Ask the Pharmacist: Drug & Health Information for the Consumer

By Richard P. Hoffmann

Useful Answers To Your Everyday Questions

This book contains useful and easy to understand answers to your questions about medications by one of America's most trusted professionals, the pharmacist. Dr. Hoffmann provides timely answers to commonly asked questions about a wide variety of medication and health-related topics including:

ADHD
Allergies & Hayfever
Alzheimer's
Anemia
Angina & Heart Problems
Arthritis
Breastfeeding
Colds & Flu
Constipation
Crohn's Disease
Depression
Diabetes
Drug Interactions
Drugs & Pregnancy
Eczema
Erectile Dysfunction
Facial Hair
Fibromyalgia
Hair Loss
Heartburn & GERD
Herbals
Hypertension
Infections
Insomnia
Irritable Bowel Syndrome (IBS)
Lowering Cholesterol
Menopause
Menstrual Cramps
Migraines
Motion Sickness
Osteoporosis
Overactive Bladder
Parkinson's Disease
Probiotics
Prostate Problems
Restless Leg Syndrome
Rosacea
Skin Problems
Smoking Cessation
Vertigo
Weight Loss
And Many Other Topics

• Language: English
• Publisher: iUniverse
• Release date: Sep 18, 2012
• ISBN: 9781475948400

Richard P. Hoffmann

Richard P. Hoffmann, RPh, PharmD has over 40 years of pharmacy and medical writing experience. He is the recipient of numerous professional awards and has written several hundred scientific publications, including a book on adverse drug reactions and medication errors. Dr. Hoffmann lives in Florida with his wife, Meg.

Book preview

Contents

Preface

Acknowledgments

Chapter 1 - Proper Medication Use

Chapter 2 - Cardiovascular Problems

Chapter 3 - Men’s Concerns

Chapter 4 - Herbal Medications & Nutritional Supplements

Chapter 5 - Gastrointestinal Problems

Chapter 6 - Mom And The Kids

Chapter 7 - Skin Care

Chapter 8 - Diabetes

Chapter 9 - Infections

Chapter 10 - Allergies

Chapter 11 - Weight Control

Chapter 12 - Arthritis And Pain

Chapter 13 - Parkinson’s Disease

Chapter 14 - Other Medical Problems

Chapter 15 - Tips And Tidbits

About the Author

To Mom and Dad,

who were proud that I became a pharmacist.

Preface

This book is a collection of previously published Ask The Pharmacist newspaper columns. It contains useful and easy to understand answers to questions about medications and is written by one of America’s most trusted healthcare professionals, the pharmacist. Dr. Hoffmann provides answers to commonly asked questions about a variety of medication and health topics. This information is needed more than ever before due to rapidly growing advances in drug research and medical technology, along with the explosion of direct-to-consumer advertising. Add to this the faster approval of new drugs by the Food and Drug Administration and switches from prescription to over-the-counter medication availability, and the complexity of drug use increases. Approximately 70% of consumers say that currently available healthcare information is overwhelming and confusing. This confusion is only part of the overall problem of medication use in America, where adverse effects from drugs are now a leading cause of death. Ask The Pharmacist provides information to assist consumers in making informed decisions about their medication needs.

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Acknowledgments

This book and my weekly Ask The Pharmacist newspaper column would not have been possible without the loving support, encouragement, and assistance of my wife, Meg. She truly complements my life in every way possible.

I would also like to thank the Citrus County Chronicle for giving me the opportunity to create a column and share my ideas and information as part of their newspaper and Chronicle Online web site for the past 16 years. Also, many thanks to all the readers who provided me with unending topics and questions to write about.

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CHAPTER 1 

PROPER MEDICATION USE

PRESCRIPTION ABBREVIATIONS

QUESTION: What do all the abbreviations on my prescriptions mean?

ANSWER: Most of the abbreviations or shorthand used in writing prescriptions come from Latin phrases. I have listed below and on the following pages some of the more commonly used abbreviations, the Latin phrase or word the abbreviation represents on the line below it, followed by its meaning.

Abbreviation

Latin Phrase or Word; Meaning

• ac

Ante cibum; Before meals

• ad

Aurio dextra; Right ear

• am

Ante meridiem; Morning

• as

Aurio sinister; Left ear

• au

Aures ultrae; Each ear

• bid

Bis in dies; Twice daily

• c

Cum; With

• d

Dies; Day

• disp

Dispensa; Dispense

• gtt

Gutta; A drop

• h

Hora; Hour

• hs

Hora somni; At bedtime

• od

Oculus dexter; Right eye

• os

Oculus sinister; Left eye

• ou

Oculo uterque; Each eye

• pc

Post cibos; After meals

• pm

Post meridiem; Afternoon or evening

• po

Per os; By mouth

• prn

Pro re nata; As needed

• qh

Quiaque hora; Every hour

• qid

Quater in die; Four times daily

• qs

Quantum sufficiat; A sufficient quantity

• RX

Recipe; Take, a recipe

• s

Sine; Without

• sig

Signa; Label

• ss

Semis; One-half

• stat

Statim; Immediately

• supp

Suppositorium; Suppository

• syr

Syrupus; Syrup

• tab

Tabella; Tablet

• tid

Ter in die; Three times daily

• ung

Unguentum; Ointment

• ud or ut dict

Ut dictum; As directed

INFORMATION YOU NEED

QUESTION: What information should I have about the medications that I take?

ANSWER: Every patient or their caretaker should have some basic information about any medication (prescription or nonprescription) that they take. Your doctor or pharmacist should provide you with this information and if they don’t, you should make sure that you ask them to. In general, you should know the following facts about your medications:

1. The name of the medication (trade name and/or generic name) and what it is supposed to do. If you see more than one doctor, you should always inform each doctor of all the medications that you take—prescription or not.

2. When and how to take it. For instance, should you take it before meals, with meals, or on an empty stomach? What times of the day or night should you take it? Does three times a day mean every 8 hours? What does as needed or as directed mean? Do you need to shake it prior to use, etc.?

3. How long you can expect to take the medication. Is it short-term or long-term therapy?

4. Can anything in the medicine cause an allergic reaction? Some medicines contain multiple ingredients that can produce an allergic reaction. Keep your doctor and pharmacist informed about any medication allergies that you may have.

5. Should you avoid alcohol, certain foods, or any other medications while on this medicine? Many drugs can interact with foods, other drugs, and alcohol causing a harmful effect.

6. Side effects that can be expected. All medications can cause side effects, but many are not serious or common. Your pharmacist and doctor can help you anticipate and understand these side effects and help you deal with them. You should report any suspected side effects to your doctor or pharmacist.

7. Is a generic version of the drug available? If there is an appropriate generic drug available, it can save you a lot of money.

8. What to do if you miss a dose. Don’t panic and take a double dose. Ask your pharmacist or doctor what to do ahead of time.

9. Pregnant women and women of child bearing age should also know whether it is safe to take the medication while pregnant or when breast feeding. Some drugs can cause birth defects and some pass into breast milk affecting the baby.

10. How the medicine should be stored. Many drugs lose their effectiveness if stored incorrectly. The medicine cabinet in the bathroom is not a good place for storage because of the moisture and heat. Remember, when in doubt about any of this information, ask your pharmacist or doctor.

GENERAL GUIDELINES

FOR MEDICATION USE

QUESTION: I often have questions about or problems with taking my medication. What general guidelines can you give me about taking medicine?

ANSWER: Here are some general recommendations to consider when taking medication:

General Principles

• Learn the names of all medications you are taking and the dosage strengths. Know why you are taking them, i.e., high blood pressure, heart, water, etc. Carry a list of your medications in your wallet for quick reference.

