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Healthy Transitions. Common Side effects and Drug Interactions. Gabriela Dimitrievski, PharmD Brian Hoff, PharmD Katie Sandison, PharmD. Take Control of your Health!. Bring your medications into your doctor appointments

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healthy transitions

Healthy Transitions

Common Side effects and Drug Interactions

Gabriela Dimitrievski, PharmD

Brian Hoff, PharmD

Katie Sandison, PharmD

take control of your health
Take Control of your Health!
  • Bring your medications into your doctor appointments
  • Keep all of your healthcare providers informed of any changes to your health
  • Keep an updated medication list
    • Include Over-the-Counter medications
    • Include herbal supplements
  • Know why you are on your medications
  • Talk to your healthcare providers
    • Ask questions!
over the counter otc medications

Over-the-Counter (OTC)Medications


NSAIDs (Motrin/Advil/Aleve/Aspirin)

Cough and Cold

Anti-diarrheals and Laxatives

Herbal Remedies

  • Generic name: acetaminophen
  • Primary Use: pain or fever
  • Maximum dose: do not exceed 4,000 mg per day (your doctor may recommend less)
  • Products that contain acetaminophen:
    • Vicodin/Lortab/Percocet
    • Multi-symptom cough and cold products
    • Tylenol PM
  • Toxicity: liver damage
    • Can occur when taken in large amounts or over long periods of time
    • Keep out of reach of children
    • Cautioned use in those who regularly consume alcohol
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Examples:
    • Ibuprofen (Advil, Motrin)
    • Naproxen (Aleve)
    • Aspirin
  • Primary Use: Pain, inflammation, fever
  • Following the dosing tables on the package
  • Adverse effects:
    • Overuse and high doses can decrease the protective effects in the stomach and intestines
    • Aspirin: prevents blood clotting (even 81 mg ‘baby’ aspirin)
    • Note: aspirin should not be used in children and teenagers due to risk of Reye’s Syndrome
cough and cold
Cough and Cold
  • Antihistamines: Benadryl, Claritin, Zyrtec
    • Benadryl can cause drowsiness, best taken before bed
    • Claritin and Zyrtec are non-drowsy and are recommended when symptom relief is needed during the day
  • Cough and mucus: Mucinex (guaifenesin) and Delsym (dextromethorphan)
    • Mucinex thins the mucus and is best taken with a full glass of water
    • Delsym: some patients experience drowsiness, dizziness, headache
  • Decongestants: Sudafed (pseudoephedrine), Sudafed PE (phenylephrine)
    • Sudafed is found behind the pharmacy counter with purchase limits
    • Sudafed can increase heart rate and blood pressure
    • Sudafed PE is safer for patients with high blood pressure not well-controlled by medications, healthy diet, and exercise

**Caution: over-use of multi-symptom formulations can be dangerous, discuss with your pharmacist or physician



  • Metamucil (fiber)
    • Can help naturally thicken stool
  • Loperamide (Imodium A-D)
  • Pepto-Bismol: liquid or tablets
  • These can be used when diarrhea lasts greater than 6 hours
  • Cautions:
    • Do not use these medications if you have bloody diarrhea, fever, or severe diarrhea
    • Some diarrhea is caused by infection and should be treated by your doctor, not with OTC medications
    • Pepto-bismol can possibly turn your tongue and stool black
    • Overuse of anti-diarrheals can lead to constipation


