Drug Use in Long-Term Care

Transcription

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
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
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Drug Use in LTC
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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.
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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-
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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.
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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.
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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.
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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.
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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.
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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
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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
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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”
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• 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
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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
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“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.
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.
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.
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.
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®).
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.
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.
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.
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.
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.
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.
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®).
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.
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.
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®.
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.
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
• 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
• 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
• 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.
• 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.
• May cause or worsen hearing loss and renal failure.
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44
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.
• 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.
• 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.
• 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.
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45
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.
• 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.
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46
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.
• 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.
• 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.
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47
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
• 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.
• 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.
• 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).
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48
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.
• 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.
• 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
Drug Use in LTC
49
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;
Drug Use in LTC
50
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
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51
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.
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52
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.
• May increase risk of confusion, sedation, and falls
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53
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
• 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.
• 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
• Disopyramide has potent negative inotropic effects (decreased force of heart contraction), which may induce heart failure in older individuals, and is also strongly anticholinergic.
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54
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.
• 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
• 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
• 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.
• 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.
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55
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
• 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.
• 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.
• 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.
• May cause fluid and electrolyte imbalance (hypo/hypernatremia , dehydration, etc.), hypotension; may precipitate or exacerbate urinary incontinence, falls.
• May cause headaches, dizziness, lightheadedness, faintness, or
symptomatic orthostatic hypotension, especially when initially started or when taken in combination with antihypertensive medications
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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.
• 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.
• 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.
• 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.
• 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.
• May cause restlessness, distress, dizziness, somnolence,
hypertension, headaches, hallucinations, or increased confusion.
INDICATIONS/DURATION
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57
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)
• 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
• 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.
• 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.
• 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.
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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.
• 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.
• 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.
• Intermediate-or longer-term use may cause hyperglycemia, psychosis, edema, insomnia, hypertension, osteoporosis, mood lability, or depression.
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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
• 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
• 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
• 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.
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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.
• 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.
• 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).
• 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.
• 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.
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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.
• 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
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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).
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63
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
• 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.
• 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.
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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
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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
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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.
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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
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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.
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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
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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).
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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
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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
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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.
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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).
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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
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
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
tolmetin
Tolectin
valproic acid Depakene, Depakote
venlafaxine Effexor
verapamil Calan
zalcitabine HIVID
zinc new
(Bold indicates a greater risk of stomach distress.)
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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
salsalate Disalcid
sertraline Zoloft
trazodone HCl Desyrel
trimethoprim Bactrim
w/sulfamethoxazole
venlafaxine Effexor
zalcitabine HIVID
zidovudine Retrovir
azithromycin Zithromax
baclofen Lioresal
calcitonin Miacalcin
ciprofloxacin Cipro
diazepam Valium
digoxin Digoxin, Lanoxin
dronabinol Marinol
estrogens ethosuximide Zarontin
fluoxetine Prozac
ibuprofen Motrin
ketorolac tromethamine Toradol lithium carbonate Eskalith, Lithobid
metoclopramide HCl Reglan
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
corticosteroids
dapsone Dapsone
diflunisal Dolobid
diltiazem Cardizem
w/atropine sulfate
dirithromycin Dynabac
donepezil Aricept
doxazosin mesylate Cadura
doxycycline Doryx, Vibramycin
epoetin alfa Epogen
erythromycin
etidronate disodium Didronel ethosuximide Zarontin
etodolac Lodine
felodipine Plendil
fluconazole Diflucan
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
lorazepam Ativan levodopa Dopar, Larodopa
magnesium, as supplement, antacid, laxative
Drug Use in LTC
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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
olanzapine Zyprexa
omeprazole Prilosec
paroxetine Paxil
penicillin
phenytoin Dilantin
propoxyphene HCl Darvon
quinapril Accupril
Generic Name
Brand Name
mineral oil
mirtazapine Remeron
misoprostol Cytotec
zinc new
nicardipine Cardene
nitroglycerin
stavudine Zerit
streptomycin tacrine Cognex
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
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Drugs That Can Cause Gastritis
Generic Name
Brand Name / Misc.
ferrous salts penicillin dyspepsia avoid GI irrit. GI ulcers & bleeding may be serious & sudden
fluoxetine Prozac
cephalexin Keflex
Generic Name
Brand Name / Misc.
