postural hypotension, and neuroleptic malignant syndrome. • May lower seizure threshold • Promethazine and prochlorperazine may cause anticholinergic effects, such as constipation, dry mouth, blurred vision, urinary retention. • May cause extrapyramidal symptoms, including medication-induced parkinsonism, acute dystonic reactions, akathisia, and tardive dyskinesia. • May alter cardiac conduction or induce arrhythmias. ADVERSE CONSEQUENCES • Relatively ineffective antiemetic that can cause significant extrapyramidal side effects in addition to lethargy, sedation, confusion. EXCEPTION: May be indicated in patients with Parkinson’s Disease taking apomorphine. continued on following page Drug Use in LTC 58 Medication Issues of Particular Relevance, cont. METOCLOPRAMIDE INDICATIONS • High-risk medication with limited clinical indication and limited demon strated effectiveness* • Not recommended for first-line treatment of gastroesophageal reflux disease, especially in older individuals.. • When used for diabetic gastroparesis, or other indications, relative benefits and risks should be assessed and documented. *Lata PF, Pigarelli DL (2003). Chronic metoclopramide therapy for diabetic gastroparesis. Ann Pharmacotherapy, 37(1), pp 122-126. ADVERSE CONSEQUENCES • Especially in older individuals, metoclopramide may cause restlessness, drowsiness, insomnia, depression, distress, anorexia, and extrapyramidal symptoms, and may lower the seizure threshold. • May increase seizures in individuals with seizure disorders or exacerbate symptoms in individuals with Parkinson’s Disease. MONITORING • It is essential to closely monitor at-risk individuals for adverse consequences. PROTON PUMP INHIBITORS (PPI), e.g. • esomeprazole • lansoprazole • omeprazole • rabeprazole INDICATIONS • Indications for use should be based on clinical symptoms and/or endo- scopic findings. • When used to treat or prevent NSAID-induced gastritis or esophagitis, documentation should exist that other, less GI-toxic analgesics have been tried or were not indicated. H-2 ANTAGONISTS, e.g. • cimetidine • famotidine • ranitidine DURATION • If used for greater than 12 weeks, clinical rationale for continued need and. or documentation should support an underlying chronic disease (e.g. GERD) or risk factors (e.g. chronic NSAID use). DOSAGE • Dosing of histamine-H2 antagonists should be based on renal function. INTERACTIONS • Cimetidine has higher incidence of medication interactions and should be avoided in older individuals. ADVERSE CONSEQUENCES • May cause or exacerbate headache, nausea, vomiting, flatulence, dysphagia, abdominal pain, diarrhea, or other gastrointestinal symptoms. • H-2 Antagonists May cause confusion. • PPIs may increase the risk of clostridium difficile colitis. GLUCOCORTICOIDS All glucocorticoids (except topical or inhaled dosage forms), e.g. • dexamethasone • hydrocortisone • methylpred-nisolone • prednisone DURATION/MONITORING • Necessity for continued use should be documented along with monitoring for and management of adverse consequences. ADVERSE CONSEQUENCES • Intermediate-or longer-term use may cause hyperglycemia, psychosis, edema, insomnia, hypertension, osteoporosis, mood lability, or depression. continued on following page Drug Use in LTC 59 Medication Issues of Particular Relevance, cont. HEMATINICS Erythropoiesis stimulants, e.g. • darbepoetin • erythropoietin INDICATIONS • Assessment of causes and categories of anemia should precede or accompany the use of this medication. MONITORING • Use must be monitored according to specific manufacturer’s instructions including blood pressure, baseline serum, iron or ferritin level, and frequent complete blood count (CBCs) to permit tapering or discontinua tion when hemoglobin/hematocrit reaches or exceeds target ranges ADVERSE CONSEQUENCES • May cause or worsen hypertension • Excessive dose or duration can lead to polycythemia, dangerous thrombotic events including myocardial infarction and stroke. IRON INDICATIONS • Iron therapy is not indicated in anemia of chronic disease when iron stores and transferrin levels are normal or elevated. DOSAGE/DURATION • Clinical rationale should be documented for long-term use (>2 months) or administration more than once daily for greater than a week, because of side effects and the risk of iron accumulation in tissues. MONITORING • Baseline serum iron or ferritin level and periodic CBC or hematocrit/ hemoglobin ADVERSE CONSEQUENCES • May cause constipation, dyspepsia. • Can accumulate in tissues and cause multiple complaints if given chronically despite normal or high iron stores. LAXATIVES All categories including bulk producing laxatives, hyperosmolar agents, saline laxatives, stimulant laxatives, emollient laxatives. MUSCLE RELAXANTS All muscle relaxants, e.g. • baclofen • carisoprodol • chlorzoxazone • cyclobenzaprine • dantrolene • metaxalone • methocarbamol • orphenadrine ADVERSE CONSEQUENCES • May cause flatulence, bloating, abdominal pain. • Bulk-forming laxatives and stool softeners may cause accumulation of stool and possible bowel obstruction, if not used with adequate fluids or in individuals with other causes of impaired bowel motility. INDICATIONS/ADVERSE CONSEQUENCES • Most are poorly tolerated by older individuals due to anticholinergic side effects (see Table II), sedation, or weakness. • Long-term use in individuals with complications due to multiple sclerosis, spinal cord injuries, cerebral palsy, and other select condi- tions may be indicated, although close monitoring is still warranted. • Abrupt cessation of some muscle relaxants may cause or predispose individuals to seizures or hallucinations. EXCEPTION: Periodic use (once every 3 months) for a short duration (not more than 7 days) may be appropriate, when other interventions or alternative medications are not effective or not indicated. continued on following page Drug Use in LTC 60 Medication Issues of Particular Relevance, cont. OREXIGENICS (APPETITE STIMULANTS) All appetite stimulants, e.g. • megestrol acetate • oxandrolone • dronabinol OSTEOPOROSIS MEDICATIONS bisphosphonates, e.g. • alendronate • ibandronate • riserdronate PLATELET INHIBITORS All platelet inhibitors, e.g. • dipyridamole • dipyridamole extended-release and aspirin (as fixed-dose combination). • aspirin • clopidogrel • ticlopidine INDICATIONS • Use should be reserved for situations where assessment and manage- ment of underlying correctable causes of anorexia and weight loss is not feasible or successful, and after evaluating potential benefits/risks. MONITORING • Appetite and weight should be monitored at least monthly and agent should be discontinued if there is no improvement. ADVERSE CONSEQUENCES • Megestrol acetate may cause fluid retention, adrenal suppression, and symptoms of adrenal insufficiency. • Oxandrolone may cause virilization of females and feminization of males, excessive sexual stimulation, and fluid retention. • Dronabinol may cause tachycardia, orthostatic hypotension, dizziness, dysphoria, and impaired cognition, which may lead to falls. DOSAGE • These medications must be taken according to very specific directions, including time of day, position, and timing relative to other medications and food. MONITORING • Individuals receiving these medications should be monitored closely for gastrointestinal complications, including esophageal or gastric erosion. ADVERSE CONSEQUENCES • Potential to cause gastrointestinal symptoms including dysphagia, esophagitis, gastritis, or esophageal and gastric ulcers, especially when given to individuals who are also taking oral corticosteroids, aspirin, or other nonsteroidal anti-inflammatory drugs (NSAIDs). INTERACTIONS/ADVERSE CONSEQUENCES • May cause thrombocytopenia and increase risk of bleeding. • Common side effects include headache, dizziness, and vomiting. • See discussion at NSAIDs regarding aspirin. • Concurrent use with warfarin or NSAIDs may increase risk of bleeding. INDICATION • Use may be appropriate in individuals who have had a previous stroke or have evidence of stroke precursors (i.e. transient ischemic attacks (TIAs), and who cannot tolerate aspirin or another platelet inhibitor. ADVERSE CONSEQUENCES • Associated with more severe side effects and considerably more toxic than other platelet inhibitors; use should be avoided in older individuals. • Most serious side effects involve the hematologic system, including potentially life-threatening neutropenia. • May also cause nausea, vomiting, and diarrhea. continued on following page Drug Use in LTC 61 Medication Issues of Particular Relevance, cont. RESPIRATORY MEDICATIONS Theophylline Inhalant medications classes, e.g. Anticholinergic, e.g. • Ipratropium • Tiotropium Beta 2 agonists, e.g. • Albuterol • formoterol • pirbuterol acetate • salmeterol Corticosteroids, e.g. • beclomethasone • budesonide • flunisolide • fluticasone • triamcinolone • acetonide Miscellaneous, e.g. • cromolyn • nedocromil sodium SEDATIVES/HYPNOTICS (SLEEP MEDICATIONS) All hypnotics Benzodiazepine hypnotics, e.g. • estazolam • flurazepam • quazepam • temazepam • triazolam Non-benzodiazepine hypnotics, e.g. • eszopiclone • zaleplone • zolpidem Melatonin receptor agonists, e.g. • ramelteon Other hypnotics, e.g. • chloral hydrate Miscellaneous agents used for sleep, e.g. trazodone) • sedating antidepressants (e.g. trazodone) • sedating antihistamines (e.g. hydroxyzine) INTERACTIONS • Potentially significant interactions with many other medications may occur, especially various antibiotics, seizure, medications, and cardiac medications. MONITORING/ADVERSE CONSEQUENCES • There should be monitoring for signs and symptoms of toxicity, such as arrhythmia, seizure, GI upset, diarrhea, nausea/vomiting, abdominal pain, nervousness, headache, insomnia, distress, dizziness, muscle cramp, tremor. • Periodic monitoring of serum concentrations help identify or verify toxicity. ADVERSE CONSEQUENCES • Inhaled anticholinergics can cause xerostomia (dry mouth). • Inhaled beta agonists can cause restlessness, increased heart rate, and anxiety. • Inhaled steroids can cause throat irritation and oral candidiasis, especially if the mouth is not rinsed after administration. INDICATIONS • Most causes of insomnia are associated with underlying conditions (secondary or co-morbid insomnia) such as psychiatric disorders (e.g. depression), cardiopulmonary disorders (e.g. COPD, CHF), urinary frequency, pain, obstructive sleep apnea, and restless leg syndrome. Insomnia may be further described by the duration of symptoms. • Before initiating medications to tret insomnia, other factors potentially causing insomnia should be evaluated, including, for example: - Environment, such as excessive heat, cold, or noise; lighting. - Inadequate physical activity. - Facility routines that may not accommodate residents’ individual needs (e.g. time for sleep, awakening, toileting, medication treatments). - Provision of care in a manner that disrupts sleep. - Caffeine or medication known t disrupt sleep. - Pain and discomfort. • Underlying conditions (secondary or comorbid insomnia) such as psychiatric disorders (e.g. depression), cardiopulmonary disorders, (e.g. COPD, CHF), urinary frequency, pain, obstructive sleep apnea, and restless leg syndrome. It is expected that interventions (such as sleep hygiene approaches, individualizing the sleep and wake times to accommodate the person’s wishes and prior customary routine, and maximizing treatment of any underlying conditions) are implemented to address the causative factor(s). • These guidelines apply to any medication that is being used to treat insomnia. Initiation of medications to induce or maintain sleep should be preceded or accompanied by other interventions to try to improve continued on following page Drug Use in LTC 62 Medication Issues of Particular Relevance, cont. SEDATIVES/HYPNOTICS (continued) BARBITURATES, e.g. • amobarbital • butabarbital • pentobarbital • secobarbital • phenobarbital • amobarbital-secobarbital • barbiturates with other medications sleep. All sleep medications should e used in accordance with approved product labeling; for example, timing and frequency of administration relative to anticipated waking time. • The use of sedating medications for individuals with diagnosed sleep apnea requires careful assessment, documented clinical rationale, and close monitoring. EXCEPTIONS: • Use of a single dose sedative for dental or medical procedures. • During initiation of treatment for depression, pain or other comorbid conditions(s), short-term use of a sleep medication may be necessary until symptoms improve or the underlying aggravating factor can be identified and/or effectively treated. DOSAGE Daily Dose Thresholds for Sedative-Hypnotic Medications GENERIC MEDICATION ORAL DOSAGE chloral hydrate* 500 mg diphenhydramine* 25 mg estazolam 0.5 mg eszopiclone 1 mg flurazepam* 15 mg hydroxyzine* 50 mg lorazepam 1 mg oxazepam 15 mg quazepam* 7.5 mg ramelteon 8 mg temazepam 15 mg triazolam* 0.125 mg zaleplon 5 mg zolpidem ER 5 mg zolpidem CR 6.25 mg *These medications are not considered medications of choice for the management of insomnia, especially in older individuals. Reference: www.ahrq.gov/downloads/pub/evidence/pdf/insomnia/insomnia.pdf DURATION • If used to induce sleep or treat a sleep disorder, refer to Section V- Tapering of a Medication Dose/gradual Dose Reduction (GDR) in the guidance. NOTE: Refers to barbiturates used to induce sleep or treat anxiety disorder. INDICATIONS • Barbiturates should not be initiated in any dose for any individuals to treat anxiety or insomnia; as they are highly addictive and cause numerous adverse effects, especially in older individuals. EXCEPTION: These guidelines do not apply to the use of phenobarbital to treat seizure disorders (see anticonvulsant section). continued on following page Drug Use in LTC 63 Medication Issues of Particular Relevance, cont. BARBITURATES (continued) THYROID MEDICATIONS All thyroid medications, e.g. • levothyroxine • triiodothyronine URINARY INCONTINENCE MEDICATIONS Urinary Incontinence Types and Agents, e.g. Urge incontinence: Anticholinergics, e.g. • darifenacin • oxybutynin • tolterodine • trospium Tricyclic antidepressants, e.g. • desipramine • imipramine Stress incontinence: Alpha adrenergic agonists, e.g. • pseudoephedrine Mixed incontinence, e.g. • estrogen replacement agents • imipramine Overflow incontinence, e.g. • alpha adrenergic antagonists (see antihypertensives) • bethanechol chloride INTERACTIONS/ADVERSE CONSEQUENCES • May increase the metabolism of many medications (e.g. anticonvulsants, antipsychotics), which may lead to decreased effectiveness and subsequent worsening of symptoms or decreased control of underlying illness. • May cause hypotension, dizziness, lightheadedness “hangover” effect, drowsiness, confusion, mental depression, unusual excitement, nervousness, headache, insomnia, nightmares, and hallucinations • May increase the risk for falls INTERACTIONS • Many clinically significant medications interactions have been identified; therefore, re-evaluation of medication doses is indicated. DOSAGE • Initiation of thyroid supplementation should occur at low doses and be increased gradually to avoid precipitating cardiac failure or adrenal crisis. MONITORING • Assessment of thyroid function (e.g., TSH, serum T4 or T3) should occur prior to initiation and periodically thereafter, including when new signs and symptoms of hypo or hyperthyroidism are present. INDICATIONS • Before or soon after initiating medication(s) to manage urinary inconti nence, assessment of underlying causes and identification of the type/ category of urinary incontinence needs to be documented. • These medications have specific, limited indications based on the cause and type/category of incontinence. MONITORING • Ongoing assessments of the effects of the medication on the individual’s urinary incontinence as well as lower urinary tract symptoms should be done periodically. ADVERSE CONSEQUENCES • Anticholinergics and TCAs may cause anticholinergic effects (see Table II). • Estrogen Replacement Agents: oral agents may cause systemic side effects and increased risks (e.g. deep venous thrombosis, breast cancer); therefore, topical agents may be preferred. • Bethanechol may cause hypotension, increased sweating and salivation , headache, cramps, diarrhea, nausea and vomiting, and worsening of asthma. Drug Use in LTC 64 anticholinergic agents The table on the following page lists common medications with significant anticholinergic properties and potential adverse consequences, but is not all-inclusive. Any of the following signs and symptoms may be caused by any of the medications in the lists below, alone or in combination, as well as by other medications not listed here that have anticholinergic properties. Medications with Significant Anticholinergic Properties Antihistamine (H-1 Blockers) chlorpheniramine cyproheptadine diphenhydramine hydroxyzine Antidepressants amoxapine amitriptylin clomipramine desipramine doxepin imipramine nortriptyline protriptyline paroxetine Antiparkinson Medication amantadine benztropine biperiden trihexyphenidyl Muscle Relaxants cyclobenzaprine dantrolene orphenadrine Antivertigo Medications meclizine scopolamine Phenothiazine Antiemetics prochlorperazine promethazine Cardiovascular Medications furosemide digoxin nifedipine disopyramide Gastrointestinal Medications Antidiarrheal Medications diphenoxylate atropine Antispasmodic Medications belladonna clidinium chloradiazepoxide dicyclomine hyoscyamine propantheline Anti-ulcer Medications Cimetidine ranitidine Antipsychotic Medications chlorpromazine clozapine olanzapine thioridazine Urinary Incontinence oxybutynin probantheline solifenacin tolterodine Potential Adverse Consequences of Medications with Anticholinergic Properties Blood pressure, increased clumsiness or unsteadiness Digestive system changes, e.g. bloating, bowel motility, decreased constipa- tion, ileus, paralytic/adynamic nausea or vomiting, swallowing difficulty with dry mouth Delirium Drowsiness Headaches Lethargy, fatigue Muscle weakness, severe Skin, changes dryness, sweating, flushing warmth Urinary retention or difficulty Breathing difficulty, changes Convulsions Mental status/behavior changes, e.g. Distress, excitement, nervousness, cognitive decline, confusion/disorientation, hallucinations. memory loss. restlessness or irritability Dizziness Fever Heart rate, increased Mucous membrane dryness Speech slurring Vision impairment, changes in acuity, blurring, glaucoma, worsening eye pain, light sensitivity Drug Use in LTC 65 This table is provided because: • Medications in many categories have anticholinergic properties; • The use of multiple medications with such properties may be particularly problematic because of the cumulative effects; and • Anticholinergic side effects are particularly common and problematic, especially in the older individual. This chapter has reviewed the 2006 Survey Guidelines. The information has been presented in order to inform healthcare professionals and to prevent adverse drug reactions and survey citations in nursing homes. Drug Use in LTC Notes 66 Drug Use in LTC 67 Chapter Five: Drugs and How Drugs Work “Nothing so distinguishes man from the animals as the desire to take medicine.” ~ Physician Sir William Osler T his chapter will introduce basic concepts of drug action in the body. How drugs interact in the body is discussed for specific examples as to how food and drug interactions take place. Food and drugs “When medication is given via the gastrointestinal tract, the mechanisms usually involved in the absorption of nutrients are “borrowed” to transport the drug into the body. In effect, the gastrointestinal tract takes on an added function. This is possible because absorbable drugs have some chemical features in common with nutrients. This facilitates the active or passive absorption of the drug.” (McCabe, 2003) Individual variation There are many resident/patient variables that can alter the action of a drug. Body weight - The larger, and overweight person requires more drug. This is why having the resident’s weight on admission is so important (in addition to nutritional factors). The physician will often use the weight to determine the drug dose. The physician usually bases the drug dose on the effective dose for 50 percent of the population aged 18 to 65, weighing 150 lb (Worthington, 2004). Body surface area (BSA) -table considering both height and weight, has been a useful tool in determining drug dose. Drug Use in LTC 68 Gender - Males and females have different body compositions. Males usually have more lean body mass, and women usually have more body fat. Age - The young require less drug because of their body size and physiology. An elderly person will usually need smaller doses because of changes in body cellular composition and function. Drugs are absorbed, distributed, metabolized and excreted less effectively in the elderly. Impaired circulation, such as with congestive heart failure, alters drug distribution. Also, with less body water and more body fat, water-soluble drugs become more concentrated, and fat soluble drugs become less concentrated. The drug dose for the elderly is usually started at a lower dose.. Illness(es) - influence the action of a drug on body processes. Renal disease, liver disease, malabsorption, dehydration, and malnutrition are all factors that influence drug use. Renal disease influences drug elimination. Liver disease influences drug metabolism. Malabsorption and malnutrition influence drug absorption. Dehydration influences drug concentration of water soluble drugs. Basal Metabolic Rate (BMR) - Those with a higher basal metabolic rate metabolize drugs more quickly. The elderly with a lower BMR metabolize drugs more slowly. Hypo- or hyperthyroid disease can influence the BMR. Cumulative effects of drugs - A drug taken for a long period of time and in too great a dose may cause toxic effects. A common example of such a drug is digoxin. Psychological factors - Some residents are very attached to their drugs, or want a drug for every problem. They may receive a placebo. Other drugs will cause a drug tolerance problem requiring an increased dose to get the same effect. These drugs can often lead to addiction. The effects of drugs have primarily been studied in healthy populations, with drugs given on an empty stomach. Under the controlled conditions, only one drug is given at a time. This is not how drugs are given in real life. With the elderly, or those with multiple chronic diseases and impaired nutritional status, the outcomes are likely to be very different. The next section discusses the basics. Drugs are available in many forms Drugs are made into a form that can be administered in a safe and effective way. Liquid drugs (or drugs in solution) may be taken by mouth, placed on the skin, or put in the eye, ear, nose or throat. Liquid drugs are usually a solvent (usually water; OR can be sugar, alcohol, or sorbitol), and one or more dissolved components or solutes containing the drug. The nutrition professional will want to be aware of the additives to liquid medications. Drug Use in LTC 69 • Syrups contain sugar; sugar-free products are available for diabetics. • Elixirs contain a mixture of alcohol with other components. • Sorbitol is a sugar alcohol, which can be a frequent cause of diarrhea if given in large doses. • Suspensions are liquid drugs that are suspended in a liquid medium. • Emulsions are dispersions of fine droplets of drugs in an oil or in a water base or water in oil base. Drugs may also be in a semi-solid form. This form of drug is usually used to treat skin disorders. Some are in a grease or gel form. The formation of the semi-solid drug correlates with the desired release rate of the drug. Sublingual, and buccal drugs are administered under the tongue or in the cheek. An example of this is nitroglycerine. This medication is absorbed “sublingually,” (under the tongue). The saliva from the mouth helps dissolve the medication. The drug taken by the sublingual route allows the drug to be absorbed into the bloodstream faster or more completely than if taken through the gastrointestinal tract. Some drugs may be administered through the nose, such as antihistamines or Miacalcin, a drug for osteoporosis. The actual drug is calcitonin-salmon. Breathing in a drug causes rapid absorption through the lungs and into the blood. The effect of drugs given this way can be systemic, for anesthetics; or locally, for an asthma attack. Suppositories are another method of drug administration. This form of drug is inserted into external body orifices. These orifices are the rectum, vagina or urethra. After the drug is inserted, the medication either dissolves or melts and the medication is released. These drugs can either have a local or systemic effect, depending on the drug formulation. Laxatives, sleeping aids, tranquilizers and anti-nausea medications are frequently administered by rectal suppositories (Wolinsky, 2002). Throat lozenges, and sprays are often used for sore throats. These products are designed to be released for a topical or anesthetic effect on the oral cavity or the throat. Topical patches are often used to permit topical drugs to enter the body through the skin, and then into the blood stream. Nitroglycerine has been formulated for use as a patch to release gradually into the blood stream where it can exert a systemic effect. Transdermal patches are placed on the skin and deliver a specific amount of drug over a period of time. When the drug is applied, the drug slowly passes from the reservoir in the patch through the skin into blood vessels. The drug is transported to the site of action in the body (McCabe, 2003; Worthington, 2004; Reiss, 1996). The importance of knowing about these various drugs forms and how they enter the body is to realize all drugs may enter the systemic circulation. Even a drug such as eye drops can have a systemic effect. Any drug in the systemic circulation of the resident can have an impact on nutritional status. Drug Use in LTC 70 The importance of knowing about these various drug forms and how they enter the body is to realize all drugs may enter the systemic circulation Food-drug interactions extend to drugs usually not considered by the nutrition professional, because of lack of awareness of how these drugs act systemically. Most tablets in the United States are in the compressed tablet form. Most pills have a disintegrating ingredient, usually cornstarch. This ingredient causes the pill to swell and break apart when it comes in contact with the fluid in the stomach. Some drugs should not be crushed. Time-released tablets should not be crushed. This allows all the drug to be released at once, rather than over a period of time, with the risk of causing a toxic reaction. What is a drug? A drug is any substance that when taken into a living organism, changes or modifies one of the body functions What is a drug? A drug is any substance that when taken into a living organism, changes or modifies one of the body functions. Drugs have a complex action on the body. The purpose, eventually, is to act at a particular target cell or tissue. The