Marys Medicine

Supplements and their effect on medications

Supplements and their effect on
medications
Seamless Care Pharmacy Mona Younis, RPh., PharmD.

Outline of Workshop
Part One: Drug Interactions
•
Introduction to Drug Interactions
Part Two: Supplements
•
Introduction to Supplements
Patient Cases using Home Portal

BREAK
Part Three: Supplements Commonly Seen in Practice
•
Glucosamine and Chondroitin

Part Four
•
Staff Discussion- Q/A

Introduction To Drug Interactions

A Brief Overview of Drug Interactions • Definition: situation which a substance affects the activity of a drug when both are administered Main categories:
1. Drug's effect is increased→ Can lead to overdose and
increase the risk of side effects 2. Drug effect is decreased→ Can lead to less benefit
from medication and worsening condition 3. New effect can be produced
4. No clinically significant effect
• HCP must look into all drug interactions, determine their severity and take appropriate action to keep patient safe (document and monitor)!

Why is this Important today?
(Hint: its in the title of this presentation) Many patients are on MULTIPLE SUPPLEMENTS Patients are also on MULTIPLE MEDICATIONS Many SUPPLEMENTS interact with many MEDICATIONS These INTERACTIONS can be SERIOUS Get FAMILIAR with these INTERACTIONS so you can . Know what to monitor, Minimize or eliminate in certain document and report

Introduction to Supplements

Introduction to Supplements
• intended to provide nutrients that may otherwise not be consumed in sufficient quantities • Supplements include vitamins, minerals, fiber, some herbals, fatty acids, amino acids etc. • More than half of the Canadian population consumes dietary supplements – Most of which are not prescribed to them by a health care • Supplements CAN be harmful- over consumption and DRUG INTARACTIONS