• If you are allergic to any medications, learn their names and carry a medic-alert card.

• Take only the medications that have been prescribed for you. Take medications only at the times ordered and in the amount ordered. Two pills are not necessarily better than one and, in fact, can be dangerous. Only stop taking your medication on your doctor’s advice or if you think you are having an allergic reaction.

• Any medication may produce an allergic or unexpected reaction, even if you have no known allergies. Contact your doctor or pharmacist to explain unusual signs or symptoms such as rash, fever, bruising, vomiting, and diarrhea.

• Keep all medications in a secure place out of reach of children.

• Do not take medication that is more than several months old without checking with your pharmacist to see if it is still safe and effective to take. Outdated medication may be ineffective and/or even harmful.

Instructions For Taking

• Always take medication exactly as ordered by your doctor. The directions are usually based on how long the drug stays in the body and the special effects of the drug.

• Be sure you understand fully the directions on the label (four times daily may mean every 6 hours around the clock or four times during the waking hours). Ask your doctor or pharmacist to clarify any questions.

• If the label reads Take with meals, this is usually done to lessen the chance of any stomach upset the medication may cause. Before or after meals directions are ordered because food may decrease the action of some drugs. The drug should be taken about one half hour before or 1-2 hours after meals. Milk may alter some medications, but water is almost always okay. Take your medication with water unless otherwise advised by your doctor.

• If an extended-release tablet is prescribed, do not break, crush, or chew it before swallowing.

Side Effects

• All drugs can cause unwanted side effects. This may include dizziness, drowsiness, dry mouth, diarrhea, constipation, headache, blurred vision, rashes, etc. In some cases, the side effect is short term and will not require medical attention. If any side effect appears, it is a good idea to ask your physician or pharmacist about it. They will be able to tell you if it is serious or will pass as your body adjusts to the drug. Some drugs are known to cause drowsiness and you should avoid driving a car or operating machinery while taking them.

Drug Interactions

• Before drinking any alcoholic beverages, it’s a good idea to check with your pharmacist. Present him/her with a list of medications you are on and he will tell you if there will be any problems. Alcohol and certain drugs can have very dangerous reactions.

• When adding a new drug to your regimen, check with the pharmacist to see if there may be side effects with your current medication.

Storage

• All medications should be stored in a cool, dry place away from direct sunlight. Care should be taken to be sure there is no easy access of medications by children. Open medication bottles should not be within reach of children.

DRUG USE IN THE ELDERLY

QUESTION: How does aging affect medication use and are there drugs that should be used with caution in the elderly?

ANSWER: The normal aging process is associated with many changes in the body, which can affect how drugs work. To begin with, body fat increases while total body water and proteins in the blood decrease with age. This change can affect how drugs are distributed in the body. Fat-soluble drugs will have increased effects, but water-soluble will have reduced effects. Age-related changes in liver and kidney function can affect the activity of drugs taken by the elderly. Although there are many differences in individuals, both liver and kidney function decrease as we age. Because of this there is a reduced ability to metabolize (detoxify) and get rid of (excrete) medications that are taken. This can lead to an increase in drug activity and side effects. Gastrointestinal changes that occur with aging may also affect how drugs are absorbed into the body and cardiovascular changes can alter the response to some drugs. Furthermore, the elderly have an increased sensitivity to drugs that affect the central nervous system and therefore dosage reductions are needed for these medications. In addition, age-related hormonal changes and immune function can affect the action of drugs. Finally, the control of bowel and bladder function decreases with age and numerous drugs can affect these physiologic activities.

Because of these age-related changes in body functions, many drugs must be used with caution or in decreased doses to prevent side effects and other problems. In general, the use of sedative-hypnotic drugs, antibiotics, cardiac drugs, antidepressants and antipsychotics, and anticoagulants are of special concern for older individuals.

I have listed some specific oral drugs that can cause problems in the elderly population. Please note that this is not a complete listing and you need to check with your doctor and pharmacist if you have any questions regarding the medication that is prescribed for you or your loved one.

Some Drugs Of Concern In The Elderly

Drug (Some Trade Names) or Drug Class

What Drug Is Used For

Notes

• Amitriptyline (Elavil)

Depression

Many side effects including sedation

• Antihistamines

Colds, etc.

Non-sedating OK, others cause many side effects

• Barbiturates

Sedative

Many side effects

• Chlordiazepoxide (Librium, Libritabs)

Sedative

Oversedation

• Chlorpropamide (Diabenese)

Diabetes

Long-action can cause side effects

• Diazepam (Valium)

Sedative, muscle relaxant

Oversedation

• Digoxin (Lanoxin)

Heart problems

May need to reduce dose

• Dipyridamole (Persantine)

Antiplatelet agent

Can reduce blood pressure in elderly

• Disopyramide (Norpace)

Abnormal heart rhythm

Many side effects

• Doxepin (Sinequan)

Anxiety, depression

Many side effects including sedation

• Flurazepam (Dalmane)

Sleep aide

Oversedation

• Indomethacin (Indocin)

Pain, inflammation

Central nervous system side effects

• Iron supplements (over 325 mg/day

Anemia

Constipation

• Meperidine (Demerol)

Pain

Other drugs more effective, neurotoxicity

• Meprobamate (Equanil, Meprospan, Miltown)

Sedative

Oversedation, addicting

• Methydopa (Aldomet)

High blood pressure

Can slow heart rate and cause depression

• Metoclopramide (Reglan)

Gastrointestinal disorders

May cause movement disorders

• Muscle relaxants & antispasmotics

Many side effects in elderly

• Pentazocine (Talwin NX, Talacen)

Pain

Central nervous system side effects

• Propoxyphene (Darvon, Darvon N, Darvocet)

Pain

Use acetaminophen (Tylenol) instead

• Reserpine

High blood pressure

Many side effects

• Ticlopidine (Ticlid)

Antiplatelet agent

More side effects than aspirin

• Trimethobenzamide (Tigan, T-Gen, Trimazide)

Nausea & Vomiting

Many side effects

QUESTION: What prescription medications can be inappropriate for people over 65?

ANSWER: Numerous prescription medications are more dangerous in people over 65 because they have side effects like memory impairment, dizziness, blurred vision, or other effects. Many of these medications should be avoided unless no other options exist. A recent Johns Hopkins Health Alert (www.johnshopkinshealthalert.com, 2009) reviewed this topic and provided the following list of potentially dangerous medications in people over the age of 65. If you are over 65 and are taking a medication on this list, please discuss this issue with your doctor to see if any other alternative medication can be used.

Inappropriate Medications

Barbiturates (amobarbital, butabarbital, pentobarbital, phenobarbital, secobarbital)

Flurazepam (Dalmane, Somnol, Novo-Flupam, Apo-Flurazepam)

Meprobamate (Equanil, Meprospan 200, Meprospan 400, Probate, ApoMeprobamate)

Chlorpropamide (Diabinese, Novo-Propamide, Apo-Chlorpropamide)

Meperidine (Demerol)

Pentazocine (Talwin, Talwin Nx)

Trimethobenzamide (Benzacot, Stemetic, Tebamide, Tigan, Tribenzagan, Trimazide)

Dicyclomine (Bentyl, Bentylol, Spas—moban, Formulex)

Hyoscyamine (Anaspaz, A-Spas-S/L, Cystospaz, Levbid, Levsin, Levsinex Timecaps, Symax SL)

Propantheline (Pro-Banthine)

Belladonna alkaloids/phenobarbital (Barbidonna, Donnatal)

Rarely Appropriate Medications

Chlordiazepoxide (Librium)

Diazepam (Valium)

Propoxyphene (Darvon, Darvon-N)

Carisoprodol (Soma)

Chlorzoxazone (Remular-S, Paraflex, Parafon Forte DSC)

Cyclobenzaprine (Flexeril)

Metaxalone (Skelaxin)

Methocarbamol (Robaxin)

Sometimes Appropriate Medications

Amitriptyline (Elavil)

Doxepin (Sinequan)

Indomethacin (Indocin)

Dipyridamole (Persantine)

Ticlopidine (Ticlid)

Methyldopa (Aldomet)

Reserpine (Serpasil, Serpalan, Novoreserpine)

Disopyramide (Norpace, Norpace CR)

Oxybutynin (Ditropan, Ditropan XL)

Chlorpheniramine (Aller-Chlor, Chlorate, ChloAmine, ChlorTrimeton)

Cyproheptadine (Periactin)

Diphenhydramine (Benadryl)

Hydroxyzine (Atarax, Rezine, Vistaril)

Promethazine (Phenergan)

QUESTION: I have poor vision and memory. What can I do to avoid mistakes with my medications?