action of the drug is more complex as it interacts with food and on its way to the target tissue. The drug is expected to have a positive effect on the body. A drug cannot create a new action in the body, but can change an existing function, or block an existing action. For example, an angiotensin converting enzyme inhibitor blocks the conversion of angiotensin I to angiotensin II, preventing vasoconstriction and aldosterone secretion. Aldosterone triggers the retention of sodium and water, causing an expanded fluid volume. The reduced vasoconstriction and the decreased fluid volume allow the damaged heart to pump more effectively, and the blood pressure to be lowered. Extra fluid volume and vasoconstriction add to the workload of an already damaged heart, or increase the blood pressure of a resident with hypertension. Some basics - Phases of drug action An easy way to remember the phases of drug action is to think of the pharmaceutical phase as getting the drug dissolved and into solution in the body fluids. The pharmacokinetic phase is most like the digestion of food in the body, from entering the body, Drug Use in LTC 71 going through absorption, to excretion of food is much like the flow of drugs through the body. The pharmacodynamic phase is the specific action of the drug at the cellular or target tissue level. The discussion of how drugs and nutrients interact in the digestive tract follows. Phases of Drug Action Drug Dose Pharmaceutical Phase Disintegration and dissolution of active components of drug dose. Pharmacokinetic Phase a. absorption b. distribution c. metabolism d. excretion of active drug component Pharmacodynamic Phase Drug-receptor interaction at target tissue site Therapeutic Effect at Target Site Pharmaceutical phase Pharmaceutical phase: getting the drug dissolved and into solution in the body fluids. The pharmaceutical phase involves the disintegration and dissolution of the active substance so the drug is dissolved in the body fluids. Drugs have a constant amount of the active drug ingredient, and contain other substances as a major part of the tablet or capsule. These ingredients found in the tablet are inert or inactive ingredients. Some of these inert ingredients may help the drug disintegrate and dissolve. The active drug must get into solution to act in the body. This is a major reason drugs are taken with water. For this reason, the Guidance to Surveyors (provided at the end of this chapter) gives specific fluid intake directions for some medications. Drug Use in LTC 72 Pharmacokinetic phase Pharmacokinetic phase: most like the digestion of food in the body, from entering the body, going through absorption, to excretion of food is much like the flow of drugs through the body The pharmacokinetic phase includes the absorption, distribution, metabolism and excretion of drugs. Pharmacokinetics and nutrient kinetics are similar, and is an easy way to remember this phase of drug action. The drug pharmacokinetics allows the drug to get into and out of the body. The first step in the pharmacokinetic phase is drug absorption. There are many factors that can influence drug absorption. Absorption of the drug occurs when the drug is in solution in the body tissues. Except for intravenous medications, all medications must enter into the blood stream first, in order to reach the target organ or tissue. Fat-soluble drugs are absorbed more easily than water-soluble drugs. Absorption Drug absorption is the process of how the drug enters the body, enters into body fluids, and finally into body tissues. This discussion will focus primarily on orally administered drugs. Most drugs are absorbed by passive diffusion, filtration or osmosis. Drugs may also be absorbed by active or facilitated transport, or endocytosis (McCance, 2003; Springhouse, 2000). The rate of absorption depends on the degree of blood flow to the tissues where the therapeutic action will take place. Areas of rapid blood flow (the heart, the brain, and vital organs) have first exposure to the drug as it enters the body. Reduced areas of blood flow (such as the skin and bone) receive delayed exposure to the drug. If faster drug action is desired, the drug may be given already in solution, or by injection. Oral or rectal medications take longer to act because they have to be dissolved and involved in the gastrointestinal processes, and then carried to the site of action. The more soluble the drug, the easier it is for the drug to enter into solution in the body tissues. The drug must be somewhat lipid soluble to pass the membranes of the body. Lipid soluble drugs cross cellular membranes by dissolving in the lipid membrane of the cell. Water-soluble drugs cross through the pores of cell membranes (Worthington, 2004; McCance, 2003; Springhouse, 2000). The pH of the drug can influence the absorption of the drug. Some drugs are protected by enteric coatings so they will pass through the acid environment of the stomach and dissolve in the alkaline environment of the small intestine. The coating can also decrease the gastric irritation caused by some drugs. The pH in the duodenum is 5-7, and rises to 7-8 in the ileum. The small intestine environment favors absorption of the uncharged of the weak bases. Drug Use in LTC 73 The small intestine has a large absorptive surface. The healthier and less scarred the small intestine, the better the drug absorption. An unobstructed blood flow to the small intestine improves drug absorption. Previous surgery, malnutrition, alcoholism and vasoconstricting diseases decrease drug absorption. Disease and disability influence drug absorption (Wolinsky, 2002). The nutrient composition of the diet can influence drug absorption. A high fat diet may cause increased micelle formation as a product of fat digestion. Fat-soluble drugs may compete with the micelles for absorption. Stress and pain also alter drug absorption. The reason is unknown. Pain and stress may alter normal physiology, such as in the stress response, which results in vasoconstriction and other physical and biochemical changes. Some drugs influence gastrointestinal motility. Drugs that increase gastrointestinal motility cause diarrhea. Laxative drugs are examples of drugs that increase gastrointestinal motility. Drugs causing constipation also influence gastrointestinal transit time, allowing for the presence of drugs in the intestinal tract for a longer period of time. Anticholinergic drugs specifically, have an effect of delaying gastrointestinal transit time. Drugs causing gastrointestinal irritation or ulceration may decrease drug absorption. Drug absorption is influenced by many factors: • presence of food(s) • drug concentration • drug pH in relationship to gastric pH • solubility of the drug • composition of the drug • effect on drug of gastric intestinal motility • health of the gastrointestinal tract Absorption of drugs is influenced by the presence or absence of food. This is important information for both nursing and dietary to consider in the timing of meals, snacks, and medications. The next pharmacokinetic stage to consider is distribution of drugs. This section will look at drug distribution and its effect on nutrition, and vise-versa. Distribution After the drugs are absorbed, they are carried to their site of action. This is called distribution. The drug goes first to areas of greatest blood flow: the heart, liver, kidneys and brain, very quickly. Some drugs do not pass the blood-brain barrier a specialized physiological barrier to protect the brain from the effects of toxic drugs. In areas of slower blood flow, such as muscle, bone, skin and fat, the drug distribution is much slower. The cardiac output and local blood flow are factors in drug distribution. Blood flow is important to adequate drug distribution. Chronic diseases such as hypertension, congestive heart failure, and renal disease can limit drug distribution. Drug Use in LTC 74 After the drugs are absorbed, many are transported to their target site in a protein bound form. The most common binding agent is albumin. Other binding agents include alpha-1-acid glycoprotein and lipoproteins. Acidic drugs usually bind to albumin. Alkaline drugs usually bind to alpha-1-acid glycoprotein (Worthington, 2004; McCance, 2003). The affinity of a drug for a binding site is like a lock and key. The better the fit, the greater the binding. The drug size, shape, polarity and valance are factors in the drug binding. When a high fat meal is eaten, the level of free fatty acids increases in the blood stream. The free fatty acid molecules bind to the same place on albumin as many drugs. This can cause competition for binding sites. This results in a decrease in drug binding, and can increase the amount of free drug in the blood stream. The free drug is now available in greater quantities than expected and can lead to drug toxicity. The serum albumin level also plays a role in drug activity. Most important to nutrition professionals is the role of plasma proteins in drug binding. Some drugs are highly bound. Drugs that remain in the blood stream for an extended period of time are bound to protein. Proteins do not diffuse through capillary walls. This is a reversible process; an equilibrium is established in the blood between the drug bound to the protein and the drug free in solution. Only the free drug is free in solution to act in the blood stream and produce drug action. Many physicians may want to be aware of the albumin levels, as albumin levels affect active drug levels. When drugs are protein bound, the drug and the amount in the blood stream are in balance, and when the drug level in the blood stream gets low, more drug is released to maintain equilibrium. If the serum albumin is low (say 2.5 gm/ dl) less drug is bound to protein than if the serum albumin were 3.5 g/dl or higher. This greatly increases the risk of drug toxicity with many drugs, but especially digoxin and warfarin, which can cause great danger. In addition to nutritional status, serum albumin levels are important to drug therapy (Wolinsky, 2002; McCance, 2003). Drugs that are bound primarily to serum albumin are released into the general circulation gradually. The receptors, called “drug receptors,” are natural components of the body intended to respond to a chemical normally found in the body. For instance, the drug receptors for morphine are the same as for the “runners high” produced by endogenously produced enkephalins and endorphins. Since the number of binding sites is limited, the drug with the greater affinity for the binding site is bound. The other drugs will be displaced and be free in the blood stream. The displaced drug could be free to cause increased drug toxicity. A low serum albumin level such as with malnutrition, liver, and renal disease could decrease the binding ability, resulting in more free drug in the circulation. Highly protein bound drugs are 85 to 90 percent bound. Following is a list of common highly protein bound drugs. Drug Use in LTC 75 Drugs that are Highly Protein Bound Generic Name Brand Name Generic Name Brand Name acetazolamide Diamox fluvastatin Lescol amiodarone Cordarone fosinopril Monopril amlodipine Norvasc glipizide Glucotrol benazepril Lotensin glyburide DiaBeta, Micronase bromocriptine Parlodel indomethacin Indocin bumetanide Bumex lansoprazole Prevacid buspirone BuSpar losartan Cozaar chlorpromazine Thorazine miconazole Monistat cisapride Propulsid naproxen Naprosyn, Anaprox, Aleve clindamycin Cleocin nefazodone Serzone clozapine Clozaril omeprazole Prilosec dapsone Dapsone perphenazine Trilafon diazepam Valium phenytoin Dilantin diflunisal Dolobid piroxicam Feldene digitalis Digoxin, Lanoxin prazosin Minipress doxazosin Cardura risperidone Risperdal doxycycline Vibramycin temazepam Restoril etodolac Lodine valproic acid Depakene, Depakote felodipine Plendil warfarin Coumadin (Pronsky, 2004) Bumping and Binding Drugs can also compete for specific binding sites. Drugs act through contact with the binding sites. The ability of the drug to cause specific therapeutic results is dependent on the ability of the drug to bind to specific receptors on a cell. If there is competition for the same binding site, one of the drugs is bumped from the binding site. This can result in more free drug in the circulation of the dislodged drug. This can be critical for two highly bound protein drugs such as aspirin and warfarin (Coumadin). Aspirin can dislodge warfarin (Coumadin) from the binding site, allowing more free warfarin in the circulation with the development of toxicity or possible hemorrhage. Such drug combinations warrant careful clinical monitoring. Drug Storage in Fatty Tissue Some drugs are highly soluble in fat, or may accumulate rapidly in fat. Fat acts as a reservoir for drugs, slowly releasing the drug back into the blood stream, prolonging its effect and delaying elimination from the body. This is why some antipsychotic or antidepressant drugs take 6 to 8 weeks to be effective. The drug levels need to build up in the fat stores to be effective. Drug Use in LTC 76 Drugs accumulate in fat and be slowly released from their fat stores. This allows the effect of the drug to continue over an extensive period of time. Drugs may also be stored in other body tissues and be slowly released into the blood stream over a period of time. After drugs are distributed in the body, they are taken to the liver, by way of the portal vein, for metabolism or biotransformation. In summary, drugs in the body can be free in solution, bound with albumin (acetic drugs) or with alpha-1 glycoprotein (alkaline drugs), or stored in the body in fat. The drug may also accumulate in other body tissues. Drug accumulation in the body is enhanced by use of other drugs, disease status, age, weight, and nutritional status. Biotransformation Biotransformation, is the process of altering the form of drug – usually in preparation for removing the drug from the body. This is an important process to eliminate or use up the drug to prevent toxic levels in the blood stream. The liver metabolizes some drugs, but also may convert some drugs to an active form. When the liver is damaged, the ability to metabolize drugs is decreased. Drug dosage that normally would be safe may cause toxicity. Laboratory tests may be indicated to learn liver status before prescribing certain drugs. The dosage of the drug is usually altered with liver disease. Nutrient Effect on Drug Metabolism Protein – A high protein diet with low carbohydrate content can increase drug metabolism by the liver. A decrease in protein intake may reduce renal blood flow and clearance of drugs by the kidney. This may be clinically important for those with renal disease eating a low protein diet. Carbohydrates – Carbohydrates are believed to have minor effect on drug metabolism. One study showed a decreased level of drug metabolism on a low carbohydrate diet. Protein and carbohydrate supplements seemed to have opposite effects on drug metabolism. Lipids – Lipids can compete for drugs binding on plasma albumin and decrease drug effectiveness by displacement of the drug. Deficiencies of fat and essential fatty acids can decrease hepatic biotransformation. Vitamins and Minerals – Vitamins needed for liver enzymatic biotransformation include: niacin, thiamine, and vitamins A, E and C. Excessive vitamin intakes can have an adverse effect. An example is an increased intake of pyridoxine for those on levodopa (Dopar). Folic acid excess can decrease the effectiveness of methotrexate (Rheumatrex), and excess vitamin K can influence negatively the action of coumadin (Warfarin). The deficiency of zinc, iodine, magnesium and potassium deficiency have shown less oxidation and clearance of drugs. Elimination – Drugs do not stay in the body indefinitely. The body eliminates excess drugs, usually through the urine. Drugs can also be excreted through the feces, lungs and sweat. Some drugs can be eliminated without metabolism and are excreted in Drug Use in LTC 77 the urine without change. These drugs enter glomerular fluid and are not reabsorbed, but are actively secreted in the tubule, which causes rapid drug elimination and a high urinary concentration of the drug. These drugs can accumulate rapidly and cause toxicity. (Please refer to the list of common drugs excreted through the kidney, later in this section.) Some drugs, after biotransformation by the liver, are released into the bile and eliminated. For some drugs the concentration in bile may be several times the blood concentration. The bile salt produced daily is 600 to 1000 mg. Drugs in the bile may reenter the small intestine and be reabsorbed and returned to the liver a second time. This reaction occurs with erythromycin and some penicillins. This process is called the enterohepatic circulation. These drugs stay in the body longer. The pH of the urine can alter drug elimination. The pH can change the form of the drug again and again, and cause the drug to be returned to the general circulation. Residents with renal disease are at greater risk of toxic reactions, because more drug accumulates in their body, and their diseased kidney is not able to eliminate the drug effectively. Common Drugs Excreted Through the Kidney Digoxin (Lanoxin) Gentamicin (Garamycin) Penicillins Atenolol (Tenormin) Cephalosporins Cimetidine (Tagamet) Ranitidine (Zantac) Lithium (Lithobid, Eskalith) Vancomycin (Vancocin) Methotrexate Captopril (Capoten) Amantadine (Symmetrel) Allopurinol (Zyloprim) Drugs can stay in the body for varying periods of time. Protein bound drugs and drugs stored in fat stay longer than drugs not using protein carriers or not stored in fat. The pH of the urine can alter the elimination of the drug. Drugs that are weak bases are better excreted in a less acid urine and weak acids are better excreted in an alkaline urine. The pH can alter the form of the drug, causing it to be reabsorbed into the enterohepatic circulation. The reabsorbed drug will remain in the body for a longer period of time (McCance, 2003; Wolinsky, 2002; Worthington, 2004). The T-time, or the half-life of a drug, is the amount of time it takes for 50 percent of the drug to be eliminated from the body. Drugs with a long half-life may only need to be given one time a day. If the drug has a short half-life, the drug may need to be given more often. Drug Use in LTC 78 Pharmacokinetic studies of drugs indicate that drug absorption, protein binding, drug metabolism, and drug clearance are altered by protein-calorie malnutrition. Malnutrition can produce consequences with drug usage. Drug disposition is altered in malnutrition. The final phase of drug action is the pharmacodynamic phase. Pharmacodynamic phase Pharmacodynamic phase: the specific action of the drug at the cellular or target tissue level Pharmacodynamics is the study of how drugs cause change (action) in the body. The drug usually targets action at the cellular level, within a specific cell, tissue or organ. Drugs act to alter body functions. When drugs reach their target, the drug may act by changing the function, or the environment of the tissue. The change can be either physical or chemical. Drug action occurs when the drug combines with a specific receptor. The cell receptor may be part of the cell membrane or on the cell surface. The more specific the drug is to the receptor site, the more effective is the action of the drug. The better the fit – the better the drug action. The fit of the drug to the receptor site is dependent on the size, geometry, valance and electrical charge of the drug. The fit is often geometric, so the better the drug fits as a key into the receptor, or the lock the more effective the drug. Cellular macromolecules that can act as drug receptors include enzymes, ion channels, and DNA. These cellular components act as receptors for hormones or neurotransmitters. Drugs may replace these hormones or neurotransmitters to change physiological activity in the body. Receptors will only react with a limited number of substances that are structurally related, or like complementary substances. Drug action can be local or systemic, depending on the number of receptor sites in the body that will produce an effective fit. Each cell or tissue has unique receptors. The cells not having these receptors cannot bind and use the drug. A drug receptor either initiates or blocks a response. A drug that initiates a response is called a drug agonist. A drug that blocks a response is called a drug antagonist. Drugs may also have a synergistic effect, which occurs when two drugs are given at the same time, and the result is a greater response than if the two drugs were given separately. This chapter has looked at the effects of drugs on nutritional status and drug action. Drug passage through the body was discussed, with particular emphasis on physiological and biochemical changes of most interest to nutrition professionals. Drug Use in LTC 79 The extent of the effect of food on the drug taken can vary by several mechanisms. The presence of food may impair or block absorption of the drug; the drug may bind with nutrients in food; the drug may be destroyed by the acetic environment of the stomach when food is present. The rate of gastric and intestinal motility is affected by the presence of food. Some drugs are better absorbed in the presence of fat, and others do best when taken with plain water. This chapter also discussed the impact of food and drugs in the general population. The next chapter will examine the effects of aging on these processes. Drug Use in LTC 80 Surveyor Guidelines Tag Number Regulation F333 Guidance to Surveyors ~ Adequate Fluids with Medications The administration of medications without adequate fluid when the manufacturer specifies that adequate fluids be taken with the medication. For example: ~ Bulk laxatives (e.g. Metamucil, Fiberall, Serutan, Konsyl, Citrucel); ~ Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) should be administered with adequate fluid. Adequate fluid is not defined by the manufacturer but is usually four to eight ounces. If the resident refuses to take adequate fluid, the facility should not be at fault, so long as they made a good faith effort to offer fluid, and provided any assistance that may be necessary to drink the fluid. It is important that the surveyor not apply this rule to residents who are fluid restricted; and ~ Potassium supplements (solid or liquid dosage forms) such as: Kaochlor, Klorvess, Kaon, K-Lor, K-Tab, K-Dur, K-Lyte, Slow K, Klotrix, Micro K, or Ten K should be administered with or after meals with a full glass (e.g., approximately 4-8 ounces of water or fruit juice). This will minimize the possibility of gastrointestinal irritation and saline cathartic effect. If the resident refuses to take adequate fluid, the facility should not be at fault so long as they made a good faith effort to offer fluid. It is important that the surveyor not apply this rule to residents who are fluid restricted. ~ Medications that Must be Taken with Food or Antacids: The administration of medications without food or antacids when the manufacturer specifies that food or antacids be taken with or before the medication is considered a medication error. The most commonly used drugs that should be taken with food or antacids are the Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). There is evidence that elderly, debilitated persons are at greater risk of gastritis and GI bleeds, including silent GI bleeds. Determine if the time of administration was selected to take into account the need to give the medication with food. Examples of commonly used NSAIDs are as follows: Generic Name Diclofenac Diflunisal Etodolac Fenoprofen Ibuprofen Indomethacin Ketoprofen Mefenamic Acid Nabumetone Naproxen Piroxicam Sulindac Tolmetin Brand Name Voltaren, Cataflam Dolobid Lodine Nalfon Motrin, Advil Indocin Orudis, Oruvail Ponstel Relafen Naprosyn, Aleve Feldene Clinoril Tolectin Drug Use in LTC 81 Chapter Six: Drugs and the Elderly “As to diseases, make a habit of doing two things – to help, or at least to not harm.” ~ Epidemics, Hippocrates Drugs can impact on nutritional status in a variety of ways. This chapter exam- ines the possible cause of drug activity in the entire gastrointestinal system from the mouth, esophagus, stomach and intestinal tract. The chapter begins with how drugs affect the gastrointestinal tract, then continues with looking at how drug use is altered in the elderly. How medications can influence the GI tract Oral Cavity Medications in the oral cavity can affect the teeth, gums, and tongue. Throat lozenges often contain sugar, which can lead to bacterial growth and tooth decay. Periodontal disease is prevalent in the elderly and is increased by the presence of bacteria found in the crevices of the teeth and the jawbone. Dilantin can trigger tooth loss if oral care for the gums is not adequate. Antibiotics and some chemotherapy drugs can lead to “Thrush.” Thrush is found when white spots appear in the mouth. The following chart lists some drugs that can affect taste, and their use(s). Drug Use in LTC 82 Drugs That Can Alter Taste Generic Name Brand Name / misc. albuterol sulfate Proventil, Ventolin allopurinol Zyloprim aluminum hydroxide Amphojel, chalky taste amphotericin Fungizone ampicillin Unasyn baclofen altered taste calcitonin Miacalcin, metallic or salty taste calcium carbonate Tums, OsCal, chalky taste captopril Capoten, metallic or salty taste carbamazepine Tegretol colchicine Colchicine diclofenac Voltaren diltiazem Cardizem, Cardizem SR & CD docusate sodium Colace etidronate disodium Didronel flecainide acetate Tambocor fluoxetine Prozac fluvoxamine maleate Luvox fosphenytion Cerebyx glipizide Glucotrol ipratropium bromide Atrovent, bitter, metallic taste ketorolac tromethamine Toradol, loss of taste Generic Name Brand Name / misc. levodopa Dopar, 5% bitter taste 20% taste loss lithium carbonate Eskalith, Lithobid, metallic taste magnesium, as supplement, antacid, laxative metformin Glucophage, metallic taste methotrexate Methotrexate, altered metoprolol tartrate Lopressor, Toprol XL metronidazole Flagyl metronidazole Flagyl MOM chalky taste nefazodone Serzone nifedipine Procardia paroxetine Paxil penicillin phenytoin Dilantin sinemet Levodopa & Carbidopa spironolactone Aldactone terbutaline sulfate Brethine tetracyclines Tetracycline, Achromycin theophylline Theobid, unpleasant trazodone HCl Desyrel, unpleasant venlafaxine Effexor zidovudine Retrovir Drugs That Can Cause Dry Mouth Dry mouth can affect the taste of food, swallowing, and cause difficulty using dentures (McCabe, 2003; Wolinsky, 2002; Pronsky, 2004). Drug categories frequently noted include: • analgesics • antidiarrheals • antipsychotics • antiulcer medications • antidepressants • antiinflammatories • anti-Parkinson’s medications • antihypertensives Drug Use in LTC 83 Drugs That Can Cause Oral Problems Generic Name Brand Name Side Effects / Misc. amoxicillin Amoxil stomatitis, glossitis, oral candidiasis, pseudomembranous colitis ampicillin stomatitis, glossitis, oral candidiasis, pseudomembranous colitis bupropion HCl Wellbutrin stomatitis carbamazepine Tegretol stomatitis, glossitis cephalexin Keflex oral