  • Metamucil (fiber)
    • Safest and most natural way relieve symptoms of constipation
    • Can take hours to days for effect
  • Stool Softeners: Docusate, Colace
    • Can take hours to days for effect
  • Stimulants: Senna, Biscaodyl
    • Quicker onset, more powerful laxatives, use with caution
  • Avoid mineral oil and herbal remedies for constipation
  • Suppositories or enemas can also be used
    • Glycerin suppositories are the safest treatment for small children and newborns
herbal remedies
Herbal Remedies
  • Herbal supplements are regulated by the Food and Drug Administration (FDA) as dietary supplements
    • Not regulated as drugs or foods
  • The FDA does not evaluate the use of dietary supplements for the specific diseases they may claim to treat
  • Many herbal medications can interact and cause side effects like prescription drugs
    • Caution should be taken when using these products
  • For safety, starting herbal supplements should be discussed with your physician or pharmacist
herbal remedies1
Herbal Remedies
  • Class A, B, and C recommendations
    • A = data allows us to assume use is beneficial
    • B = incomplete data allows us to accept the possibility of a beneficial relationship
    • C = conflicting or lack of data to establish a beneficial association with it’s use
  • In general, medications in Class A have stronger evidence for use and are more likely to be recommended by a physician or pharmacist
herbal remedies3
Herbal Remedies
  • Caution: ‘G-herbs’ = increased risk of bleeding
    • Ginger – Class B use for nausea
    • Garlic – Class A use for high blood pressure and cholesterol
    • Ginkgo – Class A use for Alzheimer's dementia
    • Ginseng – Class B use for improving mental performance
  • Drug-interactions in the liver
    • Echinacea – Class B use for Cold symptoms
    • Garlic – Class A use for high blood pressure and cholesterol
    • Black Cohosh – Class C use for menopause
    • Red Yeast Rice – Class A use for cholesterol
    • St. John’s Wort – Class A use for mild-moderate depression
    • Saw Palmetto – Class A use for BPH
    • Milk Thistle – Class B for liver disease and cirrhosis
gastroesophageal reflux disease gerd
Gastroesophageal Reflux Disease (GERD)
  • Many treatment options available both over-the-counter and by prescription
  • Most common prescription agents:
    • Histamine2-receptor antagonists (H2RAs)
    • Proton pump inhibitors (PPIs)
  • Agent usually chosen based on degree of symptoms
gastroesophageal reflux disease gerd1
Gastroesophageal Reflux Disease (GERD)
  • Histamine2- receptor antagonists
gastroesophageal reflux disease gerd2
Gastroesophageal Reflux Disease (GERD)
  • Common side effects:
    • Headaches
    • Tiredness
    • Sleepiness
    • Dizziness
    • Constipation or diarrhea
  • If elderly:
    • Confusion, especially at higher doses and with decreased kidney function
      • Memory problems, disorientation, fall risk
gastroesophageal reflux disease gerd3
Gastroesophageal Reflux Disease (GERD)
  • Drug interactions:
    • Medications that require an acid environment to work: antifungal medications, calcium carbonate, iron, and some HIV medications
    • Cimetidine (Tagamet) specifically has many drug interactions
gastroesophageal reflux disease gerd5
Gastroesophageal Reflux Disease (GERD)
  • Common side effects:
    • Headache
    • Dizziness
    • Diarrhea
    • Constipation
    • “Acid rebound”
  • Increased risk of osteoporosis/fractures with long-term use
    • Limit use!
gastroesophageal reflux disease gerd6
Gastroesophageal Reflux Disease (GERD)
  • Drug interactions:
    • Medications that require an acid environment to work: antifungal medications, calcium carbonate, iron, and some HIV medications
    • May lead to increased levels of methotrexate, phenytoin, raltegravir, saquinavir, tacrolimus, voriconazole, and warfarin
    • Omeprazole (Prilosec), and possibly others, should not be used together with clopidogrel (Plavix)
high cholesterol
High Cholesterol
  • “Statin” medications
    • Atorvastatin (LIPITOR)
    • Simvastatin (ZOCOR)
    • Rosuvastatin (CRESTOR)
    • Pravastatin (PRAVACHOL)
    • Lovastatin (MEVACOR, ALTOPREV)
    • Fluvastatin (LESCOL)
    • Pitavastatin (LIVALO)
high cholesterol1
High Cholesterol
  • Possible side effects of statins:
    • Digestive problems:
      • Nausea
      • Gas
      • Diarrhea
      • Constipation
    • Blood sugar increases
    • Memory loss or confusion
      • Usually reversible when medication is stopped
    • Increased risk of cataracts
high cholesterol2
High Cholesterol
  • Serious side effects:
    • Muscle pain and damage
      • Higher doses of medication
      • Age > 65 years old
      • Decreased kidney function
      • Untreated hypothyroidism
      • Use of fibrates
  • Liver damage
    • Unusual tiredness or weakness
    • Loss of appetite
    • Abdominal pain
    • Dark-colored urine
    • Yellowing of the skin or eyes
high cholesterol3
High Cholesterol
  • Statin drug


Shapiro and Brown, RxPrep CourseBook 2013 ed.