ANSWER: Medication errors are a big problem with some 1.5 million preventable adverse drug events occurring in the United States every year. A recent Johns Hopkins Health Alert (www.johnshopkinshealthalerts.com, 2009) provides some useful information for people with poor vision or memory that can help prevent medication mistakes. I have outlined these tips for you:

If You Have Vision Loss

• Use a medication organizer or dosette to keep track of your pills, and put larger-type labels on each compartment so that you can read the days of the week and the times of day. Ask a family member or friend to fill the medication organizer for you each week.

• Keep a magnifier handy with your pills.

• Ask your pharmacist to use different-size bottles when dispensing similarly shaped pills. Or ask about talking pill bottles. They play a recorded message telling you the name of the medication and your prescription information.

If You Have Memory Loss

• Try wrapping rubber bands around each pill bottle equaling the number of daily doses. Remove one band each time you take the medication, and then replace all of the bands for the following day.

• Keep a medication chart in order to record whether you have taken your pills. This can be a simple dry-erase board on the refrigerator door; put a check next to each medication after you take it.

• Use an alarm on your watch or cell phone to remind you when it’s time to take your medication. Some fancier versions of dosettes come with built-in alarms. There are even automated medication dispensers that announce when it’s time to take your medication, and then dole out the appropriate pill.

QUESTION: Can some medications increase your risk of falls?

ANSWER: Yes, in fact researchers at the University of North Carolina at Chapel Hill have recently put together a list of prescription drugs that may increase the risk of falling for people aged 65 and older. Falls are the leading cause of both fatal and non-fatal injuries for adults 65 and older. The prescription drugs on this list represent many different categories (i.e., antidepressants, seizure medications, pain relievers, sedatives, sleep medication, etc.) but they all work by depressing the central nervous system, which can make patients less alert and slower to react. It is recommended that if patients see a drug that they are taking on the list, they should not stop taking it, but the next time they see their doctor they should talk about the risk of falling and possible alternative medications. In addition, some nonprescription allergy medications, sleep aids, and cough/cold remedies that can cause drowsiness can put you at increased risk of falling, so be sure to read the labeling carefully.

Prescription Medications That Can Increase

The Risk Of Falls In People Age 65 & Older

Generic Name (Brand Name)

Alprazolam (Xanax)

Amitriptyline (Elavil)

Amobarbital (Amytal)

Amoxapine (Asendin)

Aripiprazole (Abilify)

Baclofen (Lioresal)

Bupropion (Wellbutrin, Wellbutrin SR)

Buspirone (Buspar)

Butabarbital

Carbamazepine (Tegretol, Tegretol XR, Carbatrol)

Chloral hydrate

Chlorazepate (Tranxene)

Chlordiazepoxide (Librium, Limbitrol, Librax)

Chlorpromazine (Thorazine)

Citalopram (Celexa)

Clidinium-chlordiazepoxide (Librax)

Clomipramine (Anafranil)

Clonazepam (Klonopin)

Clozapine (Clozaril)

Codeine (Tylenol with Codeine)

Desipramine (Norpramin)

Diazepam (Valium)

Digoxin (Lanoxin)

Disopyramide (Norpace)

Divalproex sodium (Depakote, Depakote ER)

Doxepin (Sinequan, Zonalon, Prudoxin)

Duloxetine (Cymbalta)

Escitalopram (Lexapro)

Estazolam (Prosom)

Ethosuximide (Zarontin)

Felbamate (Felbatol)

Fentanyl (Duragesic)

Fluoxetine (Prozac)

Fluphenazine (Permitil, Prolixin)

Flurazepam (Dalmane)

Fluvoxamine (Luvox)

Gabapentin (Neurontin)

Halazepam (Paxipam)

Haloperidol (Haldol)

Hydrocodone (Vicodin)

Hydromorphone (Dilaudid)

Imipramine (Tofranil)

Isocarboxazid (Marplan)

Levetiracetam (Keppra)

Levorphanol (Levo-Dromoran)

Lorazepam (Ativan)

Loxapine (Loxitane, Loxitane C)

Maprotiline (Ludiomil)

Mephobarbital

Meprobamate (Miltown, Equanil)

Mesoridazine (Serentil)

Methadone (Dolophine)

Methsuximide (Celontin)

Mirtazapine (Remeron)

Molindone (Moban)

Morphine (MS Contin)

Nefazodone (Serzone)

Olanzapine (Zyprexa, Zyprexa Zydis)

Oxazepam (Serax)

Oxcarbazepine (Trileptal)

Oxycodone (Percocet)

Oxymorphone (Numorphan)

Paraldehyde (Paral)

Paroxetine (Paxil)

Pentobarbital (Nembutal)

Perphenazine (Trilafon)

Phenelzine (Nardil)

Phenobarbital

Phenytoin (Dilantin)

Pimozide (Orap)

Pregabalin (Lyrica)

Primidone (Mysoline)

Propoxyphene (Darvon, Darvocet)

Protriptyline (Vivactil)

Quazepam (Doral)

Quetiapine (Seroquel)

Risperidone (Risperdal)

Secobarbital (Seconal)

Sertraline (Zoloft)

Temazepam (Restoril)

Thioridazine (Mellaril)

Thiothixene (Navane)

Tiagabine (Gabatril)

Topiramate (Topamax)

Tranylcypromine (Parnate)

Trazodone (Desyrel)

Triazolam (Halcion)

Trifluoroperazine (Stelazine)

Trimipramine (Surmontil)

Venlafaxine (Effexor, Effexor XR)

Ziprasidone (Geodon)

Zolpidem (Ambien)

Zonisamide (Zonegran)

USE CAUTION WITH GRAPEFRUIT

QUESTION: I am a Floridian and love grapefruit and grapefruit juice. Is it true that grapefruit can interact with some medications?

ANSWER: Yes. Although much more study and research is needed, we now know that grapefruit juice (or whole grapefruits) can interfere with a number of medications. This may be of even greater concern for people who take many of their medications at breakfast time, while enjoying grapefruit. It appears that some of the substances found in grapefruits (maybe bioflavonoids) interfere with an important enzyme in the intestinal tract, which allows more of certain medications to be absorbed. Because of this, it is like taking a much higher dose of the drug, which can cause toxic side effects. For example, antihypertensive drugs may lower blood pressure too much, which can lead to an increased heart rate, flushing, and headache. Some studies indicate that this grapefruit effect can last for up to as long as 24 hours. A solution to this problem would be to avoid grapefruit or grapefruit juice while taking medications. Orange juice does not appear to cause the same problem and is a good alternative juice. Allowing at least 6 to 8 hours separation between taking medication and grapefruit may also lessen the possibility of a significant interaction. Changing medication may be another solution for diehard grapefruit fans. I have listed many of the drugs that can potentially interact with grapefruits or grapefruit juice. Please note, however, that not all drugs have been studied for this potential problem and much more information is needed.