nabumetone Relafen
niacin
theophylline Theobid, epigastric pain/
GE reflux
valproic acid Depakene, Depakote, gastroenteritis
Drugs That Can Cause Gas
Generic Name
Brand Name
nabumetone Relafen
naproxen Naprosyn
niacin alendronate Fosamax
bisacodyl Dulcolax
corticosteroids
Generic Name
Brand Name
mineral oil
misoprostol Cytotec
ofloxacin Floxin
paroxetine Paxil
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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
ferrous salts fluvoxamine maleate Luvox
haloperidol Haldol
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
cisapride Propulsid
cyproheptadine HCl Periactin
diazepam Valium
Generic Name
Brand Name
diflunisal Dolobid
w/atropine sulfate fluoxetine Prozac
furosemide Lasix
glipizide Glucotrol
glyburide Micronase
hydrochlorothiazide HydroDIURIL
ibuprofen Motrin
isoniazid INH
ketorolac tromethamine Toradol
levodopa Dopar
lorazepam Ativan
nefazodone Serzone
nifedipine Adalat , Procardia
ofloxacin Floxin
omeprazole Prilosec
prioxicam Feldene
sertraline Zoloft
sucralfate Carafate
zidovudine Retrovir
Drug Use in LTC
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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
fluoxetine Prozac
ketorolac tromethamine Toradol lansoprazole Prevacid
magnesium as various
supplement, antacid or laxative metformin Glucophage
methotrexate Methotrexate
misoprostol Cytotec
MOM Milk of Magnesia
nabumetone Relafen
niacin paroxetine Paxil
penicillin sertraline HCl Zoloft
amoxicillin Amoxil
ampicillin
atenolol Tenormin
azithromycin Zithromax
bisacodyl Dulcolax buspirone HCl BuSpar
captopril Capoten
cimetidine Tagamet
ciprofloxacin Cipro cisapride Propulsid
clonazepam Klonopin
Generic Name
Brand Name
clozapine Clozaril
cyproheptadine HCl Periactin
diclofenac sodium Voltaren, Cataflam
diflunisal Dolobid
donepezil Aricept
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
ofloxacin Floxin
omeprazole Prilosec
prioxicam Feldene
thyroid Synthroid
triamterene Dyrenium
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
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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.
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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.
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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
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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.
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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
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
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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
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
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
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
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
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
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
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 (food delays, but does not decrease absorption)
antibiotic
antipsychotic
anti-alzheimer’s, cholinesterase inhibitor
antisecretory, antiulcer, anti-gerd
antihypertensive, calcium channel blocker
antidepressant, SSRI
antineoplastic
antihyperlipidemic
anticonvulsant (take Mg separate by 2 hours)
antihypertensive, calcium channel blocker
antiviral, anti-HIV, nucleoside analog
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
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.
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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
2. am
3 am
4 am
5 am
6 am
Digoxin / Captopril
7 am
Morning Meal time is 8 am
8 am
Hydrochlorothiazide / Ibuprofen
9 am
10 am
11 am
12 noon
1 pm
2 pm
3 pm
4 pm
5 pm
Ibuprofen
6 pm
Evening Meal Time: 5 pm
7 pm
8 pm
9 pm
10 pm
11 pm
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.
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This chapter has discussed how food intake influences drug bioavailability. The
next chapter will discuss additional ways foods and drugs can interact.
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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.
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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
glipizide ()
Glucotrol (can also  appetite)
glyburide ()
Micronase (can also  appetite)
haloperidol Haldol Generic Name
Brand Name
insulin
mirtazapine Remeron
nefazodone Serzone
olanzapine Zyprexa
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
ibuprofen Motrin, Advil, Nuprin
benztropine mesylate Cogentin
bismuth subsalicylate Pepto Bismol
captopril Capoten
carbamazepine
diuretic therapy
clonazepam Klonopin
codeine
diltiazem HCl Cardizem, Dilacor
w/ atropine sulfate ethosuximide Zarontin
iron supplements
interferon beta-1a
Avonex
interferon gamma-1b Actimmune
lansoprazole Prevacid
Generic Name
Brand Name
levodopa Dopar, Larodopa
methylphenidate Ritalin
penicillamine Cuprimine, Depen
prioxicam Feldene
antitubercular
medications selegiline Eldepryl
sertraline HCl Zoloft
sulfasalazine Azulfidine
tacrine Cognex
tetracycline
theophylline Slo- Bid, Slo- Phyllin, Theobid, Theo- Dur, Uniphyl
topiramate Topamax
trimethoprim w/ Bactrim, Septa
sulfamethoxazole venlafaxine Effexor
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Drugs that Can Cause Weight Gain
Generic Name
Brand Name
clozapine Clozaril
corticosteroids cyproheptadine HCl Periactin
mirtazapine Remeron
haloperidol Haldol
levodopa Dopar
Generic Name
Brand Name
baclofen Lioresal
dronabinol Marinol
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
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
alprazolam Xanax
dronabinol Marinol
estrogens fluvoxamine maleate Luvox
paroxetine Paxil
thyroid Synthroid
venlafaxine Effexor
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Drugs that Can Cause Edema
Generic Name
Brand Name/misc.