Supplements UP For Discussion
1. Calcium/Vitamin D 2. Iron 3. Folic acid 4. Omega 3 5. Vitamin B12 6. Vitamin E 7. Vitamin B6/ Pyridoxine 1. Calcium
CLINICAL INFORMATION
malnourished elderly , heartburn, upset stomach, osteoporosis, osteoporosis prevention Signs: calcium levels less than 8.5mg/dl (<2.13mmol/l), low bone symptoms of low densities Symptoms: muscle cramps/spasms, heart problems, depression, anxiety, memory loss, confusion, seizures furosemide (Lasix), calcitonin, bisphosphonates, fluoride, cinacalcet, ketoconazole MAIN reason why people have low calcium levels is because they have low Vitamin D Vitamin D SHOULD be given with calcium BECAUSE It INCREASES CALCIUM absorption
Remember-> low vitamin D can be caused by anticonvulsants!
1. Calcium
ADMINISTRATION INFORMATION
500mg /dose. Comes in tablet, liquid, chewable, IV once daily to three times daily with meals depending on req.
Take with meals. Usually no more than 500mg of elemental calcium per dose is absorbed. Separate from all meds if possible by 2hr especially ANTIBIOTICS high calcium levels (heart rate changes), watch for constipation! OVERDOSE: heart rate abnormalities, neuro symptoms, pancreas damage, kidney Missed Doses Depends on what its used for. More important if clinically low calcium vs. osteoporosis prevention/not prescribed by MD. Not an issue if missed one dose/patient refuses. Try not to give with next scheduled meds incase decreases their absorption. Reduces absorption of many other drugs from getting into the body-*Antibiotics like ciprofloxacin-decreases absorption of antibiotic
* iron supplements- decreases absorption of iron
Look at the medication list and changes Look at allergies, medical conditions Think about what the interactions can be What is the consequence of the interactions What can you do? 2. Iron (Ferrous)
CLINICAL INFORMATION
Treat or prevent low iron in body (iron-deficiency anemia). Iron is needed for proper oxygen supply to Signs: low iron levels and ferritin levels. Hemoglobin of <135 g/L defines anemia in men an Hb <120 g/L defines Symptoms: fatigue, pale, dizziness, irritable, weak, palpitations, short of breath, chest pain Medication-induced n/a 2. Iron (Ferrous)
ADMINISTRATION INFORMATION
200mg/day of elemental iron. Comes in tablet and IV Divided in two or three divided doses Better absorption on empty stomach with glass of water or OJ. If stomach upset
Instructions occurs can give with smal er doses with meals. Separate from other meds and
dairy products if possible by 2hrs especially ANTIBIOTICS Side Effects upset stomach (occurs less if increase dose slowly), black stools, constipation. OVERDOSE: Leading cause of deadly poisoning Depends on what used for. More important if clinically low iron with neurologic or cardiac symptoms than if not prescribed by MD. Not an issue if missed one dose/patient refuses. Try not to give with next scheduled meds incase decreases their absorption. If patient cant tolerate and refuses med- let Dr./ Pharmacist know
Interactions Iron decreases absorption of drugs from getting into body (Separate doses!): *levodopa, levothyroxine for thyroid (Eltroxin, Synthroid), antibiotics
Meds can decrease Iron's absorption: *dairy products, antacids, other stomach meds like ranitidine, pantoprazole)
Look at the medication list and changes Look at allergies, medical conditions Think about what the interactions can be What is the consequence of the interactions What can you do? 3. Folic Acid
CLINICAL INFORMATION
Low folic acid or folic acid deficiency (macrocytic anemia), used before, during and after pregnancy (they need more), excessive alcohol intake (people with poor eating habits), if on certain meds that decrease folic acid (see below) Found in leafy green vegetables, liver, legumes Signs and symptoms Signs: decreased folic acid levels of low folic acid Symptoms: see iron deficiency, neural tube defect in fetus Medication-induced Methotrexate! (need to supplement with folic acid),
alcohol, seizure meds (phenytoin, phenobarbital)
transplant/chemo meds (azathioprine, 6MP, 5-FU) HIV med (zidovudine) antibiotics (trimethoprim) 3. Folic Acid
ADMINISTRATION INFORMATION
1mg/day (sometimes 5mg /day is needed). if prevention- lower doses, if treatment-higher doses *hence the once a day/once a week, and the 1-5mg doses With or without food Instructions Side Effects Missed Doses Important not to miss doses especially if pregnant, high alcohol intake or on meds that decrease folic acid . Can take anytime if missed during the Methotrexate (not to be administered on the same day)
Phenytoin (decreases phenytoin absorption)-also decreases absorption of folic acid, can cause deficiency- *patients on phenytoin should be on folic acid, but separate doses
Look at the medication list and changes Look at allergies, medical conditions Think about what the interactions can be What is the consequence of the interactions What can you do? 4. Vitamin B12
CLINICAL INFORMATION
Low vitamin B12 or vitamin B12 deficiency (macrocytic anemia), prevent low vitamin B12 in strict vegans, chronic alcoholics and elderly patients, poor absorption. Found in dairy and meat Signs and symptoms Signs: low vitamin B12 levels of low vitamin B12 Symptoms: see iron deficiency, neurologic symptoms
(can become irreversible) – numbness, tingling, imbalance, loss of movement, vision changes Medication-induced Stomach acid reducing meds (ranitidine, pantoprazole
(Pantoloc, Tecta etc.), metformin, alcohol,
anticonvulsants (phenytoin, phenobarbital,
4. Vitamin B12
ADMINISTRATION INFORMATION
250-500ug/day by mouth, 100ug/month injection. Comes in tablet, chewable, nasal spray, sublingual, injection. With or without food Instructions Side Effects Mild diarrhea, itch, hives, swel ing, very low potassium levels Important not to miss doses especially if neurological symptoms