candidiasis, pseudomembranous colitis Cephalosporins oral candidiasis, pseudomembranous colitis ciprofloxacin Cipro oral candidiasis, pseudomembranous colitis enalapril maleate Vasotec stomatitis erythromycin oral candidiasis, pseudomembranous colitis etidronate Didronel stomatitis disodium ketorolac Toradol stomatitis tromethamine methotrexate Methotrexate stomatitis, gingivitis tetracycline HCl Achromycin-V black hairy tongue, stomatitis, oral candidiasis, pseudomembranous colitis furosemide Lasix oral irritation gabapentin Neurontin dental abnormalities, gingivitis diphenoxylate HCl Lomotil sore swollen gums w/ atropine sulfate zalcitabine HIVID pharyngitis, glossitis valproic acid Depakene, periodontal abscess Depakote trimethoprim Bactrim stomatitis, glossitis w/ sulfa methoxazole nabumetone Relafen stomatitis naproxen Naprosyn stomatitis Drug Use in LTC 84 Increased Risk of Dental Problems Generic Name amantadine HCl carbamazepine clozapine ethosuximide ferrous salts haloperidol warfarin sodium verapamil trazodone HCl propoxyphene napsylate phenytoin morphine sulfate Brand Name / Misc. Symmetrel Tegretol Clozaril Zarontin dental stains Haldol Coumadin Calan Desyrel Darvon N Dilantin MS Contin Drugs That Can Affect Swallowing Drugs taken before bedtime can cause injury to the esophagus. When laying flat in bed, the risk of esophageal damage increases. Laying flat decreases saliva and swallowing, so less of the drug is flushed out of this area. A study found gelatin capsules remained in the esophagus for 10 minutes or more when the resident was placed in the flat position after taking medication encased in a gelatin capsule. Two commonly used drugs in the elderly are likely to cause this damage: one is potassium chloride, and the other is an iron supplement. Other drugs can decrease the ability to swallow, causing esophageal difficulties. These are included in the chart on the following page. Drug Use in LTC 85 Drugs That Can Cause Esophageal Difficulties Brand Name Generic Name Used in treatment for: Benzocaine * Topical anesthetic Betoptic Kerlone Betaxolol Eye drops Thorazine Chlorpromazine* Antipsychotic Othalmic Cipro, Ciloxan Ciprofloxacin Antibiotic Digitoxin, Lanoxin, Lanoxin caps Digoxin Congestive heart failure, cardiac arrhythmias Alcohol Ethanol Cytotec Misoprostol Antiulcer with NSAID use Astramorph, Duramorph, Morphine Pain Infumorph, morphine sulfate Taxol Paclitaxel Anti-neoplastic Cuprimine, Depen Penicillamine Arthritis Eldepryl Selegiline Antiparkinson Zoloft Sertraline Anti-depressant Achromycin-V, Sumycin, Tetracycline Tetracycline Antibiotic Theobid, Theolair, Theospan, Theophylline Bronchodilator Uniphyl, Elixophyllin, Slo-Bid, Slo-Phyllin, Theo-24 Calan, Isoptin, Verlan Verapamil Anti-angina, anti-hypertensive Retrovir Zidovudine Antiviral Drugs That Can Cause Dysphagia, Esopheageal Ulcer Generic Name Brand Name / Misc. alendronate Fosamax calcitonin Miacalcin (epigastric distress, bone loss) corticosteroids (esophagitis, many uses) isoniazid INH (epigastric distress, TB) levodopa Dopar (epigastric distress, Parkinson’s) metronidazole Flagyl (antibiotic) mineral oil do not take with dysphagia phenytoin Dilantin sucralfate Carafate ( not recommended with dysphagia, delays gastric emptying) tetracycline HCl Achromycin-V troglitazone Rezulin (pharyngitis, blood sugar control) zalcitabine HIVID Drug Use in LTC 86 Drugs That Can Cause Stomach Discomfort The stomach is a common area of drug discomfort in the elderly. An ulceration of the gastric mucosa occurs because the gastric mucosal barrier is altered by some drugs. The most common classification of drugs causing risk to the elderly are the pain relievers: aspirin and nonsteroidal antiinflammatory drugs (NSAIDs). Gastrointestinal bleeding can occur without pain and without warning. The only drug known to prevent gastrointestinal bleeding when NSAIDs are prescribed is Cytotec (misoprostol) Other drugs causing gastric distress are steroids (Deltazone, Decadron, Cortef, Medrol, Aristocort), iron sulfate, potassium chloride, and spironolactone (Aldactone, a diuretic) (McCabe, 2003; Wolinsky, 2002). Drug Use in LTC 87 Drugs That Can Cause Stomach Distress Generic Name Brand Name / misc. acarbose Precose acetylsalicylic acid Aspirin acetylsalicylic acid aspirin albuterol sulfate Proventil, Ventolin alendronate sodium Fosamax amphotericin B Fungizone azithromycin Zithromax bromocriptine mesylate Parlodel bupropion HCl Wellbutrin calcium carbonate Tums, OsCal captopril Capoten carbamazepine Tegretol cephalexin Keflex ciprofloxacin Cipro cisapride Propulsid colchicine Colchicine corticosteroids diclofenac sodium Voltaren didanosine Videx diflunisal Dolobid diltiazem Cardizem diphenoxylate HCl Lomotil w/atropine sulfate donepezil Aricept dronabinol Marinol enalapril maleate Vasotec epoetin alfa Epogen erythromycin E-Mycin, ERYC, Ery-tabs, Ilosone ethosuximide Zarontin etodolac Lodine felodipine Plendil fenoprofen Nalfon fentanyl patch Duragesic patch ferrous salts fluoxetine Prozac flurbiprofen Ansaid fluvoxamine maleate Luvox fosphenytion Cognex gabapentin Neurotonin glipizide Glucotrol glyburide Glynase, Micronase haloperidol Haldol ibuprofen Motrin, Midol indomethacin Indocin interferon Beta-1a Avonex interferon Gamma-1b Actimmune ipratropium bromide Atrovent iron supplements isosorbide mononitrate Imdur, ISMO KCL ketorolac tromethamine Toradol Generic Name Brand Name / misc. ketoprofen Orudis lactulose Cephulac, Chronulac lansoprazole Prevacid levodopa Dopar, Larodopa lisinopril Prinivil, Zestril lithium carbonate Eskalith, Lithobid loperamide HCl Imodium magnesium as supplement, antacid or laxative megestrol acetate Megace metaproterenol sulfate Alupent methylphenidate HCl Ritalin metoprolol tartrate Lopressor metronidazole Flagyl mineral oil mirtazapine Remeron misoprostol Cytotec MOM Milk of Magnesia nabumetone Relafen naproxen Naprosyn nefazodone Serzone new: zidovudine Retrovir niacin nicardipine Cardene nifedipine Adalat, Procardia nitrofurantoin Macrodantin nitroglycerin ofloxacin Floxin olanzapine Zyprexa omeprazole Prilosec oxaprozin Daypro paroxetine Paxil penicillamine Cuprimine, Depen penicillin prioxicam Feldene propoxyphene napsylate Darvon-N ranitidine HCl Zantac risperidone Risperdal salicylates, NSAIDs salsalate Disalcid sertraline Zoloft spironolactone Aldactone sucralfate Carafate sulindac Clinoril tetracycline HCl Achromycin-V tolmetin Tolectin valproic acid Depakene, Depakote venlafaxine Effexor verapamil Calan zalcitabine HIVID zinc new (Bold indicates a greater risk of stomach distress.) Drug Use in LTC 88 Drugs That Can Cause Nausea / Vomiting Generic Name Brand Name ferrous salts fluvoxamine maleate Luvox metformin Glucophage MOM nausea morphine sulfate MS Contin nabumetone Relafen naproxen Naprosyn nausea, ofloxacin Floxin nefazodone Serzone niacin nitrofurantoin Macrodantin prioxicam Feldene propoxyphene napsylate Darvon-N salsalate Disalcid sertraline Zoloft spironolactone Aldactone trazodone HCl Desyrel trimethoprim Bactrim w/sulfamethoxazole valproic acid Depakene, Depakote venlafaxine Effexor zalcitabine HIVID zidovudine Retrovir azithromycin Zithromax baclofen Lioresal calcitonin Miacalcin ciprofloxacin Cipro diazepam Valium digoxin Digoxin, Lanoxin dronabinol Marinol estrogens ethosuximide Zarontin fentanyl patch Duragesic patch fluoxetine Prozac ibuprofen Motrin ketorolac tromethamine Toradol lithium carbonate Eskalith, Lithobid metoclopramide HCl Reglan metronidazole Flagyl levodopa Dopar acetylsalicylic acid Aspirin acyclovir Zovirax albuterol sulfate Proventil, Ventolin allopurinol Zyloprim aluminum hydroxide AlternaGEL amantadine HCl Symmetrel amoxicillin Amoxil amoxicillin and Augmentin potassium clavulanate atenolol Tenormin bisacodyl Dulcolax Generic Name Brand Name Cephalosporins choline salicylate and Trilisate magnesium salicylate cimetidine Tagamet cisapride Propulsid codeine colchicine Colchicine corticosteroids dapsone Dapsone diclofenac sodium Voltaren diflunisal Dolobid diltiazem Cardizem diphenoxylate HCl Lomotil w/atropine sulfate dirithromycin Dynabac docusate sodium Colace donepezil Aricept doxazosin mesylate Cadura doxycycline Doryx, Vibramycin enalapril maleate Vasotec epoetin alfa Epogen erythromycin etidronate disodium Didronel ethosuximide Zarontin etodolac Lodine felodipine Plendil fluconazole Diflucan fluvoxamine maleate Luvox furosemide Lasix gabapentin Neurontin glimepiride Amaryl glipizide Glucotrol glyburide Glynase, Micronase haloperidol Haldol hydrochlorothiazide HydroDIURIL interferon Gamma 1b Actimmune ipratropium bromide Atrovent isoniazid INH isosorbide dinitrate Isordil isosorbide mononitrate Imdur, ISMO KCL lamotrigine Lamictal lansoprazole Prevacid loperamide HCl Imodium lorazepam Ativan levodopa Dopar, Larodopa lisinopril Prinivil, Zestril magnesium, as supplement, antacid, laxative megestrol acetate Megace metaproterenol sulfate Alupent Drug Use in LTC 89 Drugs That Can Cause Nausea / Vomiting, continued Generic Name Brand Name bromocriptine mesylate Parlodel bumetanide Bumex bupropion HCl Wellbutrin buspirone HCl BuSpar calcitriol Calcijex, Rocaltrol calcium carbonate Tums, OsCal captopril Capoten carbamazepine Tegretol olanzapine Zyprexa omeprazole Prilosec paroxetine Paxil penicillin phenytoin Dilantin propoxyphene HCl Darvon quinapril Accupril ranitidine HCl Zantac risperidone Risperdal sinemet Levodopa & Carbidopa Generic Name Brand Name metoprolol tartrate Lopressor mineral oil mirtazapine Remeron misoprostol Cytotec zinc new nicardipine Cardene nifedipine Adalat, Procardia nitroglycerin stavudine Zerit streptomycin tacrine Cognex tetracycline HCl Achromycin-V theophylline Slo- bid, Slo- Phyllin, Theobid, Theolair, Uniphyl triamterene Dyrenium topiramate Topamax troglitazone Rezulin (nausea) verapamil HCl Calan, Isoptin, Verelan warfarin sodium Coumadin Drugs That Can Cause Ulcers Generic Name Brand Name diclofenac sodium Voltaren, bleeding may occur & be sudden & serious zalcitabine HIVID, oral ulcer captopril Capoten diflunisal Dolobid, caution w/GI irritants, risk of bleeding Generic Name Brand Name corticosteroids ibuprofen Motrin, sudden bleeding nabumetone Relafen naproxen Naprosyn niacin piroxicam Feldene Drug Use in LTC 90 Drugs That Can Cause Gastritis Generic Name Brand Name / Misc. ferrous salts penicillin dyspepsia avoid GI irrit. GI ulcers & bleeding may be serious & sudden ethosuximide Zarontin fluoxetine Prozac allopurinol Zyloprim cephalexin Keflex enalapril maleate Vasotec metaproterenol sulfate Alupent Generic Name Brand Name / Misc. nabumetone Relafen niacin nitrofurantoin Macrodantin spironolactone Aldactone theophylline Theobid, epigastric pain/ GE reflux valproic acid Depakene, Depakote, gastroenteritis Drugs That Can Cause Gas Generic Name Brand Name metformin Glucophage nabumetone Relafen naproxen Naprosyn niacin alendronate Fosamax bisacodyl Dulcolax corticosteroids diclofenac sodium Voltaren Generic Name Brand Name mineral oil misoprostol Cytotec nifedipine Adalat, Procardia nitrofurantoin Macrodantin ofloxacin Floxin paroxetine Paxil valproic acid Depakene, Depakote Drug Use in LTC 91 Drugs That Can Cause Constipation Drugs cause constipation in the elderly more often. This is caused by decreased motor activity in the gastrointestinal tract, less fiber and fluids, and more medications. Drugs That Can Cause Constipation Generic Name Brand Name aluminum hydroxide Amphojel baclofen Lioresal bupropion Wellbutrin chlorpromazine HCl Thorazine codeine diclofenac sodium Voltaren fentanyl patch Duragesic patch ferrous salts fluvoxamine maleate Luvox haloperidol Haldol metronidazole Flagyl morphine sulfate MS Contin nabumetone Relafen naproxen Naprosyn olanzapine Zyprexa paroxetine Paxil phenytoin Dilantin venlafaxine Effexor verapamil Calan alendronate Fosamax amantadine HCl Symmetrel attapulgite Donnagel/Kaopectate bismuth subsalicylate Pepto- Bismol (impaction in the elderly) calcium carbonate TUMS, OsCal captopril Capoten carbamazepine Tegretol cisapride Propulsid cyproheptadine HCl Periactin diazepam Valium Generic Name Brand Name diflunisal Dolobid diphenoxylate HCl Lomotil w/atropine sulfate fluoxetine Prozac furosemide Lasix glipizide Glucotrol glyburide Micronase hydrochlorothiazide HydroDIURIL ibuprofen Motrin isoniazid INH ketorolac tromethamine Toradol levodopa Dopar loperamide HCl Imodium lorazepam Ativan metoclopramide HCl Reglan metoprolol tartrate Lopressor nefazodone Serzone nifedipine Adalat , Procardia nitrofurantoin Macrodantin ofloxacin Floxin omeprazole Prilosec prioxicam Feldene propoxyphene napsylate Darvon-N ranitidine HCl Zantac risperidone Risperdal sertraline Zoloft sucralfate Carafate trazodone HCl Desyrel valproic acid Depakene, Depakote zidovudine Retrovir Drug Use in LTC 92 Drugs That Can Cause Diarrhea Drugs affect the gastrointestinal tract in multiple areas. Gastrointestinal discombort and difficulties can frequently occur with drug use (Pronsky, 2004; McCabe, 2003; Wolinsky, 2002). Drugs That Can Cause Diarrhea Generic Name Brand Name acarbose Precose cephalexin Keflex colchicine Colchicine ethosuximide Zarontin fentanyl patch Duragesic patch fluoxetine Prozac fluvoxamine maleate Luvox ketorolac tromethamine Toradol lansoprazole Prevacid lithium carbonate Eskalith, Lithobid magnesium as various supplement, antacid or laxative metformin Glucophage methotrexate Methotrexate metoclopramide HCl Reglan metoprolol tartrate Lopressor metronidazole Flagyl misoprostol Cytotec MOM Milk of Magnesia nabumetone Relafen niacin paroxetine Paxil penicillin sertraline HCl Zoloft spironolactone Aldactone tetracycline HCl Achromycin-V allopurinol Zyloprim amoxicillin Amoxil ampicillin atenolol Tenormin azithromycin Zithromax bisacodyl Dulcolax buspirone HCl BuSpar calcitonin Miacalcin captopril Capoten cimetidine Tagamet ciprofloxacin Cipro cisapride Propulsid clonazepam Klonopin Generic Name Brand Name clozapine Clozaril colchicine Colchicine cyproheptadine HCl Periactin diclofenac sodium Voltaren, Cataflam diflunisal Dolobid docusate sodium Colace donepezil Aricept enalapril maleate Vasotec epoetin alfa Epogen estrogens etidronate disodium Didronel etodolac Lodine ferrous salts furosemide Lasix glipizide Glucotrol glyburide Micronase haloperidol Haldol hydrochlorothiazide HydroDIURIL ibuprofen Motrin isoniazid INH laxatives various levodopa Dopar lisinopril Prinivil magnesium sulfate Mobidin metaproterenol sulfate Alupent mineral oil nabumetone Relafen naproxen Naprosyn nefazodone Serzone zalcitabine HIVID nitrofurantoin Macrodantin ofloxacin Floxin omeprazole Prilosec prioxicam Feldene ranitidine HCl Zantac risperidone Risperdal thyroid Synthroid triamterene Dyrenium valproic acid Depakene, Depakote venlafaxine Effexor warfarin sodium Coumadin Drug Use in LTC 93 Changes in aging The elderly over 65 years of age are 2-3 times more likely to have an adverse drug reaction. Psychotropic, hypoglycemic, cardiac drugs and diuretics are prescribed for this age group. The risk of adverse reactions increases with advanced age and the number of drugs taken. The response to drug therapy is related to the number of chronic diseases for which medications are needed, the body mass, and the physiological and psychological status of the individual. Cognitive and sensory changes also occur, such as decreased memory, vision and hearing. Some drug effects can mimic the effects of the disease process they were chosen to treat. The brain receptors are more sensitive to the effects of psychoactive drugs. The psychoactive drugs are more potent in the aging brain. Medicine is an imperfect science, and drugs may no longer work to compensate for an illness. In the elderly, it is especially important to limit the amount of medications given. The “pill for every ill” philosophy may have important consequences. Absorption The gastric emptying rate and gastrointestinal motility slow with aging. This causes a decrease in gastrointestinal emptying, intestinal absorption, and delays fecal excretion. Adding bran or fiber to the diet to prevent constipation can interfere with absorption of drugs. Digoxin is an example. Whether this has clinical consequences is unclear. Therapeutic monitoring is more important for those drugs with a narrow therapeutic index such as digoxin, in the elderly. Stimulant laxatives are known to increase drug movement through the gastrointestinal tract and can decrease the absorption of drugs and nutrients. The decrease in drug absorption of some drugs causes difficulty in predicting the correct dose. Food can also affect drug absorption by: binding drugs; limiting access to binding sites; altering the pH. This is of greater concern in the elderly where there is an increased pH due to less gastric acid production in the stomach. This may decrease drug dissolution. The pH in the gastrointestinal tract is raised, favoring drugs absorbed in a more alkaline environment, and less favorable to drugs absorbed in an acid environment. The delayed gastric emptying increases absorption of alkaline drugs by increasing absorption time. Conversely, drugs that are better absorbed in an acid environment are less well absorbed. The villi in the small intestine flatten, and there is a decreased surface area for drug absorption. Any damage to the mucosal surface of the intestinal tract such as scarring, surgery, or other damage, limits the surface area for drug absorption. Malabsorption can occur due to alcohol or other drug irritant damage, such as that caused by NSAIDs or aspirin. The movement of the entire gastrointestinal tract slows down due to decreased muscle tone. Splanchnic blood flow (blood flow to the abdominal organs) decreases by 30 to 40 percent with aging. The blood flow to these organs may be further decreased by disease conditions limiting blood flow, such as congestive heart failure and liver disease. The Drug Use in LTC 94 number of mucosal cells and cell types changes as a person ages, resulting in some loss of absorptive surface, and a decrease in the amount of the drug that reaches the systemic circulation. The blood flow to the gut is a rate limiting factor for absorption of drugs and nutrients. In summary, the elderly experience an elevated gastric acid pH, a reduction in intestinal blood flow, and a decrease in GI motility, resulting in age related changes in GI absorption. The overall drug absorption may be reduced and the therapeutic effect compromised, or the drug may be slowed in achieving its therapeutic goal, but still effective. Distribution of drugs Distribution of drugs in the elderly is changed by several physiological changes. Individual changes in the body can affect the concentration of the drug and its distribution in the body. The first is a decrease in body water content. There is a drop in body water content. As a result, elders may have a reduced volume of distribution, which may require lower loading doses for drugs like digoxin. Other drugs of concern are acetaminophen (Tylenol), morphine and cimetidine (Tagamet). With less total body water, there is potential for a higher concentration of the drug in the body, without a change in drug dosage. Residents on diuretics, and/or laxatives are at greater risk because these drugs reduce body water even further. Clinical conditions can reduce body water even more, such as diarrhea, vomiting, gastrointestinal bleeding, or fever. An inadequate fluid intake can also decrease body water content. (For further information, refer to Hydration: Maintenance, Dehydration, Lab Values and Clinical Alterations, by Annette M. Kobriger, Kobriger Presents, Inc., PO Box 55, Chilton, WI.) There is also an increase in body fat. Body fat in men increases from 25 percent at age 25, to 36 percent between the ages of 65 and 85. In women, body fat increases from 33 percent at age 25, to 45 percent between the ages of 65 and 85. Volume density of fatsoluble drugs increases the half-life of these drugs in the body. Drugs that are fat-soluble can be stored in the body fat for long periods of time. The fat-soluble drugs can be released slowly, and have an affect for long periods of time. Hypnotic and sleep aid drugs carry a risk in this regard. Some psychiatric drugs take a period of 3 to 6 weeks to be effective because they are stored in the body fat and it takes this long to achieve a therapeutic dose. Many psychotropic drugs need to be carefully monitored for this reason. When switching from one psychotropic medication to another, the drug still present in the fat stores has to be considered for the safety of the resident. With the increase in body fat, there is a decrease in the lean body mass. Along with this, there is a slight decrease in serum albumin levels for the healthy elderly. Residents who have altered health states – such as malnutrition, renal, liver, or other chronic diseases – may have even lower serum albumin levels. This means there is less protein binding of the drugs given, and the potential for more free drug in the body circulation. The drug will also not stay in the body as long, since more of the free drug is in the blood stream and is metabolized and excreted. Drug action is first heightened, and then decreased. Drug Use in LTC 95 Consequently, there is less albumin for binding active drugs and more alpha-1 acid glycoprotein for binding alkaline drugs, especially with inflammation. Edema, ascites, and obesity all play factors in the distribution of drugs. Other disease factors also play a role in the distribution of drugs in the aging body. Factors such as malnutrition, liver, renal, and cardiac disease, and their pathological changes, have to be calculated into the equation for the appropriate dosing schedule. The changes in drug distribution in the elderly are individual and age dependent. The physical, pathological and individual factors are difficult to predict. Decreased cardiac output may be reduced in those with heart disease. A decline in cardiac blood flow may decrease blood flow to the liver for metabolism, and to the kidneys for drug excretion. Those who are immobile or have circulatory disorders may also have diminished drug profiles. Decreased body weight Decreased body weight is found in many elderly residents. The decreased body weight means there is less body surface area for the drug to act. Drug dosage will need to be adjusted to prevent toxicity. Metabolism The ability of the liver to metabolize drugs slows with age. Drug metabolism in the liver can be reduced 50-66 percent, and cardiac and respiratory conditions can further decrease blood flow to the liver. The ability of the liver to clear drugs depends on blood flow and the activity of the liver enzymes to biotransform drugs. The blood flow to the liver declines, and is further complicated by the age-related decrease in liver function after age 25, which has been reported to be 0.5 to 1.5 percent per year. The enzymes in the liver active in oxidation and reduction reactions declines significantly. This affects both drug metabolism and drug detoxification. The actual size of the liver declines after age 70. The decreased liver size is proportional to the change in body weight. This means that drugs may remain in the body longer. Drugs not metabolized by the liver may be better choices for the elderly, especially those elderly with liver damage. Drugs metabolized by the liver have more intense and longer lasting effects due to hepatic changes. Elimination The renal mass, blood flow, tubular secretion rate, and the number of functioning glomeruli all decline with age. The glomerular filtration rate declines, which affects the ability of the body to eliminate drugs. The kidneys effectiveness to eliminate drugs may be reduced almost in half. An accurate assessment of renal status is necessary when using certain drugs in the elderly. The creatinine clearance is a useful tool to gauge the safety of renal excretion of Drug Use in LTC 96 drugs of concern in the elderly. The Cockcroft formula is often used for this purpose. Adults over age 60 account for 42 percent of all newly diagnosed end-stage renal disease each year (Porth, 1994). Evaluation of renal function in the elderly should include measurement of the creatinine clearance, as well as the serum creatinine. The Cockcroft and Gault equation is used to determine an estimate of the creatinine clearance by an indirect means. The estimate of creatinine clearance is given in ml/minute. (140 - age) X (body weight in kg) _________________________________ 72 X serum creatinine in mg/dl This is the equation for men. For women, multiply the result of the equation for men by 0.85, due to the decreased muscle mass. This calculation is frequently used to determine the protein prescription in the diet for those with renal disease. One drug that is renally excreted, thus requiring careful evaluation, is aminoglycosides (antibiotics). Other commonly renally excreted drugs with a narrow therapeutic index include digoxin, theophylline, amantadine (Symmetrel), lithium (Eskalith, Lithobid), cimetidine (Tagamet), Captopril (Capoten), Enalapril (Vasotec), Lisinopril (Zestril), Furosemide (Lasix), Hydrochlorothiazide (Hydro Diuril), Triamterene (Dyrenium), Amiloride (Moduretic), and Rantidine (Zantac). The BUN is not specific indicators of renal function, and may be affected by protein intake, hydration status, and effects of diet on drug excretion. This is especially important to the elderly with compromised renal function. Fever, rash, peeling skin, hepatitis, and worsening of the renal function can occur. A low protein diet can also lessen the excretion of basic drugs such as the antibiotic gentamicin (Garamycin) or the antiarrhythmic drug procainamide (Pronestyl). In summary, in the elderly, medications are absorbed and excreted slower and less completely. Impaired circulation can delay transport to the sites of drug action. Decreases in kidney and liver function, and changes in chemical binding of protein, body water content, and fat are all critical factors in the ability to detoxify and eliminate harmful substances. This completes this section of our text. The many complexities of drug use and nutritional status have been examined. The elderly can pay a high price for inappropriate and over-use of drugs. This also affects us as taxpayers, consumers and sons and daughters. The many ways that food and drugs may interact were discussed, with examples and extensive lists. The many forms of drugs and why various forms are used, and the rationale for use were discussed. Finally, drug action in the body was reviewed, along with the pharmaceutical, pharmacokinetic and pharmacodynamic stages. These stages were considered with impact on nutritional status. More specifically, drug use by the aging body was reviewed. Drug Use in LTC 97 A case study is provided for your practice. Case Study Mrs. J. has coronary artery disease. She takes: aspirin and captopril for her heart disease. For her congestive heart failure she takes digoxin and furosemide. Mrs. J. also takes fluoxetine for her depression. Use the form on the next page to see if you can identify possible causes of weight loss, decreased appetite, and a cough. Mrs. J. also complains of stomach pain. Be a food-drug interaction detective! Answer to Case Study (See form at end of this chapter for notes): Many