Potential Drug Interactions With Grapefruit

Type of Drug or Use

Generic Name (Example Trade Names(s))

• AIDS treatment

Indinavir (Crixivan)

Saquinavir (Fortovase, Invirase)

• Anticoagulant

Warfarin (Coumadin)

• Anticonvulsant

Carbamazepine (Tegretol)

• Antihistamines

Fexofenodine (Allegra)

Loratadine (Claritin)

• Anxiety

Buspirone (BuSpar)

• Blood pressure or heart medication

Felodipine (Plendil)

Nifedipine (Adalat, Procardia

Nisoldipine (Sular)

Verapamil (Calan, Isopin, Verelan)

Amlodipine (Norvasc)

Nimodipine (Nimotop)

Propafenone (Rythmol)

Nitrendipine (Baypress)

• Caffeine

Many products

• Cholesterol-lowering agents

Lovastatin (Mevacor, Altoprev)

Simvastatin (Zocor)

Atorvastatin (Lipitor)

• Estrogens

Estradiol (Estinyl, Estrace)

• Heartburn

Cisapride (Propulsid)

• Impotence

Sildenafil (Viagra)

• Leg cramping

Cilostazol (Pletal)

• Organ transplant drug

Cyclosporine (Sandimmune, Neoral)

Sirolimus (Rapamune)

Tacrolimus (Prograf)

• Sedative/hypnotic

Triazolam (Halcion)

Alprazolam (Xanax)

Midazolam oral (Versed)

QUESTION: Where can I find information about what prescription drugs can interact with grapefruit juice?

ANSWER: I often get questions about drug interactions with grapefruit juice, especially from Florida residents. Grapefruit juice contains a natural substance that can affect the way certain prescription medications are broken down (metabolized) by the body. This substance blocks an enzyme known as CYP3A4 in the intestinal tract that helps the body get rid of certain drugs. By blocking this enzyme, grapefruit juice allows more of the drug to enter the bloodstream, which can lead to adverse effects in some situations. However, most prescription drugs do not interact with grapefruit juice and most studies suggest that it is safe to consume grapefruit juice while taking nonprescription medication. To help consumers and healthcare professionals find information about drug interactions with grapefruit juice, a new Internet web site was recently established by the University of Florida and Tufts University. This site lists drugs by category, compound name, and brand name that may interact with grapefruit juice. The web site is www.druginteractioncenter.org. For those of you who do not have Internet access, I have listed below drugs by trade name and generic name that may have a strong or moderate interaction capability with grapefruit juice. Please note that not all trade names or combination products may be listed and that you should always consult with your doctor and pharmacist if you have any questions or concerns about your medication and its use with grapefruit juice.

Strong Interaction

Altocor (Lovastatin)

Altoprev (Lovastatin)

BuSpar (Buspirone)

Diastat (Diazepam)

Dizac (Diazepam)

Halfan (Halofantrine)

Mevacor (Lovastatin)

Valium (Diazepam)

Zocor (Simvastatin)

Moderate Interaction

44 Magnum (Caffeine)

357 HR Magnum (Caffeine)

Activella Tablets (17 Beta-Estradiol)

Adalat (Nifedipine)

Adalat CC (Nifedipine)

Afeditab CR (Nifedipine)

Agenerase (Amprenavir)

Alertness Al (Caffeine)

Allegra (Fexofenadine)

Alprazolam Intensol (Alprazolam)

AmVaz (Amlodipine)

Babee Cof (Dextromethorphan)

Benylin Adult Formula (Dextromethorphan)

Benylin Pediatric (Dextromethorphan)

Biaxin (Clarithromycin)

Biaxin XL (Clarithromycin)

Biltricide (Praziquantel)

Cafcit (Caffeine)

Caffedrine (Caffeine)

Calan (Verapamil)

Calan SR (Verapamil)

Cardizem (Diltiazem)

Cardizem CD (Diltiazem)

Cardizem IV (Diltiazem)

Cardizem LA (Diltiazem)

Cardizem SR (Diltiazem)

Cartia XT (Diltiazem)

Children’s ElixSure Cough (Dextromethorphan)

Clarinex (Desloratadine)

Clarinex RediTabs (Desloratadine)

Clozaril (Clozapine)

Coumadin (Warfarin)

Covera-HS (Verapamil)

Cozaar (Losartan)

Creo-Terpin (Dextromethorphan)

Crestor (Rosuvastatin)

Crixivan (Indinavir)

Delsym (Dextromethorphan)

DexAlone (Dextromethorphan)

Di-Phen (Phenytoin)

iabetuss (Dextromethorphan)

Digitek (Digoxin)

Digoxin Elixir (Digoxin)

Dilacor XR (Diltiazem)

Dilantin (Phenytoin)

Dilt-CD (Diltiazem)

Dilt-CD Extended Release Capsules (Diltiazem)

Diltia XT (Diltiazem)

E-Mycin (Erythromycin)

EES (Erythromycin)

Elixophyllin (Theophylline)

Enerjets (Caffeine)

Ery-Tab (Erythromycin)

ERYC (Erythromycin)

EryPed (Erythromycin)

Erythrocin (Erythromycin)

Estinyl (Ethinylestradiol)

Estrace (17 Beta-Estradiol)

Estradiol Tablets (17 Beta-Estradiol)

Etopophos (Etoposide)

Fastlene (Caffeine)

Fazaclo (Clozapine)

Fortovase (Saquinavir)

Gengraf (Cyclosporine)

Gynodiol (17 Beta-Estradiol)

Halcion (Triazolam)

Haloperidol Tablets (Haloperidol)

Hold DM (Dextromethorphan)

Honey Tussin Cough (Dextromethorphan)

Ilosone (Erythromycin)

Innofem (17 Beta-Estradiol)

Invirase (Saquinavir)

Isoptin (Verapamil)

Isoptin SR (Verapamil)

Jantoven (Warfarin)

Keep Alert (Caffeine)

Keep Going (Caffeine)

Ketek Pak (Telithromycin)

Ketek (Telithromycin)

Lanoxicaps (Digoxin)

Lanoxin (Digoxin)

Lescol (Fluvastatin)

Lescol XL (Fluvastatin)

Little Colds Cough Formula (Dextromethorphan)

Lucidex (Caffeine)

Luvox (Fluvoxamine)

Maximum Strength Stay Awake (Caffeine)

Medrol (Methylprednisolone)

Menostar (Ethinylestradiol)

Methylprednisolone Tablets (Methylprednisolone)

Methylpred (Methylprednisolone)

Midazolam Syrup (Midazolam)

Molie (Caffeine)

My-E (Erythromycin)

Neoral (Cyclosporine)

Nifediac CC (Nifedipine)

Nifedical XL (Nifedipine)

Nimotop (Nimodipine)

NoDoz (Caffeine)

NoDoz Maximum Strength (Caffeine)

Norvasc (Amlodipine)

Overtime (Caffeine)

PCE Dispertab (Erythromycin)

Phenytek (Phenytoin)

Pletal (Cilostazol)

Pravachol (Pravastatin)

Prefest Tablets (17 Beta-Estradiol)

Prilosec OTC (Omeprazole)

Prilosec (Omeprazole)

Procardia XL (Nifedipine)

Procardia (Nifedipine)

Quibron T (Theophylline)

Quibron T/SR (Theophylline)

Quick Pep (Caffeine)

Quin-Tab (Quinine)

Quinadure (Quinine)

Quinaglute (Quinine)

Quinidex (Quinine)

Quinine Capsules (Quinidine)

Quinine Tablets (Quinidine)