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
(edema of feet)
captopril Capoten
(angioedema)
chlorpromazine HCl Thorazine
Generic Name
Brand Name/misc.
clonazepam Klonopin cyproheptadine Periactin
epoetin alfa Epogen
gabapentin Neurontin ibuprofen Motrin
(peripheral edema)
naproxen Naprosyn
nefazodone Serzone
olanzapine Zyprexa
paroxetine Paxil
piroxicam Feldene
w/sulfamethoxazole
verapamil Calan
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Drugs that Can Cause Anorexia
Generic Name
Brand Name
digoxin Digoxin, Lanoxin
ethosuximide Zarontin ferrous salts fluvoxamine maleate Luvox
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
theophylline Theobid
sertraline Zoloft
albuterol sulfate Proventil, Ventolin
alprazolam Xanax
amantadine Symmetrel
calcium carbonate Tums, OsCal
captopril Capoten
Generic Name
Brand Name
Cephalosporins, antibiotics
codeine
diltiazem Cardizem
donepezil Aricept
erythromycin
furosemide Lasix
gabapentin Neurontin haloperidol Haldol
hydrochlorothiazide HydroDIURIL
zinc
w/atropine sulfate
w/sulfamethoxazole
prioxicam Feldene
mineral oil
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.
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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)
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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).
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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
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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.
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• 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
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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.
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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.
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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.
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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.
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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).
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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)
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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:
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• 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.
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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
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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
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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.
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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.
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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.
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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
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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.”
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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).
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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.
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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.
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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?
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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
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
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
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
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
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
Herb...
Interacts with...
Raspberry
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
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 - How Multiple Drug Use Increases Risk
Exponentially,” Postgraduate Medicine, December, Vol. 86, No. 8, pp. 179-186.
6.Chan, LN, 2000, “Redefining drug-nutrient interactions,” Nutr. Clin. Practice, 15 (5) 249-252.
7.Corbin, W. L., and Shapiro, H., 2002, “Physicians Want Education about Complementary and Alternative Medicine,” Arch. Intern. Med., Vol. 162, No. 10, pp 1176-81.
8.Cupp, Melanie Johns, 1999, “Herbal Remedies: Adverse Effects and Drug Interactions,” American
Family Physician, March 1, Vol. 59, No. 3, pp 1239-1244.
9.Dimant, Jacob, 2002, “Medication Errors and Adverse Drug Events in Nursing Homes: Problems,
Causes, Regulations, and Proposed Solutions,” Supplement to Journal of the American Medical
Directors Association, March/April, Vol. 3, No. 2, supplement.
10. Fetrow C. W., Avila J. R., 2000, The Complete Guide to Herbal Medicines, Springhouse Corporation, Springhouse, PA.
11. Fick, Donna M., et al, 2003, “Updating the Beers Criteria for Potentially Inappropriate Medication
Use in Older Adults,” Archives Intern Med., Vol. 163: 2716-2724.
12. Foster, Steven, 1996, “Herbal Medicine, An Introduction for Pharmacists,” NARD Journal, Oct., pp
127-144.
13. Graedon, Joe and Graedon, Teresa, 1995, “Deadly Drug Interactions,” St. Martin’s Griffin, NY.
14. Greenblatt, D. J., and Patki, K. C., and von Moltke, L. L., 2001 “Drug Interactions with Grapefruit
Juice: An Update,” Journal of Clinical Psychopharmacology, Vol. 21, No. 4, pp 357-9.
15. Herr, Sharon M., 2002, Herb-Drug Interaction Handbook, 2nd edition, Church Street Books, Nassau,
NY.