drugs impact on appetite, especially digoxin, fluoxetine & aspirin. Check when drugs were started and if appetite decrease corresponds with start date. Suggest MD decrease or substitute another drug. Sometimes aspirin can be reduced to 8 mg — a proven anticoagulant dose to prevent heart attacks and stoke. Electrolyte monitoring is important with drug use. Cough — likely Captopril Stomach pain — fluoxetine, aspirin (can cause GI blood loss), Captopril (can cause ulcer) Also check H/H Given Order Appetite Dry Consti- Mouth pation Nausea Anorexia Gastric Distress Con- fusion Abdominal Pain Diarrhea Rectal Bleed Sedation Potassium Notes Drug Use in LTC 98 ‘ ‘ QD QD Fluoxetine Aspirin √‘ √√ √ √ or = more significant effect √ = common QD Digoxin √- √‘ Furoseimide QD Captopril √- Gastric Distress Con- fusion √ √ √ √ Abdominal Pain Diarrhea √ √ Dry Consti- Mouth pation Nausea Anorexia √‘ Given Order Appetite TID Altered Taste √ Rectal Bleed Sedation Potassium Notes Ca Headache, drowsiness, dizziness, anxiety Monitor H/H folate Vitamin C Monitor electrolytes K, Ca, Mg Mg Na Taste changes, peptic ulcer, cough common Drug Use in LTC 99 Drug Use in LTC Notes 100 Drug Use in LTC 101 Chapter Seven: Food-Drug Interactions “All the healing techniques in the world won’t really help unless love goes with them.” ~ Louise L. Hay The influence of food How quickly the drug is able to disintegrate, dissolve and get into the general circulation is the limiting step for drug use in the body. Drugs taken by mouth have to be swallowed and dissolved in body fluids, must pass through the gastrointestinal tract, and enter the portal circulation before the drug can enter the general circulation to act. Absorption of the drug is a critical factor in how fast the drug works. Food and drugs Food entering the stomach will leave in a predictable order. One such predictable factor is: the greater the amount of food entering the body, the longer food will take to leave the stomach. Food high in fat will leave the body at a slower rate than carbohydrates and protein. The emptying rate of carbohydrates and amino acids is proportional to the amount in the stomach at that time. Larger food particles remain in the stomach longer to be subject to the action of the stomach. Fluid leaves the stomach faster than solid foods. Food served hot will leave the body faster than food served cold. Water will leave the stomach faster than beverages with a caloric content such as juice or soda products. Larger amounts of fluids with medications increases drug breakdown and is absorbed faster. On the other hand, large amounts of fluid may stimulate the intestine allowing less contact with the absorption surface of the intestine. The rate of absorption is often the rate-limiting step of drug action. The materials that are compounded with the active drug to form the capsule or pill also influence drug activity. Some of these compounds are gluten, potato starch, lactose, and sucrose. Some drugs require an acid pH and others an alkaline environment for dissolution. Drug Use in LTC 102 Food stimulates enzymes and gastric acid. Gastric acid (hydrochloric acid) decreases the pH of the stomach. Some drugs are destroyed or altered by the acid environment of the stomach. Drugs are sometimes coated to protect their travel through the acidic environment of the stomach. Water seems the best way for water-soluble drugs to pass through the stomach quickly. Fat-soluble drugs do best when taken with food. Therapeutic failure or drug toxicity may depend on the size and the composition of the meal. Effect of pH on Ability of Drugs to Cross GI Membranes Strongly acidic environments of stomach (pH 1-3) maintains weak acids in uncharged form, which is more easily absorbed. Weak bases remain charged in stomach but are converted to uncharged forms as pH approaches neutrality (pH 7) or becomes slightly alkaline (pH 7-8). Weak acids Stomach pH 1-3 Weak bases Duodenum pH 5-7 Weak bases pH 7-8 Ileum The interactions between drugs and food may lead to toxicity or drug failure. The most common mechanism to avoid the effect of food on drugs is to fast one hour before a meal and two hours after a meal. Some drugs are given first thing in the morning with water to avoid any interference with food or beverage, other than water. Alendronate (Fosamax) is reduced by 85 to 90 percent if taken within two hours of a meal. Orange juice or coffee will decrease absorption of this drug by 60 percent. Alendronate should be taken with plain water on an empty stomach. Food intake causes a 100 percent loss in absorption of etidronic acid (Didronel). The effect of eating was noted, even after two hours of a four-hour fast. Drug Use in LTC 103 Nutrients are absorbed at various places in the gastrointestinal tract. Alcohol is absorbed in the stomach. The duodenum is the absorption site for iron, calcium, magnesium and zinc. Here is where divalent cations can compete with drugs for absorption, or form complexes with drugs such as tetracyclines. Glucose, vitamin C, thiamine and riboflavin, as well as other sugars, are absorbed in the jejunum; pyridoxine, folic acid, amino acids, the fat-soluble vitamins, fat, bile salts and vitamin B12 are absorbed in the ileum. Here is where mineral oil can act as a barrier to the absorption of the fat-soluble vitamins A, D, E, and K. Sodium, potassium vitamin K and water are reabsorbed in the colon (Wolinsky, 2002). Food decreases absorption of these drugs The bioavailability and effectiveness of drugs are highly correlated acidity, bile secretions, and gastrointestinal motility. The decreased absorption of the drug is “only valid if the pharmacological effect of the drug is quantified.” (Schmidt, 2002) Food may slow the absorption of some drugs; however, the slower absorption may result in the same amount or more of the drug ultimately being available. Some drugs with a rapid absorption such as misoprostol (Cytotec) have absorption decreased by 63 percent when taken with food. The bioavailability of the drug is not altered. The drug given with food goes into the body slower, but the effect of the drug lasts longer. In fact, this drug is better taken with food to reduce gastrointestinal side effects (Schmidt, 2002). The bioavailability of an antibiotic may be reduced with slower and longer absorption. The drug level does not reach the critical level needed to destroy the microorganisms. Food in this case causes a therapeutic failure of the antibiotic. The usual recommendation is to decrease the effect of food by giving the antibiotic of concern one hour before or two hours after a meal. Cardiac and antihypertensive agents Digoxin administered with a high fiber diet decreases bioavailability by 16 to 32 percent, and may result in treatment failure. This occurs if digoxin is taken before breakfast with high fiber foods. Those with heart disease may increase fiber to lower cholesterol, by adding high fiber foods to breakfast. The bioavailability of furosemide (Lasix) is reduced by 16 to 45 percent when taken with food. Bumetanide (Bumex) does not interact with food. Clinically significant arrhythmia has developed after excessive use of potassium chloride salt substitutes. Food increases the bioavailability of nifedipine (Procardia, Nifedipine) in sustained release preparations by 28 to 31 percent. This does not occur with sustained release preparations of Aldat or Retard. Nifedipine is usually given for hypertension (Schmidt, 2002). Drug Use in LTC 104 Captopril (Capoten) has a decreased bioavailability of 42 to 56 percent, and perindopril (Aceon) of 35 percent when taken with food. This decrease in bioavailability of these two drugs is believed to be clinically significant. Some studies show no increase with the blood pressure when these drugs are given with food. The recommendation continues that these drugs be given on an empty stomach. Enalapril, (Vasotec) and lisinopril (Prinival) are not affected. These drugs cause an increase in serum potassium. Usually, a potassium supplement, potassium-sparing diuretic, or salt substitutes are not recommended with these drugs. Antimicrobial drugs Fluoroquinolones are one type of antibiotics altered by acid. One of these antibiotics commonly used in long-term care is ciprofloxacin (Cipro). Other antibiotics in this category are ofloxacin (Floxin), lomefloxacin (maxaquin), and enoxacin (penetrex). Fluoroquinolone antibiotics form insoluble complexes, or chelates with divalent cations – such as aluminum, calcium, iron, magnesium and zinc. Chelation decreases bioavailability of these drugs by 60 to 80 percent. Antacids containing divalent cations will further decrease the antibiotic absorption to 90 percent. Divalent cations are found in antacids with calcium, aluminum, and magnesium, and in laxatives, such as Milk of Magnesia. Sucralfate (Carafate) is a source of aluminum. Carafate, when given with ciprofloxecin (Cipro) decreased absorption by 30 percent. Enteral supplements are another source of divalent cations. Cipro was reduced by 25 percent when given with the nutritional supplement Resource, and not water. Another study reported the same finding when Cipro was given with Ensure. A better antibiotic choice for giving with supplements with a fluoroquinolone antibiotic is ofloxacin (Floxin) (Maka, 2000). Penicillin antibiotics may be affected by food intake. Ingestion of food, fiber, milk or formula decreases the bioavailability of phenoxymethylpenicillin (penicillin V) by 25-35 percent. Oral ampicillin given with food has a decreased absorption of 22-50 percent, and is likely to cause a therapeutic failure. Absorption of oral ampicillin suspension is not affected by food. Amoxicillin absorption is not decreased by food, formula or milk. Absorption is decreased by 21 percent if given with fiber. This is not considered a risk for therapeutic failure. Tetracyclines, if taken with food, have 46 to 57 percent less bioavailability, with dairy products have 50 to 65 percent less drug bioavailablity, and if taken with iron supplements only 19 percent of the drug is bioavailable. Small amounts of milk in coffee or tea decrease bioavilability by 49 percent. Minocycline (Dynacin, Minocin,) or Doxycycline (Vibramycin, Periostat) may be given with a milk base, but not with minerals or fortified foods. Cheleation occurs with dietary supplements. Quinolones are not decreased by food, but decreased 30 to 36 percent with dairy products. Treatment failure may occur with norofloxin (Noroxin) when taken with dairy products. A decreased absorption of 52 percent occurs when taken with dairy products. Drug Use in LTC 105 The Macrolide antibiotics, including erythromycin, E-mycin, Ery,Tabs, and EYRC, are especially vulnerable to acid secretion when taken with food. Taking these formulations with food can reduce bioavailability by 18 to 29 percent. Other formulations, erythromycin salts, and esters such as erythromycin estolate, or erythromycin ethylsyccinate, or coated tablets are suggested to increase bioavailability (Maka, 2002). The bioavailability of erythromycin with coated tablets was not affected by food. The effect of the antibiotic drug azithromycin, a Macrolide, is decreased by 50 percent if taken as a capsule with food. There is no effect with food if azithromycin is taken as a tablet or as a suspension. Other antimicrobial drugs influenced by taking with food are, isoniazid (Laniazid), ketoconazole (Nizoral) and rifadin (Rifadin) all of which should be taken one hour before or two hours after a meal. Didanosine is reduced by 41 percent when given with food and can result in treatment failure. Miscellaneous drugs Anticancer drug melphalan (Alkeran) is reduced 43 to 55 percent when taken with food. The bioavailability of mercatopurine (Purinethol) is decreased 65 percent when taken with food. Penicillamide (Cuperime, Depen) used for rheumatoid arthritis is a strong chelating drug. When taken with food, absorption is decreased 50 to 59 percent, and when taken with iron absorption is reduced by 82 percent. The immunosuppressant drug tacrolimus (Prograf) is decreased by one-third when taken with food. This can lead to therapeutic failure. Levodopa absorption is noted to decrease 27 percent when taken with food. High protein diets traditionally have been thought to limit the absorption of levodopa. This was believed to be true because amino acids were believed to compete for absorption of the drug past the blood-brain barrier. An alteration in drug distribution, rather than competition for absorption of amino acids is now thought to be the cause of decreased absorption. The competition for protein carriers of Levodopa is not is believed not to occur until the protein intake is greater than 2 gm/kg (Schmidt, 2002). Some drugs have higher absorption when taken with a meal, especially a high fat meal. Absorption enhanced with food Food may enhance the absorption of some medications. This seems like a positive response; however, the greater absorption may cause drug side effects and toxic levels of medication. Generally, fat-soluble drugs are better absorbed with a high fat meal. Older theophylline drugs show an increased absorption with food, especially with high fat meals. This causes an increased amount of drug to be absorbed. The amount of drug intended for a 24-hour period is absorbed in a 4-hour period. This causes a Drug Use in LTC 106 phenomenon known as “dose dumping.” This could cause toxicity. It is recommended, therefore, that all extended release theophylline drugs be given on an empty stomach. Theo-24 and Uniphyl are the two drugs most noted to cause this effect. The bioavailability of itraconazole is increased 31 to 163 percent when taken with a meal. Griseofulin (Fulicin) is increased 37 to 120 percent when taken with a high fat meal. The antiviral ganciclovir is increased by 20 to 22 percent when taken with food. This may be clinically important. Saquinavir taken with a meal has increased bioavailability of 600 to 1800 percent. Drug absorption of zidovudine, lamivudine and abacavir delayed by food intake is of no clinical significance Carbamamazepine (Tegretol), an anti seizure drug, provides a longer drug effect when taken with food. Drug absorption is slowed, and increased time in the stomach can lead to increased absorption of the drug and toxicity. The presence of food increases absorption by 22 percent. The controlled release formulation is unaffected by food. The absorption of itraconazole (Sporanox) and ketoconazole (Nizoral) is reduced with atropic gastritis where inadequate acid is produced in the stomach. This may be counteracted by giving the drugs with an acidic beverage – such as cola or acetic juice. Absorption is increased by 38 to 220 percent when given with these beverages. Grapefruit juice should not be used (Schmidt, 2002; Maka, 2002; Worthington, 2004). Important drugs for food interactions Drugs that have reduced bioavailability when taken with food are: • Aspirin • Captopril (Capoten) — for high blood pressure and congestive heart failure • Isoniazid (INH) — for tuberculosis • Levodopa (Dopar) — for Parkinson’s disease • Penicillin V — an antibiotic • Rifampin (Rifadin, Rimactane) • Tetracycline Drugs that have enhanced bioavailability when taken with food are: • Carbamazepine (Tegretol) • Chlorothiazide (Diuril) • Grisofuluin (Fulvicin, Grifulvin) • Hydrochlorothiazide (HydroDIURIL, Esidrix, Oretic) • Metoprolol (Lopressor, Toprol-XL) • Nitrofurantoin (Macrobid, Macrodantin) • Spironlactone (Aldactone). See charts on following pages. This completes the section on when food should be given in relationship to medication. Drug Use in LTC 107 Drugs to be Taken With Food Drug (Generic Name) Drug (Brand Name) Classification / Notes Acarbose Precose oral hypoglycemic (should be taken with first bite of food) Acetazolamide Diamox diuretic, anticonvulsant, antiglaucoma Acetylsalicylic acid Aspirin, Bufferin, NSAID, analgesic (ASA) Ecotrin Acyclovir Zovirax Allopurinol Zyloprim antigout (take after meals) Amiloride HCl and Moduretic antihypertensive, diuretic Hydrochlorothiazide Amitriptyline HCl Elavil antidepressant Atovaquone Mepron anti-pcp Bromocriptine Parlodel antiparkinson Bumetanide Bumex diuretic (loop) Bupropion HCl Wellbutrin antidepressant Calcium acetate Phos-Lo phosphate binder Calcium carbonate Tums, OsCal antacid, calcium supplement, phosphate binder Carbamazepine Tegretol antimanic, antipsychotic Cefuroxime axetil Ceftin antibiotic, cephalosporin Chlorpromazine HCl Thorazine antipsychotic, antiemetic Chlorpropamide Diabinese oral hypoglycemic, sulfonylurea (usually given at breakfast) Chlorzoxazone Parafon Forte skeletal muscle relaxant, analgesic Ciprofloxacin Cipro fluoroquinolone, antibiotic (avoid milk and yogurt) Cisapride Propulsid anti-gerd, GI stimulant (take w/beverage 15-30 min. before meals & HS) Clindamycin Cleocin antibiotic Clofazimine Lamprene antibiotic Clonazepam Klonopin anticonvulsant Codeine antitussive, analgesic, narcotic Corticosteroids Cortisone, Decadron, antiinflammatory, immuno-suppressant, hormone Cortef, Deltasone Cyproheptadine HCl Periactin antihistamine, antipruritic Diazepam Valium antianxiety, muscle relaxant Diclofenac sodium Voltaren NSAID, analgesic, antiarthritic Diflunisal Dolobid NSAID, analgesic, antiarthritic Diltiazem Cardizem, Cardizem antiangina, antihypertensive, calcium channel blocker SR & CD, (take before meals – do not crush) Dilacor XR, Tiamate Dirithromycin Dynabec antibiotic Erythromycin (Estolate, Ilosone, EES, antibiotic, macrolide Ethylsuccinate & E-Mycin enteric coated forms) Ethambutol HCl Myambutol antituberculosis Ethionamide Trecator-SC antituberculosis Ethosuximide Zarontin anticonvulsant Furosemide Lasix diuretic (loop, potassium-depleting), antihypertensive Ganciclovir sodium Cytovene antiviral Gemfibrozil Lopid antihyperlipidemic (take _ hour before breakfast and supper) Glimepiride Amaryl oral hypoglycemic, sulfonylurea (take with first meal of day) Glyburide DiaBeta, Glynase, oral hypoglycemic (take with first meal of day) Micronase Griseofulvin Fulvicin, Grifulvin, antifungal Grisactin Haloperidol Haldol antipsychotic Hydrochlorothiazide HCTZ, HydroDIURIL, antihypertensive, diuretic, thiazide (potassium depleting) Microzide Hydroxychloroquine sulfate Plaquenil antimalarial, antiarthritis (rheumatoid) Drug Use in LTC 108 Drugs to be Taken With Food, continued Drug (Generic Name) Drug (Brand Name) Classification / Notes Ibuprofen Advil, Motrin NSAID, antiarthritic, analgesic Imipramine HCl Tofranil antidepressant, tricyclic Indomethacin Indocin NSAID, antiarthritic Itraconazole Sporanox antifungal, anti-candidiasis Ketoconazole Nizoral antifungal, anti-candidiasis Labetalol HCl Normodyne, Trandate antihypertensive, Alpha1 & Beta-Blocker Lactulose Cephulac, Chronulac, laxative (take with juice, milk, or water) Duphalac Lansoprazole Prevacid antiulcer, antisecretory, proton pump inhibitor (take before a meal) Levodopa Dopar, Larodopa antiparkinson (take with low protein fruit or juice) Lithium carbonate Eskalith, Lithobid, antimanic Lithonate Lomotil antidiarrheal Lorazepam Ativan antianxiety, benzodiazepine Lovastatin Mevacor antihyperlipidemic Metaproterenol Alupent, Metaprel bronchodilator, sympathomimetic Metformin Glucophage oral hypoglycemic Metoclopramide Reglan antiemetic, anti-gerd, dopamine antagonist, take _ hr before meals & HS Metoprolol Lopressor, Toprol XL antihypertensive, antianginal, take w/ food to ≠ bioavailability Metronidazole Flagyl antibiotic, amebicide, antitrichomonal Minocycline Minocin antibiotic, tetracycline (can take with food or milk, not with antacids or mineral supplements) Misoprostol Cytotec antiulcer with NSAID use Molindone HCl Moban antipsychotic Naproxen Naprosyn, Anaprox, NSAID, antiarthritic, analgesic Aleve Nelfinvir mesylate Viracept antiviral, anti-HIV Niacin Nicobid, Nicolar antihyperlipidemic, antipellagra Nitrofurantoin Macrobid, Macrodantin antibiotic, urinary Omeprazole Prilosec antiulcer, antisecretory, anti-gerd Oxybutynin chloride Ditropan antispasmodic, anticholinergic Oxycodone Oxycontin, Roxicodone Analgesic, narcotic Pentoxifylline Trental antiperipheral vascular disease Perphenazine Trilafon antipsychotic, antinauseant, phenothiazine Phenytoin Dilantin anticonvulsant, hydantoin Piroxicam Feldene NSAID, antiarthritic Potassium chloride electrolyte supplement Propranolol Inderal LA antiarrhythmic, antianginal, antihypertensive Ranitidine HCl Zantac antisecretory, antiulcer, anti-gerd Ritonavir Norvir antiviral Salsalate Disalcid NSAID, antiarthritic, analgesic Sertraline HCl Zoloft antidepressant, anti-panic disorder, SSRI Spironolactone Aldactone antihypertensive, diuretic (potassium-sparing) Sulindac Clinoril NSAID, antiarthritic Thioridazine HCl Mellaril antipsychotic, phenothiazine Thiothixene Navane antipsychotic Trihexyphenidyl HCl Artane antiparkinson, anti EPS Trimethoprim Bactrim, Cotrim, antibiotic, sulfonamide sulfamethoxazole Septra Troglitazone Rezulin antidiabetic agent Valproic acid Depakene, Depakote anticonvulsant, antimanic, anti-migraine, do not take w/ milk or in syrup w/ carbonated beverages Venlafaxine Effexor antidepressant, SSRI Verapamil Calan, Calan SR, Isoptin antiarrhythmic, antiangina, antihypertensive Isoptin SR, Verelan Drug Use in LTC 109 Drugs to be Taken Without Food Drug (Generic Name) Drug (Brand Name) Classification / Notes Alendronate Fosamax anti-osteoporosis (take with plain water only), best 2 hr before food Aluminum hydroxide Alu-Cap, Amphojel antacid, phosphate binder (1-3 hours after eating) Magnesium hydroxide Mylanta, Maalox, Di-Gel, Gelusil antacid (one hour after eating) Ampicillin antibiotic, food rate & extent of absorption Anastrozole Arimidex antineoplastic Astemizole Hismanal antihistamine (avoid grapefruit & grapefruit juice 2 hrs. before & after taking) Azithromycin Zithromax antibiotic, macrolide, capsule or suspension Bisacodyl Dulcolax stimulant laxative (PM on empty stomach with 8 oz. juice or water), take HS; do not take within 1 hr of milk, Ca, Mg supplement Captopril Capoten antihypertensive, antidiabetic neuropathy, ACE inhibitor, take on empty stomach; food‚ absorption by 30-40 percent Chloramphenicol Chloromycetin antibiotic Cholestyramine Questran antihyperlipidemic, antidiarrheal Cisapride Propulsid take 15 minutes before meal, HS, rate of gastric emptying Cyclophosphamide Cytoxan antineoplastic alkylating agent Dicloxacillin sodium Dynapen antibiotic, penicillinace resistant Didanosine Videx antiviral, anti-HIV Digitalis Crystodigin, Digitoxin, cardiotonic, antiarrhythmic (take separately from bran fiber or high pectin foods. Digoxin, Lanoxin Fiber decreases absorption by 25 percent) Dipyridamole Persantine platelet aggregation inhibitor Erythromycin-stearate antibiotic, macrolide, only without food Etidronate disodium Didronel calcium regulator (take w/water or fruit juice), take on empty stomach - 2 hr before or after food in Ca or supplements w/Ca, Fe, Mg, within 2 hr of drug, absorption of drug Etodolac Lodine NSAID, analgesic, antiarthritic Ferrous salts, antianemic, take w/8 oz. water or juice on empty stomach; may take w/food to GI Iron supplements irritation; food‚ absorption 50%, take 1hr before or 2 hr after phytate foods; fiber supplement, tea, coffee, dairy supplement, 20 mg Vit. absorption, meat absorption; take Ca, Zn, Cu separately by 2 hr Finasteride Proscar anti-prostate hyperplagia Fioricet analgesic, sedative, barbiturate Fluconazole Diflucan antifungal, anticandidiasis Glipizide Glucotrol oral hypoglycemic (take on empty stomach, 30 min. before first meal of day) Indinavir sulfate Crixivan antiviral, anti-HIV (no grapefruit juice) Isoniazid INH antituberculosis, 1 hr before or 2 hr after eating Isosorbide dinitrate Isordil, Sorbitrate antianginal, vasodilator Methotrexate Methotrexate food absorption, peak conc & bioavailability of drug Mineral oil Agoral lubricant, laxative Mycophenolate mofetil CellCept immuno-suppressant Nabumetone Relafen NSAID, analgesic, antiarthritic Nafcillin sodium Nafcil, Unipen antibiotic, penicillin (penicillinase resistant) Nefazodone Serzone antidepressant (food rate of absorption & bioavailability) Nicardipine Cardene, Cardene SR antihypertensive, antianginal, calcium channel blocker Penicillamine Cuprimine, Depen antiarthritic, chelating agent Procainamide HCl Procanbid, Pronestyl antiarrhythmic Quinapril Accupril antihypertensive, ACE inhibitor (rate & extent of absorption‚ 25-35% w/increased fat meal) Rifabutin Mycobutin antibiotic Rifampin Rifadin antibiotic, antitubercular Sucralfate Carafate antiulcer, gastric mucosa protectant, 1 hr before eating & HS; take Ca supplement separate by 30 min. Sulfasalazine Azulfidine antiinflammatory Tacrine Cognex anti-alzheimer’s Terbutaline sulfate Brethine, Bricanyl bronchodilator, sympathomimetic Tetracycline Achromycin-V, antibiotic Sumycin, Tetracycline Thyroid Synthroid, Levoxyl, thyroid preparation Levothroid Zafirlukast Accolate antiasthma Zalcitabine HIVID antiviral, anti-HIV Zidovudine Retrovir 1 hr before eating or with a low fat meal (high fat meal about 40 gm absorption) Zinc Take at least 30 minutes before food or beverage Drug Use in LTC 110 Drugs to be Taken With or Without Food Drug (Generic Name) Drug (Brand Name) Acetaminophen Tylenol Acyclovir Zovirax Albuterol sulfate Proventil, Ventolin Alprazolam Xanax Amlodipine Norvasc Amoxicillin Amoxil Atenolol Tenormin Azathioprine Imuran Benazepril HCl Lotensin Benztropine mesylate Cogentin Buspirone HCl BuSpar Busulfan Myleran Cefaclor Ceclor Cefixime Suprax Cefprozil Cefzil Cephalexin Keflex Cephradine Velosef Clarithromycin Biaxin Clozapine Clozaril Donepezil Aricept Enalapril maleate Vasotec Famotidine Pepcid Felodipine Plendil Fluoxetine Prozac Fluoxymesterone Halotestin Fluvastatin Lescol Fosinopril sodium Monopril Gabapentin Neurontin Isradipine Dynacirc Lamivudine Epivir Lisinopril Prinivil, Zestril Losartan Cozaar Methylphenidate HCl Ritalin Nadolol Corgard Nevirapine Viramune Ofloxacin Floxin Olanzapine Zyprexa Paroxetine Paxil Penicillin, Penicillin Betapen-VK, V potassium Beepen VK, Ledercillin, Pen-Vee K, V-Cillin K Pravastatin sodium Pravachol Risperidone Risperdal Simvastatin Zocor Topiramate Topamax Torsemide Demadex Classification / Notes analgesic, pain, fever antiviral (take with full glass of water) bronchodilator (may take with food to decrease GI distress) antianxiety, anti-panic antianginal, calcium channel blocker antibiotic, penicillin, also (Augmentin) (take with full glass of water) antihypertensive, antiangina immuno-suppressant, antiarthritic antihypertensive, ACE inhibitor antiparkinson antianxiety antineoplastic, alkylating agent antibiotic, cephalosporin antibiotic, cephalosporin antibiotic, cephalosporin antibiotic, cephalosporin antibiotic, cephalosporin (food delays, but does not decrease absorption) antibiotic antipsychotic anti-alzheimer’s, cholinesterase inhibitor antihypertensive, ACE inhibitor antisecretory, antiulcer, anti-gerd antihypertensive, calcium channel blocker antidepressant, SSRI antineoplastic antihyperlipidemic antihypertensive, ACE inhibitor anticonvulsant (take Mg separate by 2 hours) antihypertensive, calcium channel blocker antiviral, anti-HIV, nucleoside analog antihypertensive, ACE inhibitor