present and was prescribed. Can take anytime if missed during the Look at the medication list and changes Look at allergies, medical conditions Think about what the interactions can be What is the consequence of the interactions What can you do? 5. Omega 3
CLINICAL INFORMATION
To lower a certain type of cholesterol (triglycerides) As dietary supplements for people at early risk of coronary artery disease Signs and symptoms of low omega 3 Medication-induced ADMINISTRATION INFORMATION
2g-4g. Available in capsules 2g twice a day with meals or 4g once a day (depends on formulation) Special Instructions With meals. Should only be taking if advised so by a physician.
Watch for fish allergies- should not be used in people with shel fish
Burping, change in taste, upset stomach, loose stools, stomach upset, heart rate irregularities, bruising, bleeding, Not significant (stays in body for a long time) beta-blockers, thiazides, estrogens worsen hypertriglyceridemia, increase effect of some blood thinners (ie. Warfarin) Look at the medication list and changes Look at allergies, medical conditions Think about what the interactions can be What is the consequence of the interactions What can you do? 6. Vitamin E
CLINICAL INFORMATION
Not really used for anything important (thought to be an anti-
oxidant). Vitamin E deficiency is very rare. Can be used for skin irritation (burn, cuts etc), cystic fibrosis, prevention of antipsychotic associated tardive dyskinesia (no
evidence to show benefit in any condition)
signs and symptoms Serum vitamin E levels <0.5 mg/dL of low Vitamin E no real symptoms Medication-induced antipsychotics ? 6. Vitamin E
ADMINISTRATION INFORMATION
100-800units/day . Comes in capsule, tablet, cream/lotion Special Instructions No one should exceed 1000mg/day (high doses linked to
increased risk of death!)
Greater than 400IU/day for a year also increases risk of death, cancers, heart attacks Fatigue, headache, increase cholesterol, blurred vision, weakness, changes in kidney function, diarrhea, heartburn, increase risk of prostate cancer, death with higher doses NSAIDs (Aspirin), antidepressants, warfarin (increase risk of
bleeding)
Increase concentration of cytotoxic meds (cyclosporine), iron, niacin, simvastatin, cholestyramine Look at the medication list and changes Look at allergies, medical conditions Think about what the interactions can be What is the consequence of the interactions What can you do? 7. Vitamin B6
Pyridoxine
CLINICAL INFORMATION
Helps metabolize carbs, proteins and fat. prevention and treatment of vitamin B6 deficiency nausea/vomiting of pregnancy, neuropathy associated with signs and symptoms seizures, dizziness, depression, confusion, scaly scalp of low Vitamin B6 Medication-induced isoniazid, hydralazine, pyrazinamide, alcoholism, oral 7. Vitamin B6
Pyridoxine
ADMINISTRATION INFORMATION
25-50mg every 8 hours by mouth Special Instructions headache, nausea, fatigue OVERDOSE: fatal neuropathy Important if trying to prevent neuropathy associated with levodopa concentration is decreased, barbiturates and phenytoin concentrations increased COMMON MEDICATIONS SEEN IN
PRACTICE
Cranberry
• 600mg-1200mg/day in divided doses Administration Used for Bladder infection prevention (not for treatment)- stops bacteria from sticking to the wal s of the bladder. No evidence Evidence isn't great for prevention Should be used with Pancreas disease caution in patients with Interactions • vitamin K antagonist (ie. Warfarin)- not to be used together
and cranberry should not be started if patient is on warfarin
without speaking to Dr./Pharmacist
• No significance. Expensive so if there is resistance to be on it, then they don't have to be Probiotics
Usual y daily, can be twice weekly Measured in mil ion/bil ion colony forming units /capsule Antibiotic associated diarrhea prevention*- decrease chance of getting diarrhea when on antibiotics and shortens duration of bacterial vaginosis, pediatric fungal infections, diarrhea (eg, acute infectious, antibiotic-associated, persistent), GI surgery, irritable bowel syndrome, respiratory infections stomach cramping, nausea, fever, soft stools, flatulence, and taste disturbances Should be used with Pancreas disease caution in patients w/ Interactions Glucosamine and Chondroitin
Available alone as glucosamine or with chondroitin sulfate Usual dose: 1.5g/day treatment of osteoarthritis stomach upset (diarrhea, heartburn, nausea, vomiting (more with chondroitin) Should be used with diabetes- may increase insulin resistance and possible glycemic
caution in patients liver and kidney disease- possible hindered renal excretion of glucosamine hydrochloride al ergy to shel fish
active bleeding
warfarin
Glucosamine and Chondroitin
• Re. glucosamine: The American Col age of Rheumatology conditionally recommends that health care providers do not use nutritional supplements (e.g., chondroitin sulfate, glucosamine) or topical capsaicin for the treatment of • That being said, the use of glucosamine in this patient population is controversial and it is common in practice to see patients on this medication. • Some studies have shown benefit in OA (and some show none). As wel , the theoretical MOA would suggest benefit in using in OA • It may not be necessary to order the patient to stop the medication or not begin at all (especially if it is safe and they find it helps relieve the pain); it is important to educate patients on the safety and caution behind the product safety (renal, diabetes caution etc.). Look at the medication list and changes Look at allergies, medical conditions Think about what the interactions can be What is the consequence of the interactions What can you do? That's al folks!

Any Questions?
Please visit our websites for more educational material:

Source: http://www.seamlesscare.ca/wp-content/uploads/2015/08/Supplements-and-Drug-Interaction-workshop.pdf