16. Higbee, Martin, 1996, 1996 Drug Formulary and Therapeutic Information Guide, Lexi-Comp Inc.,
Hudson, OH.
17. Institute of Medicine, 1999, “To Err is Human: Building a Safer Health System,” Washington, DC,
National Academy Press, publication.
18. Kanjanarat, Penkarn, Winterstein, Almut, et al, 2003, “Nature of Preventable Adverse Drug Events
in Hospitals: A Literature Review,” American Society of Health-System Pharmacists, Am J HealthSyst Pharm, 60(14); 1750-1759; accessed at: http://www.medscape.com/viewarticle/460564_print
on 9/19/2003.
19. Karch, Amy, 2004, Lippincott’s Guide to Preventing Medication Errors, Lippincott, Williams and
Wilkins, Springhouse, PA.
20. Kelly, W. J., ed., 2004, Nurse’s Drug Guide, 5th ed., Lippincott, Williams and Wilkins, Springhouse,
PA.
21. Kobriger, Annette M., 2001, Hydration: Maintenance, Dehydration, Lab Values and Clinical Alterations, Kobriger Presents, Inc., Chilton, WI.
22. Maka, Deborah A, and Murphy, Laureen K., 2000, “Drug-Nutrient Interactions: A Review,” AACN
Clinical Issues, Vol. 11, No. 4, pp 580-589.
23. Mandelbaum-Schmid, Judith, 1996, “Natural Remedies,” Self, September, pp 206-209, 226.
24. Marcus, Adam, 2004, “Herb Product Labels Vary Greatly,” abc.NEWS.com accessed
2/12/2004. http://printerfriendly.abcnews.com/printerfriendly/Pring?/fetch From
GLUE=trueGLUEser…2/12/2004.
Bibliography
154
25. McCabe Beverly J., Frankel Eric H., Wolfe Jonathan J., eds., 2003, Handbook of Food-Drug Interactions, CRC Press LLC, Boca Raton, FL.
26. McCance, Kathryn L. and Huether, Sue E., 2003, Pathophysiology - The Biologic Basis for Disease in Adults and Children, Mosby, St. Louis, MO.
27. McCue, Jack D., 1993, Geriatric Handbook for Long-Term Care, Williams and Wilkins, Baltimore, MD.
28. Morley, et. al., editors, 1990, “Drug-Food / Food-Drug Interactions,” Geriatric Nutrition, Raven
Press, Ltd., New York, NY.
29. Porth, Carol Mattson, 1994, Pathophysiology-Concepts of Altered Health Status, 4th ed., JB Lippincott Co., Philadelphia, PA
30. Pronsky Zanetta M., 2004, Food and Medication Interactions, 13th ed., Food-Medication Interactions, Birchunville, PA.
31. Reese, Diana, 1997, “Pharmacy Special Section,” Contemporary Long-Term Care, Vol. 20, No.
11, pp 65-71.
32. Reiss, Barry S., 1996, Pharmacological Aspects of Nursing Care, 5th edition, Delmar Publishers,
Albany, NY.
33. Rubin, Karen Wilk, 2003, “What You Need to Know About Herb-Drug Interactions,” FoodService Director, March 15, pp 46.
34. 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.
35. Schmidt, Lars E. and Dalhoff, Kim, 2002, “Food-Drug Interactions,” Review Article, Drugs,
2002; 62 (10); 1481-1502.
36. Shaw, Michael, 2001, Clinical Pharmacology Made Incredibly Easy, Springhouse Corporation,
Springhouse, PA.
37. Stupay, Susan and Sivertsen, Lynn, 2000, “Herbal and Nutritional Supplement Use in the Elderly,” The Nurse Practitioner, Vol. 25, No. 9, pp 56-67.
38. Walker, Janet, and Wynne, Hillary, 1994, “Review: The Frequency and Severity of Adverse
Drug Reactions in Elderly People,” Age and Ageing, 1994, Vol. 23, pp 255-259.
39. Williams, Bradley R., Nichol, Michael B., et al, 1999, “Medication Use in Residential Care Facilities for the Eldelry,” The Annals of Pharmacotherapy, Vol. 33, February, pp 149-155.
40. 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
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
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
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
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
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
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
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
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
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
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
39. tea
40. citrus juice
41. grapefruit juice
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
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

Drug Use in Long-Term Care

Transcription

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