Quinora (Quinine)

Respbid (Theophylline)

Revatio (Sildenafil Citrate)

Revive (Caffeine)

Robitussin Cough Calmers (Dextromethorphan)

Robitussin Honey Cough (Dextromethorphan)

Robitussin Maximum Strength Cough (Dextromethorphan)

Robitussin Pediatric Cough (Dextromethorphan)

Sandimmune (Cyclosporine)

SangCya (Cyclosporine)

Scopace (Scopolamine)

Scopolamine Tablets (Scopolamine)

Scot-Tussin Diabetic (Dextromethorphan)

Scot-Tussin DM Cough Chasers (Dextromethorphan)

Silphen DM (Dextromethorphan)

Simply Cough (Dextromethorphan)

Slo-bid (Theophylline)

Slo-Phyllin (Theophylline)

Snap Back (Caffeine)

Sporanox (Itraconazole)

Stay Alert (Caffeine)

Sucrets Cough Control Formula (Dextromethorphan)

T-Phyl (Theophylline)

Taztia XT (Diltiazem)

Theo-24 (Theophylline)

Theo-Bid Duracap (Theophylline)

Theo-Dur (Theophylline)

Theo-Dur Sprinkle (Theophylline)

Theo-X (Theophylline)

TheoCap (Theophylline)

Theochron (Theophylline)

Theolair (Theophylline)

Theolair SR (Theophylline)

Theovent LA (Theophylline)

Tiamate (Diltiazem)

Tiazac (Diltiazem)

Toposar (Etoposide)

Truxophyllin (Theophylline)

Tussin Honey Cough Syrup (Dextromethorphan)

Ultra Pep-Back (Caffeine)

Uni-Dur (Theophylline)

Uniphyl (Theophylline)

Valentine (Caffeine)

VePesid (Etoposide)

Verelan (Verapamil)

Verelan PM (Verapamil)

Versed (Midazolam)

Verv (Caffeine)

Viagra (Sildenafil citrate)

Vicks 44 Cough Medicine (Dextromethorphan)

Vicks 44 Cough Relief (Dextromethorphan)

Vivarin (Caffeine)

Wakespan (Caffeine)

Waykup (Caffeine)

Xanax XR (Alprazolam)

Xanax (Alprazolam)

Zegerid (Omeprazole)

Zoloft (Sertraline)

ASPIRIN INTERACTIONS

QUESTION: What drugs can interact with aspirin?

ANSWER: A number of potential drug interactions can occur when aspirin is used in combination with other medications. Acetaminophen (Tylenol) is usually recommended instead of aspirin in these situations. I have summarized some of these interactions for you:

Drug or Drug Class

Some Example Products

Potential Problem

• ACE inhibitors

Capoten (Captopril), Altace, Monopril, Prinivil or Zestril (lisinopril), Vasotec (enalapril), Accupril, Aceon

Worsening of high blood pressure or congestive heart failure.

• Anticoagulants

Coumadin (warfarin)

Risk of bleeding.

• Ginkgo

Various herbal products

Increased bleeding tendency.

• Ibuprofen

Motrin, Advil

Interference with anticoagulant effect of aspirin.

• Methotrexate in high doses

Methotrexate

Risk of methotrexate toxicity.

• Sulfonylureas for diabetes

Diabenese (chlorpropamide), Tolinase (tolazamide), Orinase (tolbutamide), Glucotrol (glipizide), Amaryl, Diabeta, Micronase, Glynase, Glyburide

Low blood sugar.

• Uricosurics for gout

Probenecid, Anturane (sulfinpyrazone)

Worsening of gout.

• Valproic acid for seizures

Depakote (valproic acid)

Increased side effects such as drowsiness or behavioral problems.

USING NASAL PRODUCTS

QUESTION: What is the best way to use nasal sprays or nasal inhalers?

ANSWER: If your nasal spray or inhaler is not used correctly, not only will you decrease its effectiveness, but you will also waste a lot of money. The proper way to use both of these products is as follows:

• Blow your nose gently to clear your nostrils.

• Clean the outer portion of your nose with a damp tissue.

• Wash your hands with soap and warm water and dry them.

• Shake the medication container. If you think a nasal inhaler might be empty, test it by removing the metal canister and placing it in a container of water. If the canister floats, it is empty. Call your pharmacist to get a refill. Reassemble the inhaler if the canister sinks; it is not empty.

• Keep your head upright. Press a finger against the side of your nose to close one nostril. With your mouth closed, insert the tip of the pump, spray, or inhaler into the open nostril. Sniff in through the nostril while quickly and firmly squeezing the spray container or activating the pump or inhaler.

• Hold your breath for a few seconds and then breathe out through your mouth.

• Repeat this procedure for the other nostril only if directed to do so.

• Rinse the spray, pump, or inhaler tip with hot water and replace the cap on the container.

• Wash your hands.

QUESTION: What is the best way to use nose drops?

ANSWER: It can be difficult giving yourself nose drops. If possible, have someone else administer the drops as follows:

• Have the patient blow his or her nose gently to clear the nostrils. Use a bulb syringe to gently clear the nostrils of an infant.

• Clean the outer portion of the nose with a damp tissue.

• Wash your hands with soap and warm water and dry them.

• Lie down (or have the patient lie on his or her back) on a bed with the head tilted back and the neck supported (allow the head to hang over the edge of the bed or place a small pillow under the neck and shoulders). Cradle an infant in your arms with the head tilted back.

• Shake the nose drops container.

• Insert the dropper tip into the nostril about 1/3 inch, and place the prescribed dose or number of drops in the nostril. Try not to touch the nose with the dropper tip.

• Stay (or have the patient stay) in the same position for at least five minutes.

• Unless otherwise directed, repeat these steps for the other nostril.

• Rinse the dropper tip with hot water and replace the cap on the container.

• Wash your hands.

USING EYE DROPS

QUESTION: What is the proper way to use eye drops?

ANSWER: Almost everyone uses eye drops at one time or another. Eye drops are used to treat eye infections, to soothe dry or irritated eyes, to treat allergies, or to treat other conditions such as glaucoma. When eye drops are not used properly the full benefit of the medication may not be realized and there may be spillage and waste if the drop does not fall directly onto the eye. In order to use eye drops correctly you should follow these steps:

• Always wash your hands first before administering eye drops.

• Shake the bottle if indicated on the label. If the bottle has been refrigerated, warm it between your hands to room temperature.

• Gently clean the eyelids if they are crusty with discharge by wiping the lid from the inner corner to the outer corner with the eye closed, using a cotton ball dampened with warm water.

• Tilt back the head, or lie down, and look upward. Using the thumb and index finger, gently pinch and pull the lower eyelid downward to form a pocket.

• Place the eye drop or drops into the pouch formed in the lower lid, not directly into the eye. If an eye ointment is used, place a ¼ inch line of ointment into the lower lid pouch. Be careful that the dropper or ointment tube does not touch the eye.

• Close your eye gently for 1 to 3 minutes or as instructed by the doctor to allow the medication to be absorbed. Some doctors recommend pressing the finger against the inner corner of the eye to keep the medication from going into the tear duct.

• If another drop of eye medication is needed, wait at least 5 to 10 minutes before administering the second eye drop so the first drop will not be washed out of the eye. The small pouch formed by the lower lid will only hold one drop at a time, and extra drops will either flow into the tear duct (and out of the eye) or down the face.

• Always recap the bottle or tube immediately after use. Never wipe or rinse the tip of the dropper to avoid contamination.

• Never wear contact lenses while using eye drops or ointments unless instructed to do so by your doctor.

• If you are told to use an eye drop and an eye ointment at the same time, use the eye drop first, wait a few minutes, and then use the ointment.