antihypertensive, angiotensin II receptor antagonist anti-narcolepsy, stimulant antihypertensive, antianginal, non-selective beta-blocker antiviral, anti-HIV antibiotic, fluoroquinolone antipsychotic antidepressant, anti-panic, SSRI antibiotic, penicillin antihyperlipidemic antipsychotic antihyperlipidemic anticonvulsant diuretic, (loop, K-depleting), antihypertensive Drug Use in LTC 111 Some drugs are recommended to be taken with 8 ounces of water to prevent gastrointestinal irritation, maintain fluid and electrolyte balance, prevent stone formation or prevent constipation. Drugs to be Taken With 8 oz of Water Generic Name Brand Name Notes acetylsalicylic acid ASA Aspirin acyclovir Zovirax 2-3 L/day alendronate Fosamax 6-8 oz. plain water only allopurinol Zyloprim 2.5 - 3 L fluids/day to produce 2 L of urine in 24 hr. aluminum hydroxide Amphojel 8 oz. fluids ampicillin 8 oz water bisacodyl Dulcolax 1500-2000 cc with · fiber docusate sodium Colace take w/full glass of water; fiber 1500-2000 ml of fluid / day isosorbide denatrate Isordil lithium carbonate Eskalith, Lithobid drink 2-3 liters of water daily; Na intake affects renal clearance of drugs 30-50 percent; limit caffeine/xanthine; avoid iodine supplement; risk of hypothyroidism methotrexate Methotrexate: encourage fluid intake to urine output Milk of Magnesia MOM take with fiber & 1500 - 2000 ml of fluids piroxicam Feldene morphine sulfate MS Contin ofloxacin Floxin Drug Use in LTC 112 Some drugs and food must be taken separately to prevent unwanted effects. The following list is given for your information. Drugs That Must be Taken Separately Generic Name Brand Name Notes aluminum hydroxide Amphojel allow separation before taking iron or folic acid, by 2 hr. Fe or folic acid take OJ separately by 3 hr. aluminum abs. atenolol Tenormin take separately from Ca supplements & antacids, Calcium salts may absorption; take separately from Fe, separately may absorption, take Mg supplement separate by 2 hr. ciprofloxacin Cipro take antacid Mg, Ca, Fe, Zn or MVT & mineral separately by 2-4 hr., milk & yogurt absorption and bioavailability Vitamin C take vitamin B12 separately by 1 hr, excessive chewable Vitamin C will break down enamel on teeth thyroid Synthroid take iron supplement separately by 4 hr., may iron absorption Tetracycline take Ca, Fe, Mg, Zn or MVI with minerals separately by 3 hr; drug chelates with Ca, Fe, Mg or zinc & both drug and mineral absorption, take Ca & Mg supplements separately by 2 hr morphine sulfate MS Contin 20 percent GI motility, adjust with meal time. nabumetone Relafen caution with K supplement; rare jaundice and hepatitis: highly protein bound nicardipine Cardene fat meat, absorption by 20 - 30 percent; caution with grapefruit juice; highly protein bound; angina ofloxacin Floxin take Mg, Ca, Fe, Zn or MVI with minerals separate by 2 hr paroxetine Paxil take separately from a trypothan supplement, caution with elderly drug conc. Drug Use in LTC 113 A medication map may be a helpful way to decide when drugs are best taken. Medication Map A medication map is given here for Mrs. G. These are her medications. Take with food: Take without food: Hydrochlorothiazide GD Captopril BID Ibuprofen TID Digoxin GD Midnight Medicine and dose planned: 1 am Medicine and dose planned: 2. am Medicine and dose planned: 3 am Medicine and dose planned: 4 am Medicine and dose planned: 5 am Medicine and dose planned: 6 am Medicine and dose planned: Digoxin / Captopril 7 am Medicine and dose planned: Morning Meal time is 8 am 8 am Medicine and dose planned: Hydrochlorothiazide / Ibuprofen 9 am Medicine and dose planned: 10 am Medicine and dose planned: 11 am Medicine and dose planned: 12 noon Medicine and dose planned: 1 pm Medicine and dose planned: 2 pm Medicine and dose planned: 3 pm Medicine and dose planned: 4 pm Medicine and dose planned: 5 pm Medicine and dose planned: Ibuprofen 6 pm Medicine and dose planned: Evening Meal Time: 5 pm 7 pm Medicine and dose planned: 8 pm Medicine and dose planned: 9 pm Medicine and dose planned: 10 pm Medicine and dose planned: 11 pm Medicine and dose planned: Lunch or Brunch Time: 12 noon, Ibuprofen Captopril Snack (if any): 7:30 pm Reference: Rybacki, James J., Pharm, D., and Long, James W., M.D., 1998, The Essential Guide to Prescription Drugs, HarperCollins Publishers, Inc., New York, NY, pp 1095. Drug Use in LTC 114 This chapter has discussed how food intake influences drug bioavailability. The next chapter will discuss additional ways foods and drugs can interact. Drug Use in LTC 115 Chapter Eight: Additional Food-Drug Interactions “We shall never know all the good that a simple smile can do.” ~ Mother Teresa of Calcutta Chapter 6 began the discussion of Food-Drug Interactions with when to take drugs in relationship to mealtime. This chapter will discuss additional ways food can interact with drugs. Drugs causing nutritional change Another type of food-drug interaction can occur when drugs cause a lack of appetite and weight loss; or stimulate the appetite and cause an excessive weight gain. Either of these situations can cause nutrition and health risks. If the weight gain is from appetite stimulation, other alternatives are considered. This may include the use of a low calorie diet and snacks, slowing of the eating process by using foods that take longer to eat, or other behavior modification strategies. Controlling the access to high calorie foods is also important. Drug Use in LTC 116 Drugs that Can Increase Appetite Generic Name Brand Name alprazolam Xanax appetite changes Estrogens calcium carbonate Tums, OsCal chlorpromazine Thorazine corticosteroids cyproheptadine Periactin dronabinol Marinol gabapentin Neurontin glipizide () Glucotrol (can also appetite) glyburide () Micronase (can also appetite) haloperidol Haldol Generic Name Brand Name insulin megestrol acetate Megace mirtazapine Remeron nefazodone Serzone olanzapine Zyprexa risperidone Risperdal steroids thyroid () Synthroid (can also appetite) trazodone HCl ) Desyrel (can also appetite) valproic acid Depakene, Depakote, however is more likely to appetite venlafaxine ) Effexor (can also appetite) Drugs that Can Decrease Appetite Generic Name Brand Name paroxetine Paxil acyclovir Zovirax albuterol sulfate Proventil, Ventolin bupropion HCl Wellbutrin ibuprofen Motrin, Advil, Nuprin benztropine mesylate Cogentin bismuth subsalicylate Pepto Bismol captopril Capoten carbamazepine diuretic therapy clonazepam Klonopin codeine colchicine Colchicine diltiazem HCl Cardizem, Dilacor diphenoxylate HCl Lomotil w/ atropine sulfate ethosuximide Zarontin iron supplements fluvoxamine maleate Luvox interferon beta-1a Avonex interferon gamma-1b Actimmune lansoprazole Prevacid Generic Name Brand Name levodopa Dopar, Larodopa lisinopril Prinivil, Zestril lithium carbonate Eskalith, Lithobid methylphenidate Ritalin morphine sulfate MS Contin penicillamine Cuprimine, Depen prioxicam Feldene antitubercular medications selegiline Eldepryl sertraline HCl Zoloft sinemet Levodopa & Carbidopa sulfasalazine Azulfidine tacrine Cognex tetracycline theophylline Slo- Bid, Slo- Phyllin, Theobid, Theo- Dur, Uniphyl topiramate Topamax trimethoprim w/ Bactrim, Septa sulfamethoxazole venlafaxine Effexor Drug Use in LTC 117 Drugs that Can Cause Weight Gain Generic Name Brand Name clozapine Clozaril corticosteroids cyproheptadine HCl Periactin mirtazapine Remeron risperidone Risperdal haloperidol Haldol megestrol acetate Megace levodopa Dopar Generic Name Brand Name lithium carbonate Eskalith, Lithobid baclofen Lioresal dronabinol Marinol gabapentin Neurontin ketorolac tromethamine Toradol nabumetone Relafen steroids terazosin HCl Hytrin Drugs that Can Cause Weight Loss Generic Name zalcitabine methotrexate benztropine mesylate bisacodyl bupropion HCl calcitonin spray captopril chlorpromazine colchicine diclofenac digitalis Brand Name HIVID, new Methotrexate Cogentin Dulcolax Wellbutrin Miacalcin Capoten Thorazine Colchicine Voltaren Digoxin Generic Name Brand Name diuretic therapy donepezil Aricept fluoxetine HCl Prozac interferon beta-1a Avonex interferon gamma-1b Actimmune lamotrigine Lamictal metformin Glucophage methotrexate Na Rheumatrex sertraline HCl Zoloft tacrine Cognex thyroid hormone Drugs that Can Cause Weight Gain or Weight Loss Generic Name Brand Name olanzapine Zyprexa valproic acid Depakene, Depakote alprazolam Xanax dronabinol Marinol estrogens fluvoxamine maleate Luvox paroxetine Paxil thyroid Synthroid venlafaxine Effexor Drug Use in LTC 118 Drugs that Can Cause Edema Generic Name Brand Name/misc. lithium carbonate Eskalith, Lithobid megestrol acetate Megace nabumetone Relafen nicardipine Cardene nifedipine Adalat corticosteroids diclofenac sodium Voltaren diltiazem Cardizem estrogens ketorolac tromethamine Toradol acyclovir Zovirax amantadine HCl Symmetrel (leg & ankles) amlodipine Norvasc baclofen Lioresal bupropion HCl Wellbutrin calcitonin Miacalcin (edema of feet) captopril Capoten (angioedema) carbamazepine Tegretol chlorpromazine HCl Thorazine Generic Name Brand Name/misc. clonazepam Klonopin cyproheptadine Periactin epoetin alfa Epogen fentanyl patch Duragesic patch gabapentin Neurontin ibuprofen Motrin metoprolol tartrate Lopressor (peripheral edema) lisinopril Prinivil, Zestril morphine sulfate MS Contin naproxen Naprosyn nefazodone Serzone olanzapine Zyprexa paroxetine Paxil piroxicam Feldene trazodone HCl Desyrel trimethoprim Bactrim w/sulfamethoxazole valproic acid Depakene, Depakote verapamil Calan Drug Use in LTC 119 Drugs that Can Cause Anorexia Generic Name Brand Name digoxin Digoxin, Lanoxin ethosuximide Zarontin ferrous salts fluvoxamine maleate Luvox metronidazole Flagyl fluoxetine Prozac (in the elderly) levodopa Dopar methotrexate Methotrexate triamcinolone zalcitabine HIVID new: zidovudine Retrovir venlafaxine Effexor valproic acid Depakene, Depakote, more likely to cause anorexia, may also cause increase appetite tetracycline HCl Achromycin-V theophylline Theobid sertraline Zoloft albuterol sulfate Proventil, Ventolin alprazolam Xanax amantadine Symmetrel bupropion HCl Wellbutrin calcium carbonate Tums, OsCal captopril Capoten Generic Name Brand Name carbamazepine Tegretol Cephalosporins, antibiotics codeine colchicine Colchicine diltiazem Cardizem donepezil Aricept erythromycin furosemide Lasix gabapentin Neurontin haloperidol Haldol hydrochlorothiazide HydroDIURIL zinc lithium carbonate Eskalith, Lithobid diphenoxylate HCl Lomotil w/atropine sulfate metformin Glucophage trimethoprim Bactrim w/sulfamethoxazole spironolactone Aldactone prioxicam Feldene mineral oil nitrofurantoin Macrodantin penicillin Drug induced nutrition deficiencies If some drugs are used without a nutrient supplement, a nutritional deficiency may result. With phenytoin (Dilantin) folic acid and vitamin B12 may become deficient. If over 2 mg/day of folic acid is given each day, the supplements can interfere with the effectiveness of the drug. Phenytoin also interferes with vitamin D metabolism. Drug induced changes in vitamin D metabolism may influence calcium and phosphate balance. A calcium supplement of 400 to 800 mg daily may be required with longterm use of this drug. Antibiotics Tuberculosis drugs (isoniazid, INH, Laniazid, Nydrazid, Pyrazinamide, and Rifadin) can cause deficiencies of niacin and vitamin B6. B6 is usually supplemented at 25 to 50 mg. Vitamin B6 helps reduce the risk of convulsions and prevents the development of Pellagra. These drugs are best taken on an empty stomach. Food decreases absorption of these drugs. Drug Use in LTC 120 The risk of drug-nutrient reactions when taking these tuberculosis drugs is increased in the malnourished, the non-milk drinkers, and the home or institutionally bound (Graedon, 1997). Drug-Induced Nutrition Deficiencies Deficiency Cause Vitamin A deficiency Mineral oil, cholestyramine, alcohol, colchicine and laxatives Thiamine Alcohol, digitalis glycosides, antacids Vitamin B6 deficiency INH, levodopa and penicillamine, alcohol. Decrease: Diuretics, Isoniazid, Levodopa, Premarin and other female hormone supplements Vitamin C deficiency High doses of aspirin, alcohol Vitamin D deficiency Mineral oil, cholestyramine, isoniazid, phenytoin, phenobarbital, laxatives Vitamin K deficiency Warfarin, antibiotics, mineral oil, cholestyramine, cephalosporin antibiotics, laxatives Sodium Diuretics Potassium Decrease (Hypokalemia): Diuretics. Laxative abuse, Kayexalate, amphotericin B, B12, Ampicillin, carbenicillin, piperacillin, ticarcillin, thiazides, furosemide Increase (Hyperkalemia): ACE inhibitors, potassium supplements, salt substitutes increase potassium, Spironolactone, penicillin G potassium Magnesium Decrease (Hypomagnesemia): Amphotericin B, diuretics, alcohol, cisplatin, cyclosporin, aminoglycosides, thiazides, furosemide, ciprofloxacin, probenecid, carbenicillin, pentamidine Increase (Hypermagnesemia): Magnesium based antacids, Milk of Magnesia, and magnesium salts Calcium Decrease: Loop diuretics, corticosteroids, anticonvulsants, laxatives, iron, Acetazolamide, Asparaginase, Aspirin, Calcitonin, Cisplatin, Heparin, Magnesium salts Increase: Vitamin D, antacids with calcium, and calcium supplements, Hydralazine, Lithium, Thiazide diuretics, Parathyroid hormone (PTH), Thyroid hormone Ca, Fe, Mg & Vit. D Etidronate (Didronel) – These nutrients react if taken within 2 hours of the medication. The drug requires adequate vitamin D and calcium. B12 Decrease: Colchicine, laxatives, Metformin, Prilosec, Tagamet, Zantac, Para- aminosalicylate Niacin Decrease: Alcohol, Isoniazid, Nydrazid, Rifamate, also B6 Zn Decrease: digitalis, diuretics B6 Folate Decrease: alcohol, antacids, salicylates, triamterene, Azulfidine, Macrodantin, Premarin, and other female hormone supplements Total calories Digitalis, antacids, SSRI’s (antidepressants), Theophylline (McCabe, 2003; Wolinsky, 2002; Worthington, 2004) Drug Use in LTC 121 Supplements Recommended Folate Antacids Aspirin Phenytoin Sulfasazine (Azulfidine) Triamterene Vitamin B6 Rifampin Calcium Phenytoin Tetracycline Glucocorticoids Zinc Amphotericin B (Fungizone) Cisplantin (Plantinol-AG) Loop diuretics Penicillamine (Cuprimene) Thiazide diuretics Vitamin D Phenytoin Rifampin Primidone Tetracycline Cathartics Thiamine Antacids Furosemide (Lasix) Vitamin C Aspirin Vitamin K Phenytoin Carthartics Antibiotics Vitamin B12 Lasoprazole (Prevacid) Omeprazole (Prilosec) Antacids H2 blockers Hemopoietic status Vitamin B12 deficiency may occur in the elderly as a result of achlorhydia, which decreases absorption of this vitamin. Antacids and protein pump inhibitors and H2 blockers may decrease the acid environment of the stomach, preventing absorption of vitamin B12. Drugs that antagonize folate can cause a secondary vitamin B12 deficiency. Vitamin C is excess of one gram a day may convert B12 into substances that are not useful to humans. Iron supplements may put the elderly at risk for overload. Divalent ions such as iron, calcium, magnesium and zinc can complex with other drugs. In addition, antacids, protein pump inhibitors and H2 blockers also impair calcium, magnesium and zinc absorption (McCabe, 2003). Iron supplementation is not recommended during an active or chronic inflammation. The disease process lowers the iron indices, and supplementation may feed the infection or cause iron overload. Steroids Prednisone use carries several nutritional risks such as hypokalemia, hyperglycemia, and calcium loss. Bone fractures with long-term care glucocorticoid use is between 30 to 50 percent. Recommendations to prevent osteoporosis with glucocorticoid use are vitamin D 800 IU/day; 1500 mg calcium intake; and use hydrochlorothiazide to blunt loss of calcium in the urine. Recommend a decrease in caffeine intake (Wolinsky, 2002). Drug Use in LTC 122 Anticonvulsants Phenytoin and Phenobarbital decrease calcium absorption. Vitamin D and calcium supplements may be required. Phenytoin also decreases folate levels. Carbamazepine (Tegretol), another anticonvulsant, does not decrease calcium absorption. NSAIDs Use of NSAIDs long-term for pain relief may cause increased losses of vitamin C, folate, potassium, vitamin K and iron. Sodium and fluid retention occur. Cancer chemotherapy Mexate (methotrexate) may lower folate, B12 and carotene, lactose and calcium. Procarbazine (Matalane) is a weak inhibitor of MAOIs and abstinence from high tyrammine foods is recommended. Cardiovascular drugs Diuretics may increase the risk of hyperglycemia. Potassium loss occurs with both thiazide and loop diuretics. Thiamine loss has been associated with the use of loop diuretics. This drug can produce a loss of appetite and decrease thiamine. The drug can induce wet beri-beri as part of congestive heart failure. A thiamine supplement of 200 mg/day is recommended. (McCabe, 2003) Loop diuretics, in addition to causing a loss of thiamine and potassium, also cause loss of calcium, sodium, and magnesium. Thiazide diuretics cause a loss of potassium and magnesium but increases calcium levels. Potassium sparing diuretics retain potassium which can be risky when taken along with potassium supplements, salt supplements, or ACE inhibitors. Anticoagulants – with warfarin (Coumadin), a constant vitamin K intake is necessary. Vitamin K is measured by a laboratory test known as prothrombin time (PT), a measure of clotting time. The result is reported as international normalized ration, INR, and measures clotting time against a known standard. Vitamins A, E, and C, as well as vitamin K, can influence INR status, as well as herbal supplements. Avocado has also been known to influence INR. Inappropriate supplement use or nutrient restrictions of certain drugs can produce toxicity or loss of effectiveness of the drug. Coumadin works by counteracting the vitamin K essential to the blood clotting action. If vegetables high in vitamin K are given, the consequence could be a life-threatening clot on the brain, lung or heart. All of the vegetables in the cabbage family, as well as asparagus and lettuce, are high in vitamin K. The key here is to avoid excessive and increased intake of vegetables high in vitamin K. Antibiotics can cause a deficiency of vitamin K. Such drugs include: Bactrim, Mandol, Moxicin, Neomycin, and Septra, and decrease the good bacteria, found in the lower Drug Use in LTC 123 intestine, that synthesize vitamin K. This in some cases could lead to unexpected bleeding due to the inability to synthesize vitamin K. Taking antibiotics when on warfarin (Coumadin) can decrease the usual amount of vitamin K available. Below is a list of commonly used vitamin/mineral supplements and the vitamin K content of each. Vitamin K Content of Commonly Used Vit/Min Supp. Vitamin / Mineral Supplement Centrum Daily vitamin w/Fe and Minerals Geritol Complete Geritol Extend micrograms vit K 25 mcg 50 mcg 25 mcg 80 mcg Wolinsky, 2002; Worthington, 2004 Some tube feedings contain a higher vitamin K content than others. Here is a list of tube feedings with more than 80 mcg/1000 kcal. Vitamin K Content of Tube Feeding (over 80 mcg/1000 kcal) Ensure Carnation Instant B Isocal HN Isocal Boost Boost High Protein TraumaCal Protain XL Choice DM Optimental Subdue 80 80 100 125 127 238 85 120 120 85 85 Drug Use in LTC 124 Drugs incompatible with foods Caffeine and theobromine, found in coffee, tea, or soda, and some drugs – can cause a variety of symptoms including increased alertness, reduced fatigue, tremors, nervousness, irritability, diuresis, gastro-intestinal distress, cardiac arrhythmias, and palpitations. Caffeine belongs to a family of chemical compounds called xanthines, and acts as a Central Nervous System (CNS) and heart stimulant. An intake of 100 to 200 mg produces significant CNS effects. Tolerance decreases with aging. Both regular and decaffeinated coffee stimulate gastric secretion. Caffeine in large amounts could stimulate a dangerous hypertensive crisis for a resident on an MAO inhibitor. Cipro (ciprofloxacin), Penetrex (enoxacin) and Noroxin (norfloxin) which may slow elimination of the caffeine from the body. Those taking the asthma drug theophylline (Bronkaid tablets, Bronkodyl, Primatene tablets, Slo-Bid, and Theo-Dur) should limit caffeine. Since theophylline and caffeine are chemical cousins and produce similar effects on the body, taking both can produce an overdose. Some headache medicines contain caffeine, especially those noted to be extra strength. Herbal remedies that claim to boost energy may also contain caffeine (Pronsky, 2004). Caffeine Content of Beverages Brewed coffee (5 oz.) drip 110-150 mg percolated 40-70 mg decaffeinated 203 mg Tea (5 oz.) - increases with brewing time 9-36 mg Soda (regular, 12 oz.)(Mello Yello, Mt. Dew, Kick) 52-55 mg Coke products (regular, 12 oz.) 18-46 mg Diet products (12 oz.) 46-59 mg Club sodas, sparkling water, Diet 7up, ginger-ale, flavored sodas 0 mg Other examples of foods incompatible with drugs include: • Fiber can reduce the absorption of non-heme iron from fortified foods and supplements. • Phosphate in meat and dairy as well as some antacids can reduce iron absorption. • Phytic acid reduces zinc absorption. Vegetarians are at greatest risk. • Soy protein inhibits the absorption of nonheme iron. • Tannins in tea can reduce absorption of non-heme iron from fortified foods and supplements. • Orange juice increases the absorption of aluminum from antacids containing this mineral. Drug Use in LTC 125 • Penicillin and erythromycin should not be taken with citrus juice or carbonated beverages because these acidic beverages could interfere with proper absorption and effectiveness of the drug. • Lanoxin; large amounts of fiber can interfere with absorption of the drug. There are numerous drugs that if given with food, have their drug effectiveness altered. Special Issues Other Drugs Incompatible with Tube Feeding Drugs Given Through a Tube Feeding Generic Name Brand Name KCL K-Dur phenytoin Dilantin mineral oil Milk of Magnesia MOM nizatidine Axid omeprazole Prilosec paroxetine Paxil Tetracycline Side Effects / Misc. May precipitate in TF, not with end stage renal disease, not with salt substitute Major problem with gums hyperplasia, usually 1 mg folate >5 mg effectiveness and bioavailability of drug, may need Vit D supplement; glucose with diabetes, tube feeding bioavailability of drug, stop feeding 2 hr before and 2 hr after giving drug, highly protein bound absorption of Vitamin ADEK & Ca, P & K, clinically significant only with long term use, do not take HS may cause lipid pneumonitis due to oil aspiration, take on an empty stomach Take Fe separately by 2 hr gastric acid secretions gastric pH, possible B12 anemia gastric acid secretion, may B12 absorption, gastric pH, highly protein bound, rare hepatitis, pancreatitis Not with tryptophan supplement, caution with elderly, drug concentration, paresthesia, sweating, highly protein bound, syncope, & chills Possible K due to bacterial synthesis in intestine, possible B vitamin deficiency with long term use, Vit A supplement may risk of benign intracranial HTN Drug Use in LTC 126 Other drugs are incompatible with feeding tubes. These include: • Feosol, elixir • Feldene (piroxicam) • MCT oil • Mylanta II • Riopan • Tagamet (cimetidine) The administration of medications through a feeding tube can interfere with the nutritional adequacy of the feeding. Changes may occur with occlusion of the tube, clumping, or thickening of the feeding in the tube. Drugs may cause stomach distress, vomiting, or diarrhea. Drugs given through the feeding tube may significantly affect the success of the enteral feeding and drug therapy. Drug absorption is the major problem. Characteristics of the formula may influence the use of drugs given through the feeding tube. Formulation of the feeding, as an example, casein-based protein has a higher potential to bind drugs, than whey-based formulas. Lower protein formulas are less likely to react with drugs. The osmolality, pH and nutritional content influence the success of drug use. The tube may also become clogged as a result of aspirating for gastric residual; flush tube before adding back aspirate. Clogging of a feeding tube may occur with: • High protein feeding with a casein protein formulation. Less clogging with a whey based protein formulation • Calorically dense formulas are best administered through a pump • Fiber containing formula • Gastric aspirate returned to feeding without a prior flush • Product contamination • Medications given together without flushing tube after each medication • Inadequately crushed medicine • More clogging occurs with silicone tubes as opposed to polyurethane • Bulk laxatives (mix with water – give immediately) For the unclogging of feeding tubes, the following does not work better than water: • Carbonated beverage • Meat tenderizer Flushing with plain water is recommended. If this does not work, one tablet of crushed pancreatic enzyme such as pancreatin mixed with a 324 mg tablet of sodium bicarbonate or 1/8 tsp baking soda, mixed with 5 ml fluid and added to tube feeding may be tried. Drug Use in LTC 127 Drugs should not be combined with enteral formula for feeding. If this is done: • Physical changes may occur in the formula which may result in clogging the tube • Drug dose may be altered – and not predictable • Alter nutritional content of feeding • POTENTIAL FOR CONTAMINATION OF FEEDING Solid medications should not be crushed and added to tube feeding. Enteric coated drugs - if crushed, delays release of drug until reaches small intestine. May cause stomach distress. Slow release drugs, if crushed, may release the entire drug at one time. This may cause toxicity and decrease the effect of the drug for an extended time. Cytoxic drugs, if crushed, may release toxic airborne particles, which may be inhaled and cause negative effects on the staff. Consequences Consequences Formulation Enteric coated drugs If crushed delays release of drug until reaches small intestine Could cause stomach distress Slow release Drug is made to be released over a period of time May release total dose and cause toxicity Cytoxic drug Airborne particles released Toxic to staff Diarrhea is a frequent problem when tube feeding. Many times the type of formula is blamed, however, liquid drugs are formulated with sorbitol, which results in an osmotic diarrhea. Not all manufacturers list sorbitol as an ingredient. It is not uncommon for a dose of liquid medicine to have 10 to 50 mg of sorbitol. Diarrhea can occur with one dose with 10 mg of sorbitol, or 50 mg of sorbitol throughout the day. Sorbitol is not present in tinctures or emulsions, but in most other liquid drugs. In one day, a resident may receive as high as 2000 mOsm/kg / in liquid sorbitol containing drugs. The antidiarrheal drug diphenoxylate is 20 to 45 percent sorbitol. Some sample liquid drugs with the sorbitol content are listed here. Diarrhea may occur with broad spectrum antibiotics and medications high in magnesium phosphorus. Drug Use in LTC 128 Drugs and Osolality Drug Osmolality Acetaminophen 5400 Acetaminophen w/codeine 4700 Amantadine 3900 Ampicillin 2250 Cimetidine 5550 Digoxin 50 mcg/L 800 Docusate 4700 Erythromycin 40 mg/ml 1750 Ferrous sulfate 4700 Furosemide 10 mg/ml 2050 Drug Osmolality Lithium citrate 6850 