high cholesterol4
High Cholesterol
  • Simvastatin
    • Doses of 80mg/day should be restricted to patients who have been stable on this dose (> 12 months) without evidence of muscle toxicity
  • Rosuvastatin
    • May increase effects of warfarin
    • Dose limits with cyclosporine, ritonavir-boosted protease inhibitor treatment, and gemfibrozil
    • Use with other cholesterol/lipid lowering medications, such as fibrates and niacin, may increase risk of muscle pain and damage
high cholesterol5
High Cholesterol
  • Fluvastatin
    • Closer monitoring when used with warfarin
  • Pitavastatin
    • Minimal interactions
    • Should not be used with cyclosporine
    • Dose limits with erythromycin and rifampin use
    • Monitor when used with warfarin
warfarin coumadin
Warfarin (COUMADIN)
  • Uses:
    • Prevention and treatment of blood clots and clots in the lungs
    • Prevention and treatment of clots and associated complications in patients with atrial fibrillation and/or heart valve replacement
    • Decrease in the risk of death, recurrent heart attack, and clot events like stroke or systemic clotting after a heart attack
warfarin coumadin1
Warfarin (COUMADIN)
  • Major side effects of warfarin = bleeding risk
    • Severe bleeding
    • Bruises that come about without an injury
    • Prolonged/frequent nose bleeds
    • Black stools or bleeding from the rectum
  • Importance of monitoring to help prevent bleeding complications
warfarin coumadin2
Warfarin (COUMADIN)
  • Other important side effects:
    • Hives, rash, itching
    • Chest pain, pressure
    • Nausea, vomiting
    • Fever or flu-like symptoms
    • Joint or muscle aches
    • Diarrhea
    • Tingling or numbness in any part of the body
warfarin coumadin3
Warfarin (COUMADIN)
  • Less serious side effects:
    • Gas
    • Feeling cold
    • Fatigue
    • Pale skin
    • Changes in the way food tastes
    • Hair loss
warfarin coumadin4
Warfarin (COUMADIN)
  • Drug interactions
    • Warfarin interacts with MANY medications
warfarin coumadin5
Warfarin (COUMADIN)
  • Common Interactions
    • NSAIDs
      • Aspirin, ibuprofen, naproxen, etc.
      • Use with warfarin can increase bleeding risk
    • Nutritional and natural/herbal products as big culprits of drug interactions
    • Vitamin K
      • Green, leafy vegetables
      • Do NOT have to avoid; key is to stay consistent
high blood pressure beta blockers
High Blood Pressure – Beta Blockers
  • Common Side Effects
    • Fatigue, depression: usually worse within the first few weeks of taking
    • Dizziness
    • Cold hands
    • Can make it more difficult to realize when your blood sugar is low if you have diabetes – be cautious with insulin, check your blood sugar often
high blood pressure ace inhibitors
High Blood Pressure– ACE Inhibitors
  • Common Side Effects
    • Dry cough – If this occurs, call your physician, as this is a common side effect that will not taper with time
    • Potassium and Kidney levels may change – your physician will monitor this
    • Dizziness
  • Avoid Excess Over the Counter NSAIDs- Motrin, Aleve, Advil, etc.
high blood pressure diuretics water pills
High Blood Pressure– Diuretics (Water Pills)
  • Common Side Effects
    • Frequent Urination – take in the morning and earlier in the day to avoid waking up at night
    • Electrolytes (potassium, calcium, sodium) may change, your doctor will monitor
    • Dizziness
  • NSAIDS may decrease their effectiveness through their actions on the kidney
high blood pressure calcium channel blockers
High Blood Pressure – Calcium Channel Blockers
  • Amlodipine (Norvasc)
    • Can cause swelling in the lower legs
    • Dizziness
  • Verapamil (Calan), Diltiazem (Cardizem)
    • Constipation
    • Drug Interactions – MANY, consult your healthcare provider before starting any new medication
      • Cholesterol reducing medications (statins)
      • Transplant medications (tacrolimus, cyclosporine, everolimus)
      • Anti-arrhythmic drugs (amiodarone, sotalol)
      • Many others!
diabetes low blood sugar
Diabetes- Low Blood Sugar
  • Blood sugar level <70 mg/dL
  • What do you do?
    • Take in 15 grams of quick acting carbohydrate/sugar source
      • Ex: ½ cup juice or regular soda (not diet), quick dissolving candy (NOT sugar-free), glucose tablets, 2 tablespoons raisins
    • Wait 15-20 min, re-check blood sugar
    • Eat a normal snack to keep sugar steady
tips for improving medication use
Tips for Improving Medication Use
  • Pillboxes
    • Help with organizing your medications
    • Make complicated regimens less frustrating
  • Keep an updated medication list
    • Pharmacists and physicians can help you update any time you have your medications changed
  • Bring all of your bottles in to your physician, including OTCs and herbals
  • Ask questions – no thought too small!