• Most eye drops should not be used longer than one month after the bottle is opened, unless otherwise stated on the label.

USING METERED DOSE INHALERS

QUESTION: I currently use both Proventil and Vanceril inhalers to treat my asthma. What is the best way to use these medications?

ANSWER: Proventil or albuterol (al-byoo-ter-ole) is a drug that expands the breathing tubes and is known as a bronchodilator. Vanceril or beclomethasone (beck-loe-meth-a-sone) on the other hand is an anti-inflammatory drug and is known as a corticosteroids. They are commonly used together to treat symptoms of difficult breathing in patients with chronic asthma. Asthma is considered to be an inflammatory disease that involves the airways and proper treatment will prevent asthma attacks and possible death. Inhalers (also called metered dose inhalers) provide an effective way to deliver medications directly to the airways where they can work.

The best way to use your inhaler is to use the bronchodilator (Proventil) first, wait a minute, and then use your anti-inflammatory medication (Vanceril). This will allow your bronchodilator to dilate or expand your airways so that the anti-inflammatory drug can be transported deeper into the lungs. This will result in greater effectiveness of the medications and better control of symptoms. Some general guidelines for using a metered dose inhaler (MDI) are as follows:

• Shake the inhaler first. If you think the inhaler may be empty, place the canister in a bowl of water. If the canister floats, it’s empty. If the canister sinks to the bottom of the bowl, it’s full. If the canister floats at an angle, it’s partially full and you should consider refilling the prescription as it starts to float closer to the surface of the water.

• After shaking, remove the mouthpiece cover, invert the canister so that the mouthpiece is in front of the mouth or between the lips above the tongue.

• Choose one of the following three acceptable methods for administering inhaler medication (choose the method that is easiest for you):

187299.jpg The preferred way is to place the MDI two finger widths in front of your open mouth.

187407.jpg A spacer can be attached to the inhaler and the mouthpiece of the spacer placed between the teeth.

187401.jpg The mouthpiece of the inhaler can be placed between the teeth, above the tongue, with the lips closed around the mouthpiece.

• Tip the head back slightly. Breathe out fully. Expel as much air as possible.

• Begin to breathe in. As you begin to take in a breath, press down on the canister and continue to breathe in the spray released by the metered dose inhaler. Close your mouth after the spray has been inhaled and count to ten.

• Exhale through your nose.

• If you are using an inhaler with a medication to dilate or open your airways when you are short of breath, use that medication first. Wait one minute and then use the inhaler with the steroid medication, using the same procedure. If you are using a spacer, the procedure is different and these instructions do not apply. The directions on the spacer device must be followed. At the end of your treatment, rinse your mouth and throat with water. Do not swallow the rinse water, spit it out. Also, rinse the mouthpiece of the MDI. Shake out the water and reassemble the inhalers.

• Check the quantity of medication remaining in your canisters before returning them to their storage place. Refill prescriptions as necessary so that you never run out of them.

• If you do not experience improved breathing after your inhaler treatment, contact your physician and your pharmacist.

STORAGE OF MEDICATIONS

QUESTION: What is the best way to store medications? How long are drugs good for?

ANSWER: Storing medications correctly is very important because many drugs will become ineffective if they are not stored properly. The bathroom medicine cabinet is not a good place to keep medicine because the room’s moisture and heat speed up the chemical breakdown of drugs. In addition, drugs should never be stored in a car’s glove compartment, as it can reach a very high temperature. Storing medication in the refrigerator is also not a good idea because of the moisture inside the unit. Some easily spoiled drugs do require refrigeration, but these should be labeled as needing to be kept in the refrigerator. Light and air can also affect drugs, but dark-tinted bottles and air-tight caps can keep these effects to a minimum. A closet is probably your best bet for storage of your medications. Pick a high shelf out of the reach of children, and be sure to use child-resistant safety caps if you have children, grandchildren or pets around.

Medications should not be used beyond their expiration date. Many medications become ineffective over time, but some drugs like tetracycline can actually become dangerous if used past their expiration date. Expiration dates, however, only apply to medicine that has been stored under good conditions. All medications should be stored in the original container and it is a good idea to throw away any medicine that has not been used in six months. Be especially sure to get rid of any solid medications that have a foul odor, have cracked coatings, or have changed color. All medications should be labeled with expiration dates, but if there is any doubt, ask your pharmacist.

DRUG DISPOSAL

QUESTION: Local authorities have advised me not to dispose of outdated or unused medications in the trash or down the toilet. The pharmacies I checked with won’t take them either. What should I do?

ANSWER: The proper disposal of outdated or unused prescription and nonprescription drugs is a concern all over the United States. When I did an Internet search on this topic, over 6 million web sites were identified. Flushing medications down the toilet may be associated with environmental damage. When medicines are flushed down a toilet, they usually go to one of two places—a septic tank or through a series of sanitary sewers into a wastewater treatment plant. In both of these situations, medicines can harm the beneficial bacteria that are responsible for breaking down waste. In addition, sewage treatment plants are not designed to remove medications and many drugs have been identified in lakes, rivers, and groundwater. In fact, in some cities researchers have reported lethargic fish swimming in water containing drugs that affect the nervous system and fish with both male and female sex organs in waterways that contain human hormones. Antibiotics are of particular concern and an increase in bacterial resistance to multiple antibiotics has been attributed to their increased release into the environment. In addition, some medications contain mercury compounds, which can pose a potential risk to humans and wildlife that consume fish from polluted waters. Issues regarding the disposal of medications in the trash include potential access of the drugs to children, pets, wildlife, and drug abusers. Furthermore, privacy may be a problem if prescription vials are thrown away with patient names on them. So what should the consumer do? There are no specific government guidelines for the disposal of drugs by consumers. Probably one of the most appropriate methods of medication disposal is via incineration, but this process is not readily available in many communities and a collection program could be difficult to set up. State and Federal rules may also interfere with drug disposal efforts. For example, the State Boards of Pharmacy, the Drug Enforcement Agency (DEA), the Department of Transportation (DOT), the Food and Drug Administration (FDA), and the Environmental Protection Agency (EPA), all have rules and regulations that may impact any disposal program. We need a national effort to develop an appropriate and practical drug disposal program in our country. In order to do this, all pertinent governmental agencies should be involved in the process along with pharmaceutical manufacturers, drug wholesalers, drug return companies, large pharmacy corporations, and national pharmaceutical organizations. Until this happens, there is no good answer to your question.

QUESTION: I got a flyer with my prescription for OxyContin about how to dispose of any unused medication. What is this all about?

ANSWER: About 6,300 pharmacies around the country have signed up for a 26—week pilot project with the Substance Abuse and Mental Health Services Administration (SAMHSA). The purpose of this pilot program is to provide practical advice to consumers on how to properly store and dispose of unused medications that have a high potential for abuse (e.g., oxycodone (OxyContin, etc.), hydrocodone (Vicodin, etc.), certain sleep aids, etc. When these drugs are dispensed at any of the participating pharmacies, consumers will receive an information sheet about how to dispose of any unused medication. This new program is important because prescription drug abuse is on the rise, and research suggests that more than half of people who misuse these drugs get them from a friend or relative. Hopefully, with this information consumers can play a major role in helping to eliminate prescription drug abuse, particularly among teens and young adults. Advice on disposing of unused medications with abuse potential includes the following:

• Don’t flush unused drugs down the toilet, unless they’re one that expressly advises that on the prescription label.

• Crush or dissolve leftover medicine in a little water. Then mix with a yucky substance—cat litter, coffee grounds, even dog waste—in a sealed plastic bag or other unmarked container, and put in the trash. That renders the drug unpalatable if a child, animal or drug abuser rummages through the trash.