Metoclopramide syrup 8350 Phenytoin 6 2000 Phenytoin 20 2500 Phenytoin 25 1500 Potassium Chloride 10% 4350 Potassium Chloride 40 mEq/5 ml 3500 Theophylline sol. 5.33 mg/ml 800 Theophylline elixir 6550 Surveyor Guidelines Tag Number Regulation Guidance to Surveyors F333 Medications Administered with Enteral Nutritional Formulas: Administering medications immediately before, immediately after, or during the administration of enteral nutritional formulas (ENFs) without achieving the following minimum objectives: ~ Check the placement of the nasogastric or gastrostomy tube in accordance with the facility’s policy on this subject. NOTE: If the placement of the tube is not checked, this is not a medication error; it is a failure to follow accepted professional practice and should be evaluated under F-Tag 281 requiring the facility to meet professional standards of quality. ~ Flush the enteral feeding tube with at least 30 ml of preferably warm water before and after medications are administered. While it is noted that some facility policies ideally adopt flushing the tube after each individual medication is given, as opposed to after the group of multiple medications is given, unless there are known compatibility problems between medicines being mixed together, a minimum of one flushing before and after giving the medications is all the surveyor need review. There may be cases where flushing with 30 ml after each single medication is given may overload an individual wiht fluid, raising the risk of discomfort or stress on body functions. Failure to flush, before and after would be counted as one medication error and would be included in the calculation for medication errors exceeding 5 percent. ~ The administration of enteral nutrition formula and administration of dilantin should be separated to minimize interaction. The surveyor should look for appropriate documentation and monitoring if the two are administered simultaneously. If the facility is not aware that there is a potential for an interaction between the two when given together, and is not monitoring for outcomes of seizures or unwanted side effects of dilantin, then the surveyor should consider simultaneous administration a medication error. Drug Use in LTC 129 Water is the best fluid for use in the tube feeding to prevent interaction with drugs. Cranberry juice may cause the tube feeding to coagulate. When medicines are given through the feeding tube, the feeding should be stopped, and flushed with 30 cc of warm water to clear the feeding from the tube. After each drug is given, the tube should be flushed with 5 cc of water. Medications should be crushed and mixed with 5 ml of water, each drug should be given and flushed with 30 ml of water, if the resident can tolerate the fluid. This procedure is part of the Surveyor Guidelines for F-Tag 333, Medication Administration. If drugs cannot be given by tube, the following options are available: • Sublingual preparation • Rectal suppository • Mouth • Injection • Patch • IV formulation • Consult pharmacist Some drugs are recommended to be given separately from the tube feeding: phenytoin, tetracycline and theophylline, as giving with feeding may decrease the amount of the drug absorbed (Pronsky, 2004). Phenytoin given through a tube with enteral feedings a decreased absorption of phenotoin of up to 75 percent was found. This result caused a significant decrease in blood levels of dilantin. A small change in dilantin absorption can lead to decline in seizure control. The mechanism is thought to be the cheleation of divalent cations binding to protein components of the feeding, specifically sodium and calcium caseinates, and serum proteins (in vivo). Dilantin also binds with calcium and magnesium in antacids when given with enteral formula. Another possible cause is the suspension formula clinging to the inside of the tube. A final cause suggested by Wolinsky (2002) is “Enteral tube feedings may also affect gastric pH by lowering the gastrointestinal pH below the point of critical solubility where phenytoin, a weak acid is absorbed.” Giving phenytoin to patients with head injury may require a dose as high as 800 mg every 8 hours in critical care. There is a change in which traumatic injury alters hepatic metabolism of the drug. The need for this high a dose of phenytoin decreases with recovery (Wolinsky, 2002). Recommendations for giving phenytoin by tube feeding • Feeding should stop two hours before dilantin is given. • The suspension should be given via the tube, followed by a 60 cc flush of water. • Wait two additional hours before restarting the feeding. Drug Use in LTC 130 Giving phenytoin by a jejunostomy tube resulted in nearly 100 percent of the drug not absorbed. Warfarin is a medication that can produce erratic laboratory results when given through a tube feeding. Drugs incompatible with food Grapefruit and grapefruit juice are incompatible with some drugs. How Grapefruit Affects some Drugs Affected Oral Drug With grapefruit Gastrointestinal Tract Mucosal Cells Inhibit Drug Level in Circulation Increases Portal Circulation Liver systemic circulation CYPA3 can stay elevated 48-72 hours little effect on CYPA3 Grapefruit and grapefruit juice have the potential for causing serious drug interactions. Flavonoids and non-flavonoid components of grapefruit are suspected to incite these reactions. Grapefruit prevents the oxidative metabolism of drugs given by mouth in the cytochrome P 450 34 A isoenzymes in the intestinal wall. This prevents presystemic clearance of the drug. The P 450 34 A enzyme in the liver is not a factor, only the isoenzyme in the intestine is the issue. The activity of this isoenxymes may be altered with ethnic groups. Grapefruit also block p-glycoprotein in the intestinal wall. This occurs before the drug goes to the liver to be metabolized. The drug level in the bloodstream may be raised to toxic levels. The effect of grapefruit on drug metabolism may last up to three days. Sandimmune (cyclosporin), a drug used for those with organ transplants, if taken with grapefruit juice, could have a profound effect on blood levels. Grapefruit juice slows down the body’s ability to metabolize the drug, and can boost the drug level by 1/3 on average, and lead to toxicity (Graedon, 1997). Drug Use in LTC 131 The table titled Effect of Grapefruit on Drugs at the end of this chapter provides guidance regarding the effect of taking grapefruit with specific drugs. Effect of Grapefruit on Drugs Drug Large Medium Calcium Channel Blockers Felodipine XX Nimodipine XX Nisoldipine XX Pranidipine XX Nicardipine XX Nifedipine XX Isradipine XX Amlopine XX Nirendipine XX Nimodipine XX Verapril XX Diltiazem Verapamil Cholesterol Lowering Agents Atorvastatin (Lipitor) XXX Cerivastatin (Baycol) XXX Lovastatin (Mevacor) XXX Simvastin (Zocor) XXX Immunosuppressants Cyclosporine (Neoral / Sandimmune) XX Tacrolimus (FK-506, Prograf) XX Sirolimus XX Prednisolone Prednisone Antibiotics Erythromycin XX Clarithomycine (Biaxin) Protease Inhibitors Saquinavir XX Ritonavir XX Amprenavir XX Psychiatric Medicines Buspirone XXX Carbamazepine XX SSRI antidepressants XX Diazepin (Valium) XX Clozapine Quetiapine (Seroquel) XX Other Sildenafil (Viagra) Amiodarone (Cordarone) XXX Cisapride (Propulsid) XXX Colchine XXX Methadone XX Tolterodine (Detrol) XX Small or Negative X X X X X X X (Pronsky, 2004; Greenblatt, 2001) Drug Use in LTC 132 Tyramine – a potentially fatal food-drug interaction. This interaction occurs with monoamine oxidase inhibitors, also known as MAO inhibitors. Nardil (phenelzine), Parnate (tranylcypromine) and Marplan (isocarboxazid) are examples of these drugs. The drugs block an enzyme monoamine oxidase which keeps tyramine levels at safe levels. The interaction causes high blood pressure, heart difficulties, visual changes, headache, and confusion, along with nausea and vomiting. Tyramine is a substance found in many foods, especially those with aged protein, and causes the release of certain biogenic amines. This is a group of chemical substances which is capable of altering cerebral and vascular function. This group includes: epinephrine, dopamine and serotonin. When the breakdown of these substances is inhibited by MAO inhibitors, the blood pressure may rise and result in intracranial bleeding, and death. The tyramine content of foods can vary. The content of tyramine increases as the food ages. Some Foods High in Tyramine Some foods high in tyramine: • Cheddar cheese • Other aged cheeses • Chicken livers • Pickled herring • Chianti wine • Beer • Avocados • Luncheon meats • Chocolate – in large quantities • Protein dietary supplements Other drugs that can offer a reaction to these foods are used for Tuberculosis control. These drugs include isoniazid (Nydrazid NIH), rifampin (Rifadin), and INH. MAO inhibitors are used infrequently because of the dietary restrictions and availability of other drugs. Those taking isonaiazid must be careful with flesh of red fish meat, i.e., tuna, mackerel and mahi-mahi stored at unsafe temperatures. Loss of Metabolic control reaction: Some drugs, if given to residents/patients with diabetes, can cause alterations in the blood sugar. Examples of these drug reactions include: Those with diseases that require the use of sulfa drugs and aspirin and related drugs for the treatment of arthritis, are at greater risk for hypoglycemia. Medications that may contain sugar as a significant calorie source can influence diabetes and weight control. Some examples include: Drug Use in LTC 133 • Cough syrups: Coricidin, Triaminic, Vick’s • Expectorants: Cheracol, Formula 44D, Guaifenesin syrup • Throat Lozenges • Allergy relief products: Chlor-Trimeton Allergy Syrup, Pseudoephedrine Syrup • Analgesics: Liquiprin, Tylenol Extra Strength Liquid • Tranquilizers: Mellaril suspension and Thorazine suspension Other nutrition-drug issues are noted in the table, “Special Issues” on the following pages. Drug Use in LTC 134 Special Issues — Other Generic Name alendronate allopurinol Brand Name Side Effects / Misc. Fosamax Adequate Ca & Vit. D intake essential. Do not take HS, may require Ca & Vit. D supplement, not with Ca Zyloprim Avoid large doses of Vit C to kidney stones, maintain alkaline urine to risk of xanthine calculi ASA Not for those prone to a Vit. K deficiency acetylsalicylic acid atenolol calcitonin Miacalcin carbamazepine Tegretol cimetidine Tagamet ciprofloxacin Cipro colchicine Colchicine corticosteriod diazepam Valium docusate sodium Colace donepezil Aricept estrogens fluvoxamine Luvox maleate folic acid fosinopril sodium Monopril hydrochlorothiazide isoniazid INH, Pyr supplement levodopa Dopar lorazepam Magnesium Avoid natural licorice; Natural H2O retention counteracting effects of the drug For post menopausal bone loss; Vit D > 400 iu > Ca 1000 mg, to hyper-calcemia; may need ‚ Ca & Vit D; avoid Ca & Vit D supplement SIADH, edema, water intoxication Take Ca or Mg separately by 1 hr, take Ca or Mg separately by 1 hr, gastric acid secretions gastric pH Avoid milk, yogurt when taken; avoid or limit caffeine/xanthine; cause caffeine May absorption of Vit B12, Fe, Ca, K fat & nitrogen K, Vit A, C, D, Ca & P Limit caffeine to < 40 mg/day with Alters intestinal absorption of water & electrolytes Risk of dehydration & possible hypotension & syncope Over 1 gm/day of Vit C may estrogens to toxic levels; bone loss, Ca absorption; Zn No tryptophan supplements Is inhibited by def of Pyr, B12, C & or E Avoid salt substitutes; take Ca or Mg separately by 2 hr, cough Caution with Ca and/or Vit D supplement, risk of hypercalcemia 25-50 mg necessary to prevent peripheral neuropathy, MAO, like activity avoid histamine foods; Pyr- peripheral neuropathy, maybe fatal in the elderly, fatigue, weakness, fever Limit Pyr <5 mg, 1 day, may drug effect, not with protein food, protein re: distribute 7:1 CHO to pro may stabilize drug effects; not with acids or protein hydrolysates, take Fe separately absorption of drug; Dyskinesia with LT use, flushing, psychological change Limit caffeine < 500 mg / day, memory impairment As an antacid, take after meals and HS, as Mg supplement, 5 mg/kg/day, take folate or iron supplement separately by 2 hr, not with ESRD, high alcohol intake Mg needs by excretion, not used with hypoglycemia. Limit caffeine metaproterenol Alupent sulfate methotrexate Methotrexate Folate or MVI may decrease drug response can cause hemorrhagic enteritis, liver & lung toxicity, nephrotoxicity, infection, platelets, bone marrow suppression Zn SO4, Precipitates in tube feedings, excess intake may cause Ca or Fe deficiency; more to take separately; take Cu, Fe, P, Ca, Fol separately by 2 hr from food, in Ca, P, bran fiber; long term 100-300 mg/day causes chronic toxicity, Cu or Fe deficiency, immune response, acute toxicity in a single dose 2 gm Drug Use in LTC 135 Special Issues — Other, continued Generic Name Brand Name Side Effects / Misc. warfarin sodium Coumadin Consistent intake of vitamin K essential, Vit K, effect, Vit K effect, avoid high intake of Vit K or multivitamin intake, avoid dose Vit A, E, >400 IU/day, avoid with > 60g raw or fried onions, avoid or limit some herb & herbal teas, avoid avocado Vitamin K Caution with · dose of Vitamin A, D or E supplement, platelets, clotting factors Vitamin E Water miscible form · absorption, · polyunsaturated fat intake Vit E toxicity causes nausea, diarrhea, flatulence, long term intake > 400-800 IU/day hypervitaminosis E Vitamin C Do not stop abruptly, taper off, rebound scurvy B12 Limit alcohol, limit absorption with gastric achlorhydria, gastrectomy, HIV, antiulcer drug, neuropsychiatric damage due to grade deficiency is not accompanied by anemia in 30 percent of cases, Vit K Vitamin A Water miscible form increases absorption. Adequate protein, fat, and vitamin E needed for proper absorption, Vitamin E and Zinc are needed for proper absorption. Avoid doses vitamin E, deplete vitamin E supplement, malnutrition , absorption of Vitamin A with low protein in the diet verapamil Calan Caution with calcium and/or vitamin D supplements, hypercalcemia effect of drug valproic acid Depakene, Indigestion, also bone density, risk of osteoporosis with long term use and Depakote cause of fecal incontinence, gas, not to be used with liver disease, highly protein bound triamterene Dyrenium Avoid K supplements or K based salt substitutes, caution with diabetes or end stage renal disease, bicarb thyroid Synthroid Caution with diabetics on insulin or sulfonylurea glucose, 99 percent serum protein bound, cholesterol thiamine vitamin B1 Anti- beriberi dose is 5-10 mg TID, folate or protein deficiency ‚ absorption of thiamine, impaired utilization in elderly Theophylline Theobid Requires consistent intake of protein and carbohydrate. A pro CHO diet increases the metabolism of the drug and decreases effective blood levels. Smoking and passive smoking blood levels by metabolism resulting in 1/2 life and blood level sucralfate Carafate pepsin actively by 32 percent, caution with tube feeding ‚ gastric emptying can result in bezoar formation spironolactone Aldactone Dehydration, avoid excessive K intake, caution with ESPD, highly protein bound sertraline HCl Zoloft 40 percent ‚ plasma clearance in elderly, 98 percent serum protein bound, food absorption salsalate Disalcid Tinnitus ‚ hearing, T3 & T4, rare hepatitis, Reye’s syndrome, limit caffeine ranitidine Zantac Possible B12 with long term use, rare pancreatitis and hepatitis, limit caffeine and xanthine Drug Use in LTC 136 In this chapter we have discussed ways that food or drugs can affect eachother and how drugs can alter food intake. The next chapter will discuss herbal supplements and other nutritional supplements. Drug Use in LTC 137 Chapter Nine: Nutritional Supplements and Drug Interactions “Life is like long division. You take a risk, make an educated guess, and see what happens. Be prepared to make adjustments. Always be ready to start over.” ~ Melinda French Gates Herbal supplements over time Herbal products have been used since the start of time. The Middle East, the Greeks, Chinese and Indians have practiced herbal medicine for centuries. About 25 percent of the drugs used today have come from plant-based medicine. Aspirin, for instance, comes from white willow bark and meadow sweet plant (Fetrow, 1999). Plant-based medicine in the US started with remedies brought from Europe and remedies taught to the settlers by Indians. For US citizens, since the beginning of our country, herbal medicines and supplements have been a concern. The early colonists, in 1652, passed laws to protect the population from fraud, unsafe food, and risks and alterations of the food supply. Before the Food and Drug Administration (FDA) was formed in 1938, the United States Pharmacopedia (USP) was important in regulating the food and drug supply. USP was created in 1820. At the time, herbs were considered medicines and could be labeled for treatment of specific ailments. This was documented and published in US Pharmacopedia. This publication is now in its 20th edition. The USP group recently started a voluntary program to certify the “efficacy, purity and active ingredients” for herbs used as medicines. The USP symbol continues to be used on the label of products in compliance with this group. Drug Use in LTC 138 For US citizens, since the beginning of our country, herbal medicines and supplements have been a concern. In the early 1900s, over 100 (human) deaths occurred after consumption of a toxic elixir of sulfanilamide. The deaths were caused by acute renal failure. As a result of this tragedy, the Federal Food, Drug and Cosmetic Act was enacted in 1938. Food and drug administration When the Federal Food and Drug Administration (FDA) was formed in 1938, the Food and Drug Act defined food and drugs. All drugs and herbal products were ‘grandfathered-in’ and were not required to meet rigorous new standards. Herbs were put into the food category by the FDA, although herbs were not specifically included in this Act. The FDA classified herbal remedies in the Generally Recognized as Safe (GRAS) category 1, unsafe or ineffective category 2, or category 3 inadequate information to determine safety or effectiveness. These categories did not distinguish between a small amount of an herb used as a seasoning and a large amount of an herb used as a medication. The herbal supplements discussed in this chapter concern herbs used as nutritional supplements, not herbs used in small amounts as seasonings. The lack of information on the safety and effectiveness of herbs led to a demand by the American public for more information on the safety and effectiveness of herbs. Concerns with herbal safety Concerns with herbal products currently include: • No quality control. • Lack of standardization. • Lack of regulation. • Variation in plant chemicals, potential for contamination. • Lack of research and validity of effectiveness. • Potential for misleading information. • Allergic and toxic potential. • Lack of knowledge of interaction with prescription and nonprescription drugs, • No individualization for patient using herbs. In the 1990s, Congress acted to increase the ability of the federal government to regulate health claims. Penalties were determined for violating the Food, Drug and Cosmetic Act. Another issue was the Federal Trade Commission Act, which would ban nutritional or therapeutic claims on supplement labels. FDA was also looking at tighter regulation on supplement labels. Drug Use in LTC 139 The supplement industry became active to have consumers continue to purchase dietary supplements. The supplement industry told consumers the FDA would not allow them to purchase vitamins. This caused a massive consumer response to Congress. The regulation of supplements was greatly reduced as a result of consumer and supplement industry activity. What resulted was the Dietary Supplement Health and Education Act (DSHEA) of 1994. The DSHEA defines supplements as “dietary substances used by man to supplement the diet by increasing total dietary intake … including … a concentrate, metabolite, constituent, extract, or combination …” Herbal remedies are neither fish nor fowl, or are neither a food nor a drug. Lack of testing for safety and effectiveness were lost in the public demand for, and creation of, new products. The DSHEA gave the responsibility of herbal safety to the manufacturers of supplements. Additional third party literature is allowed at the point of sale for herbal products per the 1994 DSHEA. Dietary supplements cannot make claims for diagnosis, prevention or mitigation or cure of disease. They may only state the effects of the supplement on the structure and function of the body (Stupay, 2000). The office of dietary supplements The Office of Dietary Supplements (ODS) was established at the National Institute of Health (NIH) in 1995. The ODS was created with the Dietary Supplement and Health Education Act passed by Congress. This office is charged with obtaining knowledge and understanding of dietary supplements, including: • Evaluating scientific data, • Conducting research, and • Educating the public The Office of ODS is a component of NIH, under the US Department of Health and Human Services. The web site address is: http://dietary-supplements.info.nih.gov/. In 1998, the FDA issued requirements for the labeling of supplements. A revised requirement went into effect in 1999. The Nutrition Labeling Act required herbal supplements to be labeled and define the health purpose of the supplement. The label on herbal supplements must include: • Identity • Contents • Function of product • Directions • Facts Panel • Ingredients in descending order, and • Address of the manufacturer Drug Use in LTC 140 In 1998, Congress established the National Center for Complementary Alternative Medicine (NCCAM). The goal of this organization is to: stimulate, develop, and support research on complementary and alternative medicines for the benefit of the public health.” Information to the public Information is available in popular books, magazines, on talk shows and television, and the worldwide web. Some manufacturers offer coupons as incentives to try supplements. Herbal manufacturers are not required to prove the effectiveness of their products or have Food and Drug Administration (FDA) regulated drug trials. The credibility of this information is not known. The nutrition supplement manufacturers have much lower costs than drug companies. Supplement manufacturers have millions of dollars to spend on advertising, and their products are less expensive than prescribed drugs. Those selling herbal products to the public are not health professionals. Their goal is to sell product. Those selling herbal products to the public are not health practitioners. Their goal is to sell product. Herbal issues Traditional drug companies are not interested in doing research on herbal medicines. Herbal remedies have been available for thousands of years, so drug companies cannot patent them. The patent is what gives drug companies exclusive rights to sell a product and make a profit. Herbal remedies provide no financial incentives for drug companies. The National Center for Complementary and Alternative Medicine currently provides grants to study nutritional supplements. There is concern for those with chronic diseases such as diabetes, heart disease, liver or renal disease. The kidneys excrete medications; the liver metabolizes drugs; and the heart is instrumental to circulating drugs in the body. Damage to these organs may impair the activity of the supplement in the body. A study by Judith Garrard at the University of Minnesota, School of Public Health, found 20 percent of Americans take prescription drugs along with nutritional supplements: vitamins and minerals, or “natural remedies.” According to Adam Marcus, HealthDay reporter for ABC news.com (2004), “Diet aids exist in a regulatory limbo. The US Food and Drug Administration has relatively weak oversight of the industry compared to its control over prescription drugs.” Drug Use in LTC 141 The Garrard study looked at the leading herbal supplements sold in 1998. She analyzed Echinacea, St. John’s Wort, Ginko Biloba, garlic, saw palmetto, ginseng, goldenseal, aloe, Siberian ginseng and valerian for product content. When the researchers shopped at 20 local grocery stores, pharmacies, discount stores and health food stores, they found over 880 formulations of these products. Label information for dose and ingredients agreed less than 50 percent of the time. Ingredients were accurately listed 20 percent of the time, and 37 percent of the labels were incomplete. The consumer taking herbal supplements needs to know: plant parts in the bottle, and if the label is correct. Nutritional supplements are inaccurately portrayed on the label according to this study (Marcus, 2004). Worldwide use of supplements Worldwide, 80 percent of the population uses herbal medicines. In Europe, products require proof of efficacy and safety before a new drug is sold on the market. There are over 60,000 phytomedicine products on the market. In Germany, 70 percent of the physicians prescribe herbal remedies. The German Regulatory system published a report on plant medicines based on a separate expert commission known as Commission E. This publication standardized therapeutic monologues on herbal medications (MandelSchmid, 1996; Rubin, 2003; Foster, 1996). In the US, most health professionals have little experience or training in the use of herbal or nutritional supplements. There is incomplete research available. Most research on herbal supplements has been conducted outside of the US. Therefore, most research is published in a foreign language. These studies have rarely been peer reviewed. Many of these studies were done on animals, not humans (Fetrow, 2000). There is even less information available for the health professional or the general public on the interaction of nutrition supplements and prescription and non-prescription drugs. Why supplements have become so popular Why have herbal supplements regained such popularity with the American public after all these years? Americans spent over $11.3 billion on alternative medicines in 2000. This was an increase from $3.9 billion spent in 1998. Each year, one-third of Americans use a supplement. Many of us have lost faith in the traditional medical system; others have found no relief from traditional medicine; still others have no money to pay for health care; and finally, many think “natural medicine” is best. Most people using herbal remedies are white, highly educated, and have good incomes. They do not abandon traditional medicine. However, they use alternative therapies with traditional medications, and combine both in complimentary medicine (Stupay, 2000). Drug Use in LTC 142 A study conducted in Wisconsin found that 50 percent of women and 42 percent of men aged 65-84 currently were using herbal supplements, and less than 40 percent told their doctor (McCabe, 2004). One study found up to 70 percent of patients did not discuss the use of herbal medications with their physician or pharmacist (Karch, 2003). Herbs with Special Risks Herb Blood root Chan su Chaparral tea Colts foot