• Remove and destroy the prescription label and any other personal identifying information from the original drug container before throwing it away.

• An alternative is to call pharmacies or local environmental or hazardous waste collection sites, to see if they run drug take-back programs.

QUESTION: What medications should be flushed down the toilet?

ANSWER: I’ve written about the disposal of unused medicines in past columns and most of these medications should not be flushed down the sink or toilet due to potential environmental problems. Unused or expired medicines that do not have flushing directions in the label can be disposed of safely in the household trash by:

• Mixing them with something that will hide the medicine or make it unappealing, such as kitty litter or used coffee grounds.

• Placing the mixture in a container such as a sealed plastic bag.

• Throwing the container in your household trash.

Drug take-back programs for disposal can be another good way to remove unwanted or expired medicines from the home and reduce the chance that someone may accidentally take the medicine.

On the other hand, certain medicines may be especially harmful and, in some cases, fatal in a single dose if they are used by someone other than the person the medicine was prescribed for. For this reason, these medicines have special disposal directions that indicate they should be flushed down the sink or toilet after the medicine is no longer needed. If you dispose of these medicines down the sink or toilet, they cannot be accidentally used by children, pets, or anybody else. Recently the FDA has identified numerous prescription medications that should be flushed to get rid of them right away and help keep your family and pets safe. I have listed these medicines below. More information on this subject can be obtained at www.fda.gov or by calling the FDA at 1-888-463-6332.

Medicine/Active Ingredient

Actiq, oral transmucosal lozenge/Fentanyl Citrate

Avinza, capsules (extended release)/Morphine Sulfate

Daytrana, transdermal patch system/Methylphenidate

Demerol, oral solution */Meperidine Hydrochloride

Demerol, tablets */Meperidine Hydrochloride

Diastat/Diastat AcuDial, rectal gel/Diazepam

Dilaudid, oral liquid */Hydromorphone Hydrochloride

Dilaudid, tablets */Hydromorphone Hydrochloride

Dolophine Hydrochloride, tablets */Methadone Hydrochloride

Duragesic, patch (extended release) */Fentanyl

Embeda, capsules (extended release)/Morphine Sulfate; Naltrexone

Fentora, tablets (buccal)/Fentanyl Citrate

Kadian, capsules (extended release)/Morphine Sulfate

Methadone Hydrochloride, oral solution */Methadone

Methadose, tablets */Methadone Hydrochloride

Morphine Sulfate, oral solution */Morphine Sulfate

Morphine Sulfate, tablets (immediate release) */Morphine Sulfate

MS Contin, tablets (extended release) */Morphine Sulfate

Onsolis, soluble film (buccal)/Fentanyl Citrate

Opana ER, tablets (extended release)/Oxymorphone

Opana, tablets (immediate release)/Oxymorphone

Oramorph SR, tablets (sustained release)/Morphine Sulfate

Oxycontin, tablets (extended release) */Oxycodone

Percocet, tablets */Acetaminophen; Oxycodone

Percodan, tablets */Aspirin; Oxycodone

Xyrem, oral solution/Sodium Oxybate

*These medicines have generic versions available or are only available in generic formulations.

ACCESSORY LABELS

QUESTION: Would you please explain some of the sticker labels that are put on prescription containers?

ANSWER: Pharmacists frequently put stickers or accessory labels on vials or bottles that contain prescription drugs to provide reminders or additional information to patients. Use of these labels can help to prevent side effects or drug interactions and can assist patients in using their medications correctly. An explanation of some of the most common accessory labels is provided below, but if you ever have any questions about using or storing your medicine, be sure to ask your pharmacist:

Take On An Empty Stomach

Foods and beverages in your stomach may interfere with the absorption of certain medications, or slow the time it takes them to begin working. To avoid these problems, take the medication either one hour before, or two hours after eating or drinking. You should take all medication with a full glass of water.

Take With Food

On the other hand, many medications can irritate or upset the stomach. They should be taken with food or right after a meal.

Avoid Prolonged Exposure To Sunlight

This means you, not the medication. Certain medications, such as sulfa drugs and tetracyclines (as well as others), may make you more sensitive to sunlight or tanning lamps, causing you to burn more easily. You should limit exposure to the sun when you are taking these medications. If your skin does become more sensitive, use a sunscreen (SPF 15 or more), avoid spending a long time in the sun, and wear protective clothing.

Keep In The Refrigerator

Medications requiring storage in the refrigerator should generally be kept at a temperature of 36 to 46 degrees Fahrenheit to maintain their potency. Refrigerate only those medications that have this instruction. Refrigerating other medications could cause them to lose their effectiveness because of low temperatures and high humidity. Medication should not be kept in the freezer unless specifically instructed to do so.

May Cause Discoloration Of Urine Or Feces

Some medications may change the color of your urine or stools. This effect is not harmful and will stop when the medication is discontinued. If you wear soft contact lenses you may not want to wear them while using this type of drug, as the medication may also discolor your tears and permanently stain the contact lenses.

Shake Well

The active ingredient in many liquid medications is in the form of a fine powder, which can settle to the bottom of the bottle. To be sure that you get the right dose, shake the bottle for 15 to 30 seconds every time you take or give the medication.

NON-STEROIDAL ANTI-

INFLAMMATORY DRUGS (NSAIDS)

QUESTION: You’ve written several columns about non-steroidal anti-inflammatory drugs (NSAIDs) and their possible gastrointestinal problems. What is the best way to take these medications to prevent these side effects?

ANSWER: Numerous prescription and non-prescription medications known as NSAIDs are available to treat pain and inflammation. Older drugs like aspirin, ibuprofen (Motrin, Advil), diclofenac (Voltaren, Cataflam), naproxen (Anaprox, Aleve), ketoprofen (Orudis, Actron), and many others are probably more likely to cause GI side effects like ulcers and or bleeding compared to the new types of NSAIDs called COX-2 inhibitors (Celebrex) but the jury is still out on this question. These side effects can be a big problem for heavy users of NSAIDs like patients with arthritis. It has been estimated that there are about 20,000 hospitalizations and 2,600 deaths each year in the U.S. alone due to side effects from these types of drugs amongst rheumatoid arthritis patients. Your question is timely because recent study results from the UK have shown that if you take NSAIDs with meals, the risk of ulcer bleeding is reduced by about 50%. On the other hand, if you take these medications one hour or more before a meal you have twice the risk of GI bleeding. Lying down after taking NSAIDs and smoking also appear to significantly increase the risk of GI side effects. It was no surprise in this study that patients with GI bleeding were more likely to take high doses of these drugs and to take them more often than twice a day. However it was a surprise that alcohol had no effect of the risk of ulcer bleeding with NSAID use in the study. The bottom line is that you should always take these medications with food. In addition, you should avoid lying down after taking them and avoid smoking if possible. Never use these medications in a higher dose or more frequently than recommended on the product package or as prescribed by your doctor.

PLEASE NOTE: Celebrex now has a black-box warning in its labeling about an increased risk of serious and potentially life-threatening gastrointestinal and cardiovascular events associated with use of this drug.

QUESTION: I take nonprescription naproxen for arthritis. How can I reduce the risk of upset stomach and stomach bleeding from this drug?