Comfrey Jin bu huan Kombucha tea Lobelia Ma huang Pennyroyal Sassafras Yohimbe bark Herbal supplement use Risk Death due to vomiting Fatal Liver failure Liver damage Liver problems, cancer Hepatitis Acidosis Respiratory paralysis and death Heart attack, stroke, death Death Banned by FDA Psychotic behavior (Fetrow, 2000) Sixty million US citizens use nutritional supplements. Nutritional supplements include: herbs, additional plant products, amino acids, enzymes and extracts from organs and plants. Also included in nutrition supplements are vitamins and minerals. The Federal Food and Drug Administration (FDA) does not approve dietary supplements. There are also non-herbal supplements, such as glucosamine, coenzyme Q and creatine. Nutrition supplements also include probiotics and prebiotics, (products that use microbes or use substances to induce stimulation of microbial balance in the gastrointestinal tract). An example of probiotics is active culture yogurt. Supplements are defined by law as, “So for regulatory purposes, a dietary supplement is a product taken by mouth that contains an ingredient intended to supplement the diet for preventive or therapeutic purposes.” (Worthington, 2004). Supplements are available as capsules, pills, infusions, teas, tinctures, extracts, oils or salves (Stupay, 2000). In the US, over 16,000 dietary supplements and 2,000 botanical species are available. Many dietary supplements contain multiple products. In 2000, $11.3 billion were spent on herbal therapies. Drug Use in LTC 143 From a recent catalog I received in the mail, are examples of nutritional supplements available: • Glucosamine, Chondroitin and MSM • Garlic with Vitamin E, Hawthorn Berry and Cayenne • Neuromins DHA (This product is made from oceanic algae sources) • Prostate Essentials Plus • Leg Vein Essentials • Kidney Essentials • Extra-Strength Lecithin, Kelp, B6, and Cider Vinegar • Vitamin O • Kyo-Green (rich in vitamins, minerals, chlorophyll, barley, Pacific kelp, wheat grasses, brown rice and broken cell wall chlorella) In the US, over 16,000 supplements and 2,000 botanical species are available. Many dietary supplements contain multiple products. In 2000, $11.3 billion were spent on herbal therapies. There are also functional foods or foods that are fortified to add an additional benefit. Examples are: • Iodized salt • Margarine fortified with sterols and stanols • Breakfast cereals fortified with vitamins, soy and calcium formulated for women. • Chicken broth fortified with Echinacea to enhance the immune system is available on the market. • St John’s wort in tomato juice is used for mood enhancement. This is in no manner a small issue. “By age 33, 30 percent of pre-baby boomers, 50 percent of baby boomers, and 70 percent of post-baby boomers may have used some form of complementary or alternative medicine” (Corbin, 2002). Most drugs have only one active ingredient, such as acetylsalicylic acid in aspirin. Herbs may have multiple nutritional and pharmacological properties. These products are unpredictable and their use is unregulated. A diuretic taken along with licorice may deplete the body of potassium. Warfarin taken with a garlic supplement increases the risk of bleeding. Golden seal may keep a drug for hypertension from being effective. Drug Use in LTC Supplements and interactions 144 There are multiple ways herbal products interact with both nonprescription and prescription drugs. Drugs and herbal supplements are metabolized by the same liver enzymes. Proteins used in the transport of nutrients, drugs and herbal products require the same carriers for absorption, distribution and elimination of drugs. This may influence drug and herbal product levels in the body, with potential toxic effects. Drugs and herbal supplements may also compete with the same binding site in the body. Alternative therapies often treat more than one disorder. So, if a patient is taking an herbal supplement for diabetes, the supplement may interfere with his anticoagulant therapy. This may be unknown to the patient. Bilberry, for example, may increase or decrease the blood glucose level. St. John’s wort, as an example, can cause serious consequences when taken with selective serotonin uptake inhibitors (SSRIs) such as Prozac or Zoloft. This herb may also interact with digoxin and chemotherapy drugs, and cause possible treatment failure. Yet, there is little documentation of how herbal medications interact with traditional medications. Side effects from “natural” herbs may be written off as ‘old age,’ especially in the elderly, and treatment may be delayed. The most dangerous drugs to use with dietary supplements are drugs with a narrow therapeutic index. These drugs have a very low range of therapeutic benefit. The drug level, when altered slightly either way, can cause loss of benefit, or toxicity. The drugs most important in this category are: digoxin, dilantin, insulin and warfarin. There are an estimated 4,000,000 people at risk for such reactions. Thirty to forty percent of the calls to poison control centers involve herbs and dietary supplements (Worthington, 2004). Current textbooks on pharmacology have minimal information on herbs. The public generally believes herbs and nutritional supplements are regulated by the government; however, nutritional supplements receive little government review. Independent review finds herbals labeling grossly inaccurate. Adulteration with prescription drugs has been found. Herbal companies do not have to provide evidence for their claims, nor do they have to do expensive research. Provided for you is a list of common nutrition supplements and prescription drugs. The complexity of the task of monitoring food-drug and “nutritional supplements” has increased. Have you ever considered the use of herbal drugs? How many of those listed on the following page have you tried? Drug Use in LTC 145 Herbal Medications ~ How Many Have You Tried? Aloe Bilberry Cacoa Capsicum Cascara sagrada Catnip Chamomile tea Chicory Coffee Cola tree Cranberry Dandelion wine Echinacea Elderberry wine Eucalyptus Flax Garlic Ginger Ginko Ginseng Green tea Hops Horehound Kava Kelp Lavender Licorice Mint Mustard Oats Black pepper Safflower oil St. John’s wort Sarsaparilla Sassafras Saw palmetto Senna Spirulina Tea tree Valerian Wintergreen Witch hazel for skin injuries for poor vision a plant used in cococa used as a topical antiseptic as a laxative for your kitty for relaxation in your coffee to wake you up for a soft drink for a urinary tract infection no explanation needed! for a cold mmmm… for nasal congestion for constipation or prevention of heart disease for colds, high cholesterol, fighting off vampires! for preventing nausea or motion sickness for memory enhancement or to stimulate mental alertness to enhance mental performance and stamina, or as an aphrodisiac to fight infection, cancer, or to fight heart disease in beer! to decrease coughing or relaxation, depression, or anxiety for weight loss for insomnia or anxiety for coughs or colds for stomach discomfort, indigestion, or nausea (in Ben-Gay, Robitussin cough drops, and Vicks vapo-rub) plaster – for chest cold as Cheerio oats (Cheerios), or oatmeal on your steak to cook foods for depression or anxiety in soda in tea for urinary and prostate problems as a treatment for constipation as an appetite suppressant shampoo – as a scalp treatment for relaxation for joint and muscle strain for personal care Drug Use in LTC 146 Interactions to monitor with nutrition supplements and prescription drugs Note that herbal therapy can alter the effect of prescribed drugs (Fetrow, 2000). See charts at the end of this chapter for more details. This concludes our final chapter on food-drug interactions in long-term care. Drug Use in LTC 147 Interactions of Prescribed Drugs & Herbal Products Monitor drug levels if taking ... and ... Anticoagulants Angelica Cat’s claw Cat’s claw Celery Chamomile Chondroitin Dong quai Ergot Feverfew Feverfew Garlic Ginger Ginko Ginko Ginseng Goldenseal Grape seed extract Green leaf tea Horse chestnut Horse chestnut seed Motherwort Myrrh Poplar bark Prickly ash Pyllium Red clover Sage Tumeric Willow bark Theophylline Cacoa Ephedra Guarana Worsening Parkinson’s Kava Glucose / blood sugar medications Apple Basil Bay Bee pollen Bilberry Blackberry Burdock Burdock Celery Dandelion root Ephedra Fenu greek seeds Garlic Ginger Ginseng Glucomanan Guar gum Gymnence Hops Horehound Java plum Juniper berries Ma huang Marshmallow Mistletoe leaves Red clover Sage Tarragon Xuan Seng Coma Kava with alprazolam Monitor for Liver Toxicity if taking Borage Echinacea Squaw vine Valerian Valerian Went rice Digoxin Betel palm Chinona bark Digoxin Dog bane Foxglove Ginko Ginseng Golden seal Hawthorn Licorice Lily of the valley Ma huang Milkweed Motherwort Quinine Rue Shepard’s purse Siberian ginseng Squill St. John’s wort Antihypertensives Betabl Chinese Angelica Coleus For skohlii Ephedra Hawthorn (Ace I) Licorice Ma huang Sage Yohimke B12 Damiana Spirulina NSAIDS Seizure medications Bromelain Creatine Elder bark or flowers Ginko Ginseng Allspice Borage Evening primrose Anticonvulsants Borage Evening primrose Ginko Sage Wormwood Cholesterol medications Bilberry Chinese mill Fenugreek Gamboges Hawthorn Psyllium Drug Use in LTC 148 Herbal Interactions With Drugs Herb… Interacts with… Ackee Apple Seed Insulin, oral hypoglycemics Aconite Antihypertensives, digoxin, antiarrhythmics Agremony Anticoagulants, insulin, oral hypoglycemics Alfalfa May cause flair-up in lupus, oral hypoglycemics, insulin, lipid lowering drugs, oral anticoagulants Aloe Steroids, digoxin, diuretics, insulin, oral hypoglycemics, licorice Andographis Acetaminophen, anticoagulants, antihypertensives, immunosuppressants, oral hypoglycemics Angelica Anticoagulants Anise Anticoagulants, anticonvulsants, iron, MAOIs Arnica Anticoagulants Ashwaganha CNS depressants, Cytoxan, Neosar, Immunosuppressants, insulin, oral hypoglycemics, thyroid replacements Bai Zhi Nifedipine, insulin, oral hypoglycemics Balloon Colton Digoxin Balsam of Peru Azulfidine or Bactrim Banana Oral hypoglycemics, insulin Barberry Acetaminophen, tetracycline, antiarrhythmics, anticoagulants, calcium channel blockers, digoxin, MAOIs Basil Insulin, oral hypoglycemics Bay leaf Insulin, oral hypoglycemics Bearberry Diuretics, ascorbic acid Betel palm Alcohol, glaucoma drugs, beta blockers, calcium channel blockers Betony Antihypertensives Bilberry Anticoagulants, insulin, oral hypoglycemics Bishop’s Weed Antihypertensives, insulin, oral hypoglycemics, calcium channel blockers, digoxin Bitter melon Oral hypoglycemics, insulin Black catechu Calan, Captopril, antihypertensives, Imuran, Narcotic pain relievers, iron, insulin, oral hypoglycemics Black cohosh Antihypertensives Black currant Diuretics, anticoagulants Black haw Anticoagulants (coumadin) Black pepper Anticoagulants, NSAIDs, Theo-Dur, acetaminophen Black root Iron, Lanoxin, Transderm-scop Black seed Anticoagulants, antihypertensives, chemotherapy Blackberry Insulin, oral hypoglycemics Blue cohosh Antihypertensives, calcium channel blockers, nitroglycerine, sorbitrate or Vascor, nicotine replacement products Blueberries Antiplatelet drugs, anticoagulants (European), Huckleberries Bnomelain Tetracyclines, anticoagulants, cyclosporine Bog bean Anticoagulants, antiplatelet drugs Borage Anticoagulants Broom Antihypertensives, beta blockers, tricyclics, heart conditions Buchu Anticoagulants Buckthorn Steroids, digoxin, diuretics Buglewood Beta blockers, thyroid hormone drugs Burdock Insulin, oral hypoglycemics, acetaminophen Butcher’s broom Cardura, Hytrin, Minipress, or MAO inhibitors, drugs that treat BPH (benign prostatic hyperplasia) Cacao tree MAOIs, acetaminophen, anticoagulants, Theo-Dur Drug Use in LTC 149 Herbal Interactions With Drugs, continued Herb … California poppy Capsicum Carjenne Casara Sagrada Cat’s claw cine Celadine Celery Chamomile Cinchona Bark Coffee Coltsfoot Condurango Coriander Corkwood Cowslip Cucumber Dandelion DHEA Dong quai Ephedra Evening primrose Fenugreek Figwort Flax Fumitory Galanthamine Garlic Ginger Ginko Ginseng Glucomannan Goldenseal Gossypol Gota kola Green Tea Guarana Hawthorn Interacts with… Analgesics, CNS depressants, MAOIs MAOIs, antihypertensives ACE Inhibitors, antihypertensives, anticoagulants, CNS depressants, insulin, oral hypoglycemics, NSAIDs, MAOIs, theophylline Antiarrhythmics, steroids, digoxin, diuretics Antihypertensives, anticoagulants, chemotherapy drugs, immuno-suppressants, pneumococcal vacDigitalis, morphine, antihypertensives, sulfa drugs, Tagamet, Clozapine, Luvox, Ibuprofen, iron, Lithium, MAOIs, Methotrexate, Theophylline, Verapamil Acetaminophen, anticoagulants, thyroxine Anticoagulants, CNS depressants, iron Anticoagulants, digoxin Fosamax, acetaminophen, aspirin, Tagamet, clozapine, Luvox, grapefruit juice, ibuprofen, insulin, oral hypoglycemics, methotrexate, quinolones, antibiotics, theophylline, verapamil Antihypertensives, cardiovascular drugs, can cause liver damage Iron, digoxin, Norvir, Paxil Insulin, oral hypoglycemics Beta blockers, Lanoxin, Symmetrel, tricyclic antidepressants Diuretics, antihypertensives, sedatives Diuretics Diuretics, antihypertensives, insulin, oral hypoglycemics, anticoagulants, Ciprofloxacins and other quinolones, Lithium Drugs: antrogens or estrogen hormones Blood thinners, acetaminophen Morphine, theophyllines, MAO inhibitors, diuretics, insulin, oral hypoglycemics, Ritalin, beta blockers, Decadron, steroids, antacids, Bupropion, caffeine, digoxin, elavil, anticoagulants, phenothiazides, Sudafed, Theo-Dur Antipsychotics Insulin, oral hypoglycemics, anticoagulants Digitalis, beta blockers, calcium channel blockers Laxatives, stool softeners, anticoagulants, oral hypoglycemics, insulin Antihypertensives, beta blockers, calcium channel blockers, Lanoxin MAOIs Acetaminophen, antacids, insulin, oral hypoglycemics, antiplatelet drugs, anticoagulants Anticoagulants Anticoagulants, anticonvulsants, thiazide diuretics, Desyrel, Methotrexate, morphine Oral hypoglycemics, MAOIs Oral hypoglycemics, lipid lowering drugs, digoxin, insulin, MAOIs Anticoagulants, alcohol, benzodiazepines, antihypertensives, beta blockers, calcium channel blockers, Lanoxin, acetaminophen, tetracycline Alcohol, digoxin, diuretics, Lasix Insulin, oral hypoglycemics, lipid lowering drugs, alcohol Adriamycin Adenocard, Antabase, Cipro, Clozapine, Fooxin, Neg Gram or Noroxin, beta blockers, Theophyitine, Verapamil, iron, Lithobid, Neo-Synephrine, Tagamet, Theo-Dur, tobacco, anticoagulants, acetaminophen, Lithium, MAOIs, Methotrexate, oral hypoglycemics, Quinolone antibiotics, insulin Alcohol, antihistamines, sedatives, tranquilizers, narcotic pain relievers, antihypertensives, lanoxin, nitrates, anticoagulants Drug Use in LTC 150 Herbal Interactions With Drugs, continued Herb… Interacts with … Hops Alcohol, atropine, SSRIs, antihistamines, antipsychotic drugs, anxiety drugs Horehound Antidepressants, arrhythmics, antihypertensives, Imitrex, insulin, oral hypoglycemics, Kytril, Zofran Horse chestnut Anticoagulants, diuretics, insulin, oral hypoglycemics Horsetail Diuretics, nicotine replacements, digoxin, Irish moss, anticoagulants, Lithium Ill-bearing surge ACE Inhibitors, antilirium, Aricept, barbiturates, anticoagulants, Ery-Tab, Sandimmune Jaborandi Tree Antilirium, Aricept, beta blockers Jamaican Barbiturates, antihistamines, muscle relaxants, narcotic pain relievers, sedatives, seizure dogwood medications, tranquilizers Jambul Barbiturates, antihistamines, muscle relaxants, narcotic pain relievers, sedatives, tranquilizers. Jimsonwood Antihistamines, L-dopa, Norpace, phenothiazides, Procan SR, Symmetrel, thiazide diuretics, tricyclic antidepressants Kava Benzodiazepines, L-dopa, Xanax, antipsychotics, alcohol, anticoagulants Kelp Anticoagulants, antiplatelet drugs, Lithium, thyroid replacement Kelpware Anticoagulants, antiplatelet drugs Khat Decongetstants, arrhythmics, antihypertensives, MAOIs, beta blockers, ampicillin, amoxicillin, thyroid replacement therapy Khella Anticoagulants, calcium channel blockers, antihypertensives Lavender Benzodiazepines, narcotic pain relievers Licorice Claritin, Procan SR, steroids, Aldactone, diuretics, antihypertensives, Lanoxin, acetaminophen, anticoagulants, aspirin, Tagamet, steroids, diuretcis, insulin, oral hypoglycemics Lily of the Valley Beta blockers, calcium channel blockers, calcium, Lanoxin, steroids Lovage Anticoagulants Lung wort Anitcoagulants Malefern Prevacid, Prilosec Marshmallow Insulin Milk thistle Acetaminophen, aspirin, insulin, oral hypoglycemics, tacrine Mistletoe Alcohol, allergy drugs, tranquilizers, narcotic pain relievers, antiseizure drugs, MAOIs, cardiac medications Motherwort Anticoagulants, drugs for liver and cardiac disease, beta blockers, Lanoxin Mugwort Anticoagulants Myrrh Insulin, oral hypoglycemics Myrtle Insulin, oral hypoglycemics, NSAIDs, Theo-Dur, Tylenol, anticoagulants Nettle Diuretics, anticoagulants, insulin, oral hypoglycemics Night-blooming Lanoxin, ACE Inhibitors, antiarrhythmics, beta blockers, calcium channel blockers cereus Nutmets Antipsychotics Oak Caffeine, digoxin, iron, morphine Oleander Digoxin Oregano Iron Pansy Aspirin Parsley Antidepressants, anticoagulants, dextromethorphan, Lethobid, narcotic pain killers Pau d’arco Anticoagulants Pennyroyal Biaxin, Diflucan, Ery-Tab, Nizoral, Prilosec, Tagamet, Zithromax Pineapple ACE Inhibitors, anticoagulants Plantains Digoxin, beta blockers, Lithobid, Tegretol Poplar Anticoagulants, aspirin, antiplatelet drugs Pumpkin Diuretics Drug Use in LTC 151 Herbal Interactions With Drugs, continued Herb... Interacts with... Raspberry Insulin, oral hypoglycemics Rauwolfia Nitroglycerin, NSAIDs, tricyclic antidepressants, alcohol, antihistamines, narcotics, tranquilizers, seizure drugs, Laradopa Red clover Anticoagulants, aspirin Rue Digoxin, antihypertensives, anticoagulants Sage Antiseizure drugs Sea holly Diuretics Segega Anticoagulants, insulin, oral hypoglycemics, aspirin, antihistamines Senna Calcium channel blockers, corticosteroids, digoxin, Licorice, diuretics Shepherd’s purse Digoxin, antihypertensives, calcium channel blockers, sedatives or hypnotics Siberian Ginseng B1, B2 and C, anticoagulants Skull cap Imuran, Prograf and Sandimmune Spirullna May have toxic levels of mercury, arsenic, cadium and lead Squaw vine Atropine, digoxin, iron containing products, Antabuse Squill Digoxin, antiarrhythmics, beta blockers or calcium channel blockers, drugs that stimulate the central nervous system St. John’s Wort Antidepressant drugs, narcotic pain medications, Tegretol, Lanoxin, Xanax Sweet cicely Diuretics, ulcers or inflammatory bowel disease Sweet flag Antidepressants, antipsychotics, or central nervous system stimulants, antizeizure drugs, or narcotic pain relievers Sweet violet Laxatives Tansy May contain toxic components Tea tree Avoid taking internally Thyme Not with cardiac disease Tonka bean Anticoagulants (i.e., coumadin), FDA – herb unsafe Tormentil Ephedrine, digitalis or antiarrhythmics Tragacanth Fat soluble vitamins A, D, E or K Turmeric Anticoagulants, immune suppressants, NSAIDs Valerian Alcohol, antidepressants, antipsychotics Vervain Anticoagulants, seizure disorders, iron Watercress NSAIDs, acetaminophen Wild cherry Toxic Wild yam Avoid if family history of a hormone related disorder Willow Anticoagulants, diuretics, antihypertensives, NSAIDs, allergy to aspirin Wintergreen Aspirin, anticoagulants Witch hazel Do not take internally Wormwood Acetaminphen Yarrow Alcohol, antihistamines, antidepressants, antipsychotics, antiseizure drugs, anticoagulants, antihypertensives Yellow dock Diuretics, dilantin, Micalcin Yerba mate Alcohol, antihistamines, antiseizure drugs, narcotic pain relievers, Antabuse, caffeine, nicotine, Calan, Cipro, diuretics, Tagamet Yew Cancer, chemotherapy drugs, Nizoral Yohimbe Antidepressants, SSRI, tricyclic antidepressants, foods high in tyramine, coffee, antihistamines, MAOIs, beta blockers, morphine, antihypertensives, clonidine, Levodopa Drug Use in LTC 152 Non-Herbal Alternative Medicines — Use and Concerns SUPPLEMENT / USE Acidophilus - GI problems, canker sores, diarrhea, IBS, stomach ulcers, ulcerative colitis, acne, bacterial vaginosis Agar - Constipation CONTRA-INDICATIONS Lactose intolerance DRUG INTERACTIONS Fiber absorption of penicillin Electrolyte solutions, alcohol or tannic acid (tea), acetV & digoxin aminophen, Tagamet, insulin or hypoglycemic agents, nitorfurantoin, penicillin Insulin or oral hypoglycemic Bee pollen - Allergies, asthma, high Diabetes agents, anticoagulants or blood pressure, ASHD, inflammaNSAIDs, edema tory conditions, poor circulation, prevent cancer Oral hypoglycemics, antihyCoenzyme Q10 - Angina pectoLiver dysfunction pertensives especially beta ris, heart failure, ischemic heart blockers disease, high blood pressure, gum disease, deafness CreatinE - Antineoplastic, Impaired renal function, dehy- Caffeine, Tagamet muscle performance, dration, glucose impaired neuromuscular Glucosamine - Osteo-arthritis, Peptic ulcer, shellfish allergy regenerates damaged cartilage, improves joint function, decreases joint inflammation Melatonin - Cancer, insomnia, jet lag, slows weight loss w/cancer, anti-aging factor, presurgery anxiety, immune stimulant DHEA (fish oil) - Atherosclerosis, autoimmune disease, diabetes, depression, cancerous tumors, prevent osteoporosis, slow aging (‘fountain of youth’), coronary artery disease (CAD), arthritis Octasosanol - Amyotropic lateral sclerosis (ALS – Lou Gehrig’s Disease), Parkinson’s disease Psyllium - Constipation, lower cholesterol, IBS, diarrhea Shark cartilage - Cancer, analgesic, psoriasis, anti-inflammatory SAM-E – S-Adenosyl-L-methionine (Adomet) - Depression, liver disease, osteoarthritis, general well-being Alcohol intake, hypertension, seizures, depression, liver function, may increase psychiatric symptoms of psychiatric patients Not w/liver or renal disease, stroke, neurological disease or depression, hormonally sensitive cancer risk of breast cancer in women and risk of prostate cancer in men, autoimmune disease Insulin, oral hypoglycemics Beta blockers, calcium channel blockers, SSRIs, tricyclic antidepressants, thyroid replacement therapy, isoniazid Oral anticoagulants, heparin, platelet inhibitors Sinement Esophageal stenosis, GI steno- May decrease absorption of sis, not w/bowel obstruction Tegretol, copper, warfarin, glucose level, lithium, magnesium, B12, zinc Liver disease SIDE EFFECTS Gas Abdominal pain, swallowing problems, vomiting, GI obstruction, chest pain, breathing difficulties OTHER FDA does not recommend for treatment of diarrhea Take w/8 oz. of water Headache, indigestion, irritability, nausea, pain, epigastric distress, diarrhea, constipation Anorexia, nausea, diarrhea, Take w/ food heartburn, GI distress, insomnia Dehydration, muscle cramps, weight gain due to water gain, GI distress, nausea, vomiting, electrolyte imbalance Constipation, diarrhea, drowsiness, nightmares, exacerbate psychiatric patients, heartburn, rash, rapid pulse Altered sleep patterns, chills, confusion, drowsiness, headache, abdominal cramps, in blood pressure Hair growth, aggressiveness, sleeplessness, mood or behavior changes, acne, masculinizing effects in women Not recommended by the Arthritis Foundation, may insulin resistance Not for long term use Alternative to anabolic steroids, lowers stress hormones Dissiness, jerkiness, nervousness Gas, stomach pain, may absorption of nutrients Take drugs 1 hr before or 2 hrs after using psyllium Diarrhea, hepatitis, nausea, vomiting Diarrhea, GI distress, nausea, manic episodes w/ bipolar disorders, headaches Potential for toxic contamination Bibliography 153 1.Ackerman Richard, J., et. al. 1995, “Reducing Polypharmacy in The Nursing Home: An Activist Approach,” Journal of the American Board of Family Practice, Vol. 8, pp. 195-205. 2.American Society of Consultant Pharmacists, 2000, “ASCP’s Prescription for Quality Care: Preventing Medication-Related Problems Among America’s Seniors,” ASCP, Alexandria, VA; www.ascp. com. 3.Beers, Mark H., 1997, “Explicit criteria for determining potentially inappropriate medical use by the elderly,” Archives of Internal Medicine, 157: 1531-1536. 4.Beers, Mark H., MD, et al, 1992, “Inappropriate Medication Prescribing in Skilled-Nursing Facilities,” Archives of Internal Medicine, Vol. 117, No. 8, Oct. 15, 1992, pp 684-689. 