ANSWER: Naproxen is known as a non-steroidal anti-inflammatory drug or NSAID for short. Numerous NSAIDs are available as prescription drugs or over-the-counter (OTC) products. Other nonprescription NSAIDs include ibuprofen, aspirin, and ketoprofen. Commonly used OTC brand-name products containing one of these NSAIDs include Motrin, Advil, Orudis, Excedrin, and Aleve. They are also contained in many common OTC cold and flu products such as Advil Cold and Sinus, Dimetapp Sinus, Motrin IB Sinus, and Aleve Cold and Sinus. It is estimated that every day more than 30 million people take OTC and prescription NSAIDs for relief from pain, headaches, and arthritis. These drugs have been available for a long time, but like all drugs they can produce side effects. NSAIDs can cause serious gastrointestinal problems ranging from upset stomach to stomach bleeding, stomach pain, ulcers (a hole in the lining of the stomach), and even death. These side effects lead to more than 100,000 hospitalizations and 16,000 deaths each year in the U.S. alone. Some people are at a greater risk of these side effects, including people:

• Over the age of 60.

• Have had previous ulcers.

• Taking steroid medications such as prednisone.

• Taking blood thinners such as warfarin (Coumadin).

• Consuming alcohol on a regular basis.

• Taking high doses of NSAIDs.

• Taking several different medications that contain NSAIDs.

• Taking NSAIDs for a long period of time.

While about 80% of people who have serious stomach problems from NSAIDs have no warning symptoms, you should see your doctor immediately if you have stomach pain; have dark black, tarry, or bloody stools; or are vomiting blood or materials that look like coffee grounds.

There are several measures that you can take to reduce your risk of developing a serious stomach problem from taking NSAIDs. These include the following steps:

• Read the product label and follow instructions carefully. Do not take more than the recommended dose or for a longer time than recommended. Know all of the ingredients in the medications that you take. If unsure, ask your doctor or pharmacist.

• Make sure your doctor and pharmacist know all the medications that you take.

• Avoid or limit the use of alcohol when taking NSAIDs.

• Take NSAIDs with food, milk, or antacids.

• Consider taking acetaminophen (Tylenol) or one of the newer NSAIDs that may cause fewer stomach problems. Ask your doctor and pharmacist about possible alternative NSAID medications, or other drugs that can help reduce your risk of stomach problems if taking NSAIDs.

• Do not take aspirin without talking to your doctor or pharmacist.

• Report all side effects to your doctor and pharmacist.

• Review the risk factors noted above.

ALCOHOL AND MEDICATION USE

QUESTION: I drink alcohol occasionally. What medicines can cause problems when taken with alcohol?

ANSWER: Alcohol use can be dangerous when combined with many types of prescription or non-prescription medication, including some herbal preparations. Alcohol produces depressant effects on the central nervous system and when combined with other drugs that affect the nervous system numerous side effects can occur. Because of this, the use of alcohol can be dangerous when it is combined with sedatives, sleeping medication, antidepressants, tranquilizers, and some prescription pain relievers. Alcohol can also affect blood sugar levels and therefore caution needs to be observed when using alcohol with anti-diabetic medications. In addition, the use of alcohol can lead to gastrointestinal irritation and liver damage, which can be magnified when other drugs are used in combination with it. In the table below I have listed some of the more common drug interactions with alcohol. Please note that this list is not complete and if you have any questions about the use of alcohol with medications that you are taking please be sure to Ask The Pharmacist or your physician for advice.

Some Types of Drug Interactions With Alcohol

Drug Type

Some Examples

Problem

Non-Prescription Medications

• Antihistamines

Diphenhydramine (Benadryl), chlorpheniramine (Chlor-Trimeton), clemastine (Tavist)

Increased sedative effects, drowsiness, confusion

• Herbals

Kava kava, St. Johns Wort

Increased sedative effects, drowsiness

• Pain Relievers—Non-Steroidal Antiinflammatory Drugs (NSAIDs)

Ibuprofen (Motrin, Advil), aspirin, ketoprofen (Actron, Orudis), naproxen (Aleve)

Possible stomach and intestinal ulceration or bleeding

• Pain Relievers—Other

Acetaminophen (Tylenol)

Increased risk of liver problems

Prescription Medications

• Antidepressants

Amitriptyline (Elavil), clomipramine (Anafranil),

desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), protriptyline (Vivactil), maprotiline (Ludiomil), mirtazapine (Remeron), trazodone (Desyrel), bupropion (Wellbutrin), venlafaxine (Effexor), nefazodone (Serzone)

Increased sedative effects, confusion

• Anti-diabetic

Chlorpropamide (Diabenese), tolazamide (Tolinase), glipizide (Glucotrol), glyburide (Micronase), metformin (Glucophage)

May cause dangerous drops in blood glucose and other side effects

• Anti-infective

Metronidazole (Flagyl)

Reaction causing facial flushing, headache, nausea, stomach pain

• Heart medication

Nitroglycerin

May produce a dangerous drop in blood pressure

• Pain relievers

NSAIDs (See some examples above); Narcotics and narcotic-like drugs (codeine, morphine, propoxyphene (Darvon, Darvocet), fentanyl (Actiq, Duragesic), methadone (Dolophine), oxycodone (Oxycontin, Tylox), hydrocodone (Vicodin, Lortab), pentazocine (Talwin, Tramadol (Ultram))

Possible stomach and intestinal ulceration or bleeding; Excessive depressant effects (drowsiness, sedation, confusion), difficult breathing

• Sedatives, Tranquilizers

Alprazolam (Xanax), chlorazepate (Tranxene), chlordiazepoxide (Librium), diazepam (Valium), lorazepam (Ativan), oxazepam (Serax), hydroxyzine (Vistaril), meprobamate (Equanil)

Increased sedative effects, drowsiness

DRUG INFORMATION SOURCES

QUESTION: Where can I get good information about the medications that I take?

ANSWER: Besides the Ask The Pharmacist column there are many other useful sources of drug information available. Everyone should become better informed about their illnesses and medications that they take, both prescription and non-prescription. Patients need to know why they are taking each medication and what benefits can be expected from them. They should also know exactly how to take medications, if drugs, foods, or alcohol should be avoided, and what side effects are possible. Most pharmacies now provide printed drug information with new prescriptions so that patients can be better informed. If they don’t, or if you have additional questions, be sure to ask the pharmacist or your doctor. The local library is another good place to find medical and drug information. Most libraries have a special section with health-related books. The reference section of the library will also usually carry an up to date copy of the Physician’s Desk Reference (PDR) or similar references. If you have access to the Internet (and most libraries provide this service), you can find many good medical and drug information resources available on the World Wide Web. You should note, however, that there is a great deal of misleading or inaccurate information on the Internet. A few useful and accurate sites include: www.drugs.com; www.consumermedsafety.org has a search feature where patients can enter the name of a prescription drug they are taking and the site searches for safety information and features of that drug; Medlineplus (www.medlineplus.gov) which has a wealth of information about drugs and diseases; Food and Drug Administration information for consumers (www.fda.gov/opacom/morecons.html) which provides information regarding newly approved drugs, proper use of prescription drugs, and herbal products; www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Surveillance/ucm090385.htm which provides risk summaries of approved drugs based upon health reports from companies, consumers, and physicians after drugs are approved; MayoClinic.com (www.mayohealth.org/home) and Johns Hopkins Medicine (www.johnshopkinshealthalerts.com) which cover illnesses, drugs, and wellness; The Merck Manual Home Edition (www.merckhomeedition.com) with a variety of health and drug information for consumers; The Natural Pharmacist (www.tnp.com) with information on herbs and dietary supplements including drug interactions; www.my.webmd.com with extensive medical information including diseases, drugs and herbals, health and wellness; Pharmacy and You (www.pharmacyandyou.org/) covering medications, self-care, and pharmacist’s services; and the National Council on Patient Information and Education (NCPIE) provides a wide variety of consumer-oriented medication information (www.talkaboutrx.org).

QUESTION: I heard that the FDA has a new web site to obtain drug information. What is it?

ANSWER: The FDA recently launched a new Internet web site to help consumers and health professionals find information they need about drug products. I’ve tried it. It is easy to use