5.Cadieux, Roger J., 1989, “Drug Interactions in the Elderly - 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Wolinsky I, Williams L, editors, 2002, Nutrition in Pharmacy Practice, American Pharmaceutical Association, Washington, DC. 41. Worthington, Patricia H., 2004, Practical Aspects of Nutritional Support: An Advanced Practice Guide, Saunders, An Imprint of Elsevier, Philadelphia, PA. Appendix A 155 Drugs Commonly Used in LTC List of Generic Drugs with Brand Names GENERIC NAME ACE INHIBITORS Benazepril Captopril Enalapril Fosinopril Lisinopril Quinapril Ramipril Spirapril BRAND NAME Lotensin Capoten Vasotec Monopril Zestril, Prinivil Accupril Altace Renormax ADRENERGIC AGENTS Clonidine Catapres Doxazosin Cardura Guanabenz Wytensin Guanfacine Tenex Methyldopa Aldomet Prazosin Minipress Terazosin Hytrin ANALGESICS Opioids Buprenorphine Buprenex Butophanal Standol Codeine Fentanyl Sublimaze, Duragesic Hydromorphone Dilaudid Levorphanol Levo-Dromoran, Levorphan Meperidine Demerol Methadone Dolophine Methadone Morphine Duramorph, MS Contin, Astramorph, Roxanol Oxycodone Roxicodone, OxyContin Oxymorphone Numorphan Pentazocine Talwin Propoxyphene Darvon, Profene Sufentanil Sufenta Salicylates Aspirin Various Choline Magnesium Salicylate Trilisate Choline Salicylate Arthropan Magnesium Salicylate Magan, Doan’s, Mobidin Salsalate Salsalate, Disalcid, Amigesic, Salsitab Sodium Salicylate Sodium Thiosalicylate Rexolate, Tusal OTHER ANALGESICS Acetaminophen Datril, Tylenol Acetaminophen / propoxyphene Darvocet-N 100 Lidocaine/Prilocaine cream Emla Tramadol Ultram NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) Bromfenac Sodium (Acetic Acid) Duract Diclofenac Potassium (Acetic Cataflam Acid) Diclofenac Sodium (Acetic Acid) Voltaren GENERIC NAME BRAND NAME NSAIDs (Non-Steroidal Anti-Inflammatory Drugs), continued Diflunisal (Propionic Acid) Dolobid Etodolac (Acetic Acid) Lodine Fenoprofen (Propionic Acid) Nalfon Flurbiprofen (Propionic Acid) Ansaid Ibuprofen (Propionic Acid) Advil, Ibuprin, Ibuprofen, Motrin, Trendar Indomethacin (Acetic Acid) Indocin Ketoprofen (Propionic Acid) Orudis, Oruvail Ketorolac (Acetic Acid) Ketorolac, Toradol Meclofenamate (Fenamate) Meclomen Mefenamic Acid (Fenamate) Ponstel Nabumetone (Acetic Acid) Relafen Naproxen (Propionic Acid) Naproxen, Anaprox, Naprosyn Naproxen Sodium (Propionic Acid) Aleve, Anaprox, Anaprox DS Oxaprozin (Propionic Acid) Daypro Oxyphenbutazone (Propionic Acid) Oxalid Piroxicam Feldene Salsalate Disalcid Sulindac (Acetic Acid) Clinoril Suprofen (Propionic Acid) Profenal Tolmetin (Acetic Acid) Tolectin ANTACIDS Aluminum Hydroxide AlternaGEL, Dialume, Alu-Cap, Alu-Tab, Amphojel Besmuth Subsalicylate Pepto-Bismol Calcium Carbonate Caltrate, Maalox, Os-Cal, Tums, Rolaids, Oyster Shell calcium Magaldrate Riopan Magnesium Oxide Maox, Mag-200 Sodium Bicarbonate Soduim Bicarbonate ANTI-AIDS (ANTI-RETROVIRALS) Delavirdine Rescriptor Didanosine DDI, Videx Indinavir Crixivan Integrase Zintevir Lamivudine 3TC, Epivir Nelfinavir Viracept Nevirapine Viramune Ritonavir Norvir Saquinavir invirase Stavudine D4T, Zerit Zalcitabine Dideoxycytidine, DDC, Hivid Zidovudine AZT, Retrovir ANTI-ALZHEIMER’S Donepezil Tacrine Vitamin E ANTIANXIETY AGENTS Alprazolam Buspirone Chlordiazepoxide Clonazepam Aricept Cognex Various brands Xanax BuSpar Librium Klonopin Appendix A, continued GENERIC NAME BRAND NAME ANTI-ANXIETY AGENTS, continued Diazepam Valium Hydroxyzine HCl Atarax Hydroxyzine Pamoate Vistaril Lorazepam Ativan Oxazepam Serax Prazepam Centrax ANTIARRHYTHMICS (Heart rhythm regulators) Atenolol Tenormin Digitoxin Crystodigin Digoxin Lanoxin Disopyramide Norpace Procainamide Procan SR, Pronestyl Verapamil Calan, Isoptin ANTIBIOTICS Bleomycin Blenoxane Dactinomycin Cosmegen Daunorubicin Cerubidine Methotrexate Folex PFS, Rheumatrex, Methotrexate Mitomycin Mutamycin Mitoxantrone Novantrone Aminoglycosides Amikacin Amikin Clarithromycin Biaxin, Macrolide Gentamicin Garamycin Kanamycin Kantrex Neomycin Mycifradin, Neobiotic Paromymycin Humatin Streptomycin Streptomycin Tobramycin Nebcin, Tobramycin Fluoroquinolones Ciprofloxacin Cipro Levofloxacin Levaquin Lomefloxacin Maxaquin Norfloxacin Noroxin Ofloxacin Floxin Sparfloxacin Zagam Macrolides Azithromycin Zithromax Clarithromycin Biaxin Dirithromycin Dynabac Erythromycin Various Troleandomycin TAO Penicillins Amoxicillin Trimox, Wymox, Polymox, Amoxil, Larotid Amoxicillin/Clavulanate Augmentin Ampicillin Totacillin, Principen, Polycillin N, Marcillin, Omnipen Ampicillin and Sulbactam Unasyn Bacampicillin Spectrobid Cloxacillin Cloxapen, Tegopen Carbenicillin Geocillin, Geopen, Pyopen Dicloxacillin Dycill, Dynapen, Pathocil, Veracillin Imipenem/Cilastatin Primaxin Methicillin Staphcillin Mezlocillin Mezin Nafcillin Unipen, Nafcil, Nallpen GENERIC NAME Penicillins , continued Oxacillin Penicillin G Penicillin G Benzathine Penicillin G Procaine Penicillin V Piperacillin Robicillin-VK, V-cillin K Ticarcillin Ticarcillin and Clavulanate Tetracyclines Demeclocycline Doxycycline Minocycline Oxytetracycline Tetracycline Miscellaneous Antibiotics Acetohydroxamic Acid Cinoxacin Co-trimoxazole Methenamine Mandelate Metronidazole Nitrofurantoin Vancomycin HCL ANTICOAGULANTS Warfarin Anisindione Dicumarol ANTICONVULSANTS Anti-psychotic (non-trade) Carbamazepine Clonazepam Diazepam Ethosuximide Felbamate Gabapentin Lamotrigine Mephenytoin Phenobarbital Phenytoin Primidone Risperidone Valproate / Valporic acid Topiramate ANTIDEPRESSANTS Tricyclics Amitriptyline Amoxapine Desipramine Doxepin Imipramine Nortriptyline Other Antidepressants Bupropion Clomipramine 156 BRAND NAME Prostaphlin Pentids, others Bicillin L-A Wycillin Pen Vee K, V-Cillin K, Veetids, others Pipracil Ledercillin-VK, Pencillin-VK, PenVee, Beepen-K, Betapen-VK, Robicillin, Veetids, Wincillin UK Ticar Timentin Declomycin Vibramycin, Doryx, Doxychel Minocin, Dynacin Terramycin Achromycin, Panmycin, Sumycin, Teline, Tetracyn, Tetram Lithostat Cinobac Pulvules Septra, Bactrim Mandelamine Flagyl Macrodantin Vancocin Coumadin, Panwarfin, Sofarin Miradon Tegretol Klonopin Valium Zarontin Felbatol Neurontin Lamictal Mesantoin Luminal Dilantin Mysoline Risperidal Depakene/Depakote Topamax Elavil, Endep Asendin Norpramin, Pertofrane Sinequan Tofranil Pamelor, Aventyl Wellbutrin, Wellbutrin SR Anafranil Appendix A, continued GENERIC NAME BRAND NAME Other Antidepressants, continued Fluoxetine (SSRI) Prozac (Bicyclic Antidepressant) Fluvoxamine Luvox Hypericum St.-John’s-wort Imipramine Tofranil Maprotiline (Tetracyclic) Ludiomil Nefazodone Serzone Paroxetine (SSRI) Paxil Sertraline (SSRI) Zoloft Tranylcypromine Parnate Trazodone Desyrel Venlafaxine (Bicyclic Effexor Antidepressant) MAO Inhibitors Phenelzine Nardil Tranylcypromine Parnate ANTIDIABETICS Oral Alpha-Glucosidase Inhibitors Acarbose Precose Miglitol Glyset Biguanides Metformin Glucophage Sulfonylureas Refer to section: Sulfonylureas Injectable Insulin ANTIDIARRIAHEALS Attapulgite Kaopectate, Donnagel Bismuth Subsalicylate Pepto-Bismol Diphenoxylate Lomotil Loperamide Imodium ANTIDYSRHYTHMICS Acebutolol Sectral Amiodarone Cordarone Digoxin (Antiarrhythmic, Digoxin, Lanoxin Cardiotonic) Disopyramide Norpace Flecainide Tambocor Lidocaine Xylocaine Mexiletine Mexitil Phenytoin Dilantin Procainamide Procan Propafenone Rythmol Propranolol Inderal Quinidine Quinora, Cardioquin, Quinidex Tocainide Tonocard Verapamil Calan, Isoptin, Verapamil, Verlan ANTIEMETICS Chlorpromazine Thorazine Cyclizine Marezine Dimenhydrinate Dramamine Diphenhydramine Benadryl Granisetron Kytril Hydroxyzine Atarax, Vistaril Meclizine Antivert, Bonine Ondansetron Zofran GENERIC NAME ANTIEMETICS, continued Prochlorperazine Promethazine Scopolamine Trimethobenzamide ANTIFUNGALS Amphotericin B Butenafine Clotrimazole Fluconazole Flucytosine Griseofulvin Itraconazole Ketoconazole Lipid-associated amphotericin B Miconazole Nystatin Terbinafine Tioconazole ANTI-GLAUCOMA Acetazolamide Betaxolol Brimonidine Dipivefrin Dorzolamide Epinephrine Lanoprost Levobunolol Metipranolol Pilocarpine Timolol ANTI-GOUT Allopurinol Colchicine Diclofenac Fenoprofen Ibuprofen Indomethacin Ketoprofen Mefenamic Acid Naproxen Oxaprozin Piroxicam Probenecid Sulfinpyrazone Sulindac ANTIHISTAMINES Astemizole Azatadine Azelastine Brompheniramine Carbinoxamine Cetirizine Chlorpheniramine Clemastine Cyclizine Cyproheptadine Dimenhydrinate 157 BRAND NAME Compazine Phenergan Transderm Scop Tigan Fungizone Mentax Mycelex Diflucan Ancobon Fulvicin, Grifulvin, Grisactin Sporanox Nizoral Abelcet Monistat Mycostatin Lamisil Vagistat-1 Diamox Betoptic Alphagan Propine Trusopt Glaucon Xalatan Betagan Optipranolol Pilocar Betimol, Timoptic, Timoptic-XE Zyloprim Cataflam, Voltaren Nalfon Advil, Motrin, Nuprin, Rufin Indocin Orudis Ponstel Anaprox, Naprosyn Daypro Feldene Benemid Anturane Clinoril Hismanal Optimine Astelin Dimetane, others Clistin, Rondec Zyrtec Chlor-Trimeton, Teldrin Tavist Marezine Periactin Dramamine Appendix A, continued GENERIC NAME BRAND NAME ANTIHISTAMINES, continued Diphenhydramine Benadryl Doxylamine Unisom Hydroxyzine Altarax Loratadine Claritin, Claritin Extra Meclizine Antivert, Bonnie Orphenadrine Norflex Pheniramine Component of Triaminic Promethazine Phenergan, others Terfenadine Seldane Tripelennamine Pyribenzamine, PBZ Triprolidine Component of Actifed and Sudahist Non-sedating or Minimally Sedating: Astemizole Hismanal Cetirizine Zyrtec Fexofenadine Allegra Loratadine Claritin Terfenadine Seldane ANTIHYPERTENSIVES Amlodipine/Benazepril Lotrel Bisoprolol / Hydrochlorothiazide Ziac Clonidine Catapres Doxazosin Cardura Enalapril/Felodipine Lexxel Guanabenz Wytensin Guanadrel Hylorel Guanethidine Ismelin guanfacine Tenex Hydralazine Apresoline Hydrochlorothiazide / Benazepril Lotensin Methyldopa Aldomet Minoxidil Loniten Prazosin Minipres Reserpine Serpasil Terazosin Hytrin See also: ACE Inhibitors, Angiotensin-2-Receptor Antagonists, BetaBlockers, Calcium Blockers and Diuretics Angiotensin-2-Receptor Antagonists Losartan Cozaar Valsartan Diovan ANTI-INFECTIVES Refer to the specific anti-infective / anti-biotic drug class: Amebicides Aminoglycosides Antifungal Drugs Antileprosy Drugs Antimalarial Drugs Antituberculosis Drugs Antiviral Drugs Cephalosporins Fluoroquinolones Macrolide Antibiotics Penicillins Sulfonamides Tetracyclines Miscellaneous Anti-Infective Drugs Atovaquone Mepron Chloramphenicol Chloromycetin Clindamycin Cleocin 158 GENERIC NAME BRAND NAME Miscellaneous Anti-Infective Drugs, continued Colistin Coly-Mycin S Furazolidone Furoxone Lincomycin Lincocin Nalidixic Acid NegGram Nitrofurantoin Furadantin, Macrodantin Novobiocin Albamycin Pentamidine Pentam-300 Trimethoprim Proloprim, Trimpex Vancomycin Vancocin ANTI-LEPROSY (Hansen’s Disease) Clofazimine Lamprene Dapsone Dapsone ANTI-METABOLICS Cytarabine Cytarabine, Cytosar-U Doxorubicin Adriamycin, Rubex, Doxorubicin Etoposide Etoposide, VePesid Fluorouracil Adrucil, Fluorouracil Mercaptopurine Purinethol ANTI-MYCOBACTERIAL AGENTS Rifabutin Mycobutin ANTI-NEOPLASTICS Alkalating Agents Busulfan Myleran Carboplatin Paraplantin Carmustine BiCNU Chlorambucil Leukeran Cisplatin Plantinol Cyclophosphamide Cytoxan Dacarbazine DITC-Dome Lomustine CCNU-CeeNU Mechlorethamine Mustargen Melphalan Alkeran Thiotepa Thiotepa Miscellaneous Antineoplastics Altretamine Hexalan Asparginase Elspar Hydroxyurea Hydrea Interferon Alpha 2a Roferon-A Interferon Alpha 2b Intron-A Mercaptopurine Purinethol Methotrexate Rheumatrex Pentostatin Alpha N3 Alferon K Nipent Procarbazine Matulane Vinblastine Veblan Vincristine Oncovin, Uincasar, Uincristine Hormonal Agents Aminogluethimide Cytaren Estramustine Emcyt Flutamide Eulexin Goseelin Zoladex Leuprolide Lupron Megesterol Megace Mitotane Lysodren Tamoxifen Nolvadex, Tamoxifen Appendix A, continued GENERIC NAME BRAND NAME ANTI-OSTEOPOROTICS Alendronate Fosamax Calcitonin Miacalcin Calcium Estrogen Various brands ANTI-PARKINSON’S Amantadine Amantadine, Symadine, Symmetrel Benztropine Cogentin Biperiden Akineton Bromocriptine Parlodel Carbidopa and Levodopa Sinemet Diphenhydramine Benadryl Levodopa Dopar, Laradopa Levodopa/Bensarazide Prolopa Levodopa/Carbidopa Sinemet, Sinemet CR Pergolide Mesylate Permax Selegiline Eldepryl Tolcapone Tasmar Trihexyphenidyl Artane ANTIPLATELET DRUGS (Platelet Aggregation Inhibitors) Aspirin Dipyridamole Persantine Sulfinpyrazone Anturane Ticlopidine Ticlid ANTIPSYCHOTICS Acetophenazine (Phenothiazine) Tindal Chlorpromazine (Phenothiazine) Thorazine Clozapine Clozaril Fluphenazine (Phenothiazine) Permitil, Prolixin Haloperidol Haldol Lithium Various Loxapine Loxitane Mesoridazine (Phenothiazine) Serentil Molindone Moban Olanzapine Zyprexa Perphenazine (Phenothiazine) Trilafon Pimozide Orap Prochlorperazine Compazine (Phenothiazine) Promazine (Phenothiazine) Sparine Risperidone Risperdal Thioridazine (Phenothiazine) Mellaril Thiothixene Navane Trifluoperazine (Phenothiazine) Stelazine Triflupromazine (Phenothiazine) Vesprin ANTIPYRETICS (Fever-Reducing) Acetaminophen Aspirin NSAIDs ANTI-TUBERCULOSIS Aminosalicylate Sodium Sodium P.A.S. Capreomycin Capasat Cycloserine Seromycin Esponiazid INH Ethambutol Myambutol Ethionamide Trecator-SC GENERIC NAME ANTI-TUBERCULOSIS, continued Isoniazid Pyrazinamide Rifabutin Rifampin Streptomycin ANTI-VIRALS Acyclovir Amantadine Cidofovir Didanosine Famciclovir Foscarnet Ganciclovir Lamivudine Nelfinavir Nevirapine Penciclovir Ribavirin Rimantadine Ritonavir Saquinavir Stavudine Valacyclovir Vidarabine Zalcitabine Zidovudine B-ADRENERGIC BLOCKERS Acebutolol Atenolol Betaxolol Bisoprolol Bisoprolol and Hydrochlorothiazide Carteolol Esmolol Labetalol Metoprolol Nadolol Penbutolol Pindolol Propranolol Sotalol Timolol BARBITURATES Amobarbital Aprobarbital Butabarbital Mephobarbital Metharbital Pentobarbital Phenobarbital Primidone Secobarbital Talbutal BENZODIAZEPINES Alprazolam Bromazepam Chlordiazepoxide 159 BRAND NAME Laniazid, Nydrazid Pyrazinamide Mycobutin Rifadin, Rimactane Zovirax Symmetrel Vistide Videx Famvir Foscavir Cytovene Epivir Viracept Viramune Denavir Virazole Flumadine Norvir Invirase Zerit Valtrex Vira A Hivid Retrovir Sectral Atenolol, Tenormin Kerlone Zebeta Zilac Cartrol, Ocupress Brevibloc Normodyne, Trandate Lopressor, Toprol XL Corgard Levatol Visken Inderal Betapace Blocadren Amytal Alurate Butisol Mebaral Gemonil Nembutal Solfoton, Luminal Mysoline Seconal Lotusate Xanax Lectopam Librium, Libritabs Appendix A, continued GENERIC NAME BENZODIAZEPINES, continued Clonazepam Clorazepate Diazepam Flurazepam Halazepam Ketazolam Lorazepam Midazolam Nitrazepam Oxazepam Prazepam Quazepam Temazepam Triazolam BRONCHODILATORS Albuterol Aminophylline Bitolterol Dyphylline Ipratropium Isoetharine Isoproterenol Metaproterenol Pirbuterol Salmeterol Terbutaline Theophylline BRAND NAME Klonopin Tranxene Valium, Vazepam Dalmane Paxipam Loftran Ativan, Lorazepam Versed Mogadon Serax, Apo-Oxazepam Centrax Doral Restoril Halcion Albuterol, Airet, Proventil, Ventolin, Volmax Truphylline Tornalale Dilor, Neothylline, Lufyllin Atrovent Bronkometer, Bronkosol, Dey- Lute Isuprel Alupent, Metaprel, Prometa Maxair Serevent Brethine, Bricanyl Theo-Dur, Theolair, Uniphyl, Slo- Phyllin, Slo-bid, Theo-24, Elixophyllin, others CALCIUM CHANNEL BLOCKERS Amlodipine Norvasc Bepridil Vascor Diltiazem Cardizem, Dilacoc, Dittiazem Felodipine Plendil Isradipine DynaCirc Mibefradil Posicor Nadolol Corgard, Nadolol Nicardipine Cardene Nifedipine Adalat, Nifedipine, Procardia Nimodipine Nimotop Nisoldipine Sular Verapamil Calan, Isoptin, Verelan CARBONIC ANHYDRASE INHIBITORS Acetazolamide Diamox CEPHALOSPORINS (Anti-Infectives) Cefaclor Ceclor Cefadroxil Duricef, Ultracef Cefamandole Mandol Cefazolin Anacef, Kefzol, Zolicef Cefepime Maxipime Cefixime Suprax Cefmetazole Zefazone Cefonicid Monocid Cefoperazone Cefobid Ceforanide Precef 160 GENERIC NAME BRAND NAME CEPHALOSPORINS (Anti-Infectives), continued Cefotetan Cefotan Cefoxitin Mefoxin Cefpodoxime Vantin Cefprozil Cefzil Ceftazidime Fortaz, Tazidime, Tazicef Ceftibuten Cedax Ceftizoxime Cefizox, Claforan Ceftriaxone Rocephin Cefuroxime Ceftin, Kefurox, Zinacef Cephalexin Keflex, Biocef, Keftab Cephalothin Keflin Cephradine Velosef, Cefadyl, Anspor Loracarbef Lorabid Moxalactam Moxam CORTICOSTEROIDS Amcinonide Cyclocort Beclomethasone Beclovent, Vancenase, Beconase Betamethasone Celestone, Vanceril Budesonide Rhinocort, Pulmicort Cortisone Cortone Dexamethasone Decadron Fludrocortisone Florinef Flunisolide Aero-Bid, Nasalide, Nasarel Fluorometholone FML Fluticasone Flonase Hydrocortisone Cortaid, Acticort, Cortel, Hydrocortone, Westcort, Cortef Medrysone HMS Opthalmic Suspension Methylprednisolone Medrol, Depo-Medrol, Solu-Medrol Prednisolone Cortef, Prednisolone, Delta-Cortef Prednisone Deltasone, Orasone Triamcinolone Aristocort, Kenacort, Triamolone, Azmacort DIURETICS Acetazolamide Thiazides Bendroflumethiazide Benzthiazide Chlorothiazide Cyclothiazide Hydrochlorothiazide Thiazide-Like Chlorthalidone Indapamide Metolazone Loop Bumetanide Ethacrynic Acid Furosemide Torsemide Potassium Sparing Diuretics Amiloride Amiloride and Hydrochlorothiazide Spironolactone Triamterene Triamterene and Hydrochlorothiazide Diamox Naturentin Aquatag, Exna, Marazide Diuril Anhydron Hydro-Chlor, Hydro Diuril, Oretic, Esidrix Hygroton, Thalitone Lozol Zaroxolyn, Diulo Bumex Edecrin Lasix Demadex Midamor Moduretic Aldactone Dyrenium Dyazide, Maxzide Appendix A, continued GENERIC NAME BRAND NAME H2 BLOCKERS Cimetidine Tagamet Famotidine Pepcid Nizatidine Axid Omeprazole Prilosec Ranitidine Zantac HYPNOTICS (See also: Barbiturates) Acetylcarbromal Paxarel Chloral Hydrate Aquachloral, Noctec Estazolam ProSom Ethchlorvynol Placidyl Flurazepam Dalmane Paraldehyde Paral Quazepam Doral Temazepam Restoril Triazolam Halcion Zolpidem Ambien HYPOGLYCEMICS Acetohexamide Dymelor Chlorpropamide Diabinese Glipizide Glucotrol Glyburide Micronized Glynase Glyburide Non-micronized Micronase Tolazamide Tolinase LAXATIVES Bulk Psyllium Metamucil Saline Magnesium Salts MOM Sodium Phosphate / Fleets, Enema Bi Phosphate Stimulants Bisacodyl Bisacodyl, Dulcolax Cascara Phenolphthalein Alophen, Modane Senna Senokot Stool Softeners Docusate Colace Osmotic Agents Glycerin Osmogluyn Lactulose Cephulac, Enulose NITRATES Amyl nitrate Amyl nitrate, others Erythrityl tetranitrate Cardilate Isosorbide Dinitrate Isordil, Sorbitrate, others Isosorbide Mononitrate Ismo, Imdur Nitroglycerin Nitro-Bid, Nitrostat, others Pentaerythritol Tetranitrate Duotrate, Peritrate NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs) (Aspirin Substitutes) Refer to Analgesic section 161 GENERIC NAME BRAND NAME PAIN SYNDROME MODIFIERS (also adjuvants) Carbamazepine (also Tegretol anticonvulsant) Gabapentin (also Neurontin anticonvulsant) Phenytoin (also anticonvulsant) Dilantin Strontium-89 Metastron PENICILLINS Refer to section: Anti-infectives PROKINETIC AGENTS Cisapride Propulsid Metoclopramide Reglan PROTON PUMP INHIBITORS (H/K ATPase Inhibitors) lansoprazole Prevacid Omeprazole Prilosec SALICYLATES Refer to section: Analgesics SULFONAMIDES Multiple sulfonamides Triple Sulfa No. 2 Sulfadiazine Sulfasalazine (Anti-inflammatory) Azulfidine, Sulfasalazine Sulfisoxazole (Antibiotic) Gantrisin SULFONYLUREAS (Oral Antidiabetic Drugs) Acetohexamide Dymelor Chlorpropamide Diabinese Glimepiride Amaryl Glipizide Glucotrol Glyburide DiaBeta, Micronase Tolazamide Ronase, Tolamide, Tolinase Tolbutamide Orinase THYROID HORMONES Levothyroxine Levothroid, Synthroid, Levoxine Liothyronine Cytomel Liotrix Thyrolar Thyroid Armour Thyroid, S-P-T, Thyrar, Thyroid Strong, Westhroid XANTHINES (Bronchodilators) Theophyllline Bronkodyl, Slo-Phyllin, Theolair, others Appendix B 162 Terms to Describe Food-Drug Interactions Appetite Changes Appetite either significantly increases or decreases. Anorexia - a severe decrease in appetite. Appetite disorder - appetite either increases or decreases. Weight Changes Weight increases or decreases may be related to appetite, drugs, disease, edema. Nausea and vomiting, as well as diarrhea can cause weight changes. Diuretics causing fluid loss also relate to weight loss. Edema Fluid retention due to drugs or disease. Altered Taste Food does not taste the same - may be bitter, sweet, salty, etc. Some cancer medications can cause food to taste metallic. Peculiar taste, dysgeusia, taste distortion all apply to this category. Thirst Desire to drink. Dry Mouth Can be caused by drugs that cause fluid loss or drugs that affect the mouth to have decreased saliva. Other drugs increase saliva production. High Risk Dental Problems Some drugs cause gum problems, others cause a dry mouth that decrease saliva, which is important to dental health. Other drugs may contain sugar or in other ways may increase dental caries. Drugs may also cause tooth pain. Heartburn, GI Pain This list includes: • Dyspepsia - pain in the stomach • Abdominal Cramping - cramps • Abdominal Pain - general discomfort • Gastric Irritation - ulcer-like pain • Abdominal Distention (bloating), gas or flatulence • Epigastric Distress - heartburn Nausea and Vomiting Nausea decreases appetite. Vomiting means the forceful expulsion of food and fluid. Diarrhea Diarrhea is the frequent loss of stools, usually over three per day. Constipation Constipation is no bowel movement for one to three days, or hard, dry stools. Appendix B, continued 163 Terms to Describe Food-Drug Interactions Blood Pressure Change The drug either increases or decreases the blood pressure. Diuretic and antihypertensive drugs are usually expected to decrease the blood pressure. Drowsiness and Weakness Some drugs cause sleepiness or weakness that interferes with eating or drinking or feelings of hunger and thirst. Words that may be considered in this category include: confusion, dizziness. These may accompany dehydration or low blood pressure. Take with Food Food either helps drug absorption or reduces gastric distress. Avoid Caffeine or Alcohol These two substances alter the effect of the drug. Highly Protein Bound These drugs bind to protein, if the serum albumin is low; more drug is released in the blood stream and can cause toxicity. Liver Damage Drug can cause damage to the liver. The liver metabolizes most drugs. Altered Glucose Levels These drugs either raise or decrease the blood glucose level. This is especially for those with diabetes. At times, the addition of a glucose altering drug may cause a new diagnosis of diabetes. Hyperglycemia = increased blood sugar. Hypoglycemia = decreased blood sugar. Other • Fecal Impaction - severe constipation • Fluid/Electrolyte Imbalance - may cause dehydration or fluid retention and changes primarily in sodium and potassium. • Hyperuricemia - high uric acid levels, can result in gout. • Incontinence - unintentional urine or stool loss. • Dysphagia - difficulty swallowing. • Oliguria - little urine production. Examination 164 Drug Use in Long Term Care (Effects on Nutrition & Health Status) C120-11 Answer each question by checking the correct answer online or filling the circle corresponding to the correct answer on the answer sheet. There is one best answer for each question. If you want a record of your answers, photocopy the answer sheet or record your choices on another piece of paper. Do not detach the examination from the book. This exam has 50 questions. 1. The responsibility for DNI (Drug-Nutrient Interactions) in hospitals approved by JCAHO includes these professionals: a. nurses b. dietitians c. physicians d. all of the above 2. Reasons the elderly are at risk for DNIs include all but: a. greater sensitivity to drugs b. elderly take fewer drugs c. more chronic illness d. decreased renal function 3. The percent of today’s elderly expected to spend time in a nursing home is: a. 25% b. 50% c. 65% d. 75% 4. An example of a drug with a narrow therapeutic index is: a. digoxin b. potassium chloride c. ACE inhibitor d. haldol 5. The over-the-counter medications likely to cause a gastrointestinal bleed are: a. laxatives b. NSAIDs c. milk of magnesia d. antihistamines 6. In the study by Gurwitz, the most common cause of adverse drug events was: a. failure to monitor drug b. delay response to symptoms c. transcription of drugs d. ordering of medication Examination cont‘d 165 7. The Institute of Medicine (IOM) found medical errors to be the _____ leading cause of death. a. 12th b. 4th c. 5th d. 8th 8. This category of drugs can cause kidney (renal) problems: a. aminoglycosides b. Cognex c. anticholinergic drugs d. antidepressants 9. Dyskinesia is defined as: a. drop in blood pressure associated when rising to sitting or standing b. slow heartbeat, less than 60 beats per minute c. an involuntary loss of urine due to a cough or sneeze d. impaired voluntary motion producing movements that are partial or incomplete 10. Side effects and ADRs of NSAIDs include all but: a. sodium retention b. ulcers c. orthostatic hypotension d. gastrointestinal upset 11. Pseudoephedrine is contraindicated in hypertension because: a. increases blood pressure b. high sodium content c. bladder flow obstruction d. causes low potassium levels 12. Bladder flow obstruction can be made worse by the use of this drug: a. Plavix b. Urispas c. MAOIs d. Tagamet 13. The drug that can prevent gastrointestinal bleeding with NSAIDs is: a. Tagamet b. Ritalin c. Cytotec d. Zantac C120-11 Examination cont‘d 166 14. The antidepressant drug most likely to trigger a seizure is: a. Wellbutrin b. Luvox c. diazepam d. Paxil 15. Which drug is designed for use with artificial heart valves? a. Serpasil b. Diabinese c. Persantine d. Vistaril 16. Factors that must be taken into account when a drug is prescribed are all but: a. gender b. age c. body weight d. body temperature 17. Liquid drugs safe to give to those with diabetes are: a. syrups b. suspensions c. sorbitol d. drugs in a semi-solid form 18. Drugs that are inserted into body orifices are called: a. topical patches b. suppositories c. sublingual d. lozenges 19. The disintegration of a medication in the body is called: a. pharmacodynamic phase b. absorption phase c. metabolic phase d. pharmaceutical phase 20. Drugs frequently causing weight loss in the elderly include all but: a. digoxin b. theophylline c. calcium d. SSRIs C120-11 Examination cont‘d 167 C120-11 21. Which categories of drugs are controlled by Federal legislation? a. controlled substances b. prescription drugs c. over the counter drugs d. all of the above 22. The most common way to administer drugs is: a. sublingually b. buccally c. orally d. nasally 23. Supplements which may be required with long term isoniazid use are: a. vitamin D b. niacin c. vitamin B6 d. all of the above e. a and c only 24. A resident is taking: Neurontin, Xanax, Dilantin and Lasix. Which drugs are most likely to cause weight gain? a. Neurontin and Lasix b. Xanax and Neurontin c. Dilantin and Lasix d. Lasix and Xanax Mr. Abrahms takes mineral oil, thiazide diuretics, aspirin, digitalis and two laxatives. 25. What would be the expected effect on potassium? a. no change b. increased c. decreased 26. Vitamin K levels could be affected by: a. mineral oil b. laxatives c. diuretics d. all of the above e. a and b only Examination cont‘d 168 27. Factors that influence drug absorption include all but: a. presence of food b. protein binding c. drug concentration d. solubility of the drug 28. The phase of drug action most like the absorption, digestion, metabolism, and excretion of food is: a. pharmaceutical phase b. pharmacokinetic phase c. pharmacodynamic phrase d. none of the above 29. Which is true about changes in body content in the elderly? a. decreased body water content b. greater bone mass c. increased body fat content d. a and c only e all of the above 30. Antipsychotic drugs are usually: a. water soluble b. fat soluble c. soluble in bone 31. A drug known to affect the oral cavity is: a. Lasix b. Dilantin c. Laxatives 32. Concerns with herbal safety include all but: a. no quality control b. large scale double blind studies demonstrating safety c. lack of regulation d. potential for contamination 33. Dietary supplements include: a. herbs b. enzymes and extracts from organs c. amino acids d. all of the above C120-11 Examination cont‘d 169 34. The estimated risk for nutrition supplements-drug interactions affects how many people? a. 4,000,000 b. 10,000,000 c. 500 d. 50,000 35. To prevent clogging of the feeding tube, which of these actions is recommended? a. Use of silicone tubes b. Use of a calorically-dense formula without a pump c. Use of a whey-based formula d. Use of fiber-containing formula 36. The best fluid to use to unclog a feeding tube is: a. Coca-Cola b. meat tenderizer c. cranberry juice d. water 37-41. Match the food incompatible with the drug: 37. fiber is incompatible with ___ 38. avocado is incompatible with ___ 39. tea is incompatible with ___ 40. citrus juice is incompatible with ___ 41. grapefruit juice is incompatible with ___ a. penicillin b. iron supplements c. buspirone d. lanoxin e. warfarin 42. The scope of evaluating nutrition-drug interactions extends to which of these substances? a. parenteral feedings b. herbs c. vitamins d. all of the above 43. The OBRA regulations require evaluation of all but __________ in the nutrition assessment. a. diuretics b. beta blockers c. oral hypoglycemics d. cardiac glycosides C120-11 Examination cont‘d 170 44. Health care data from America and England show what percent of elderly patients are hospitalized due to adverse drug reactions? a. 22% b. 70% c. 30% d. 50% 45. An unneeded iron supplement can cause all but __________ in the elderly patient. a. anorexia b. increased appetite c. abdominal discomfort d. constipation 46-50. Match the definition to the correct condition: 46. ___ state of decreased alertness 47. ___ an abrupt drop in blood pressure with position change 48. ___ a slow heartbeat 49. ___ impaired voluntary movement linked to psychotropic drugs 50. ___ loss of control over voluntary movement, especially walking Conditions: a. orthostatic hypotension b. dyskinesia c. sedation d. ataxia e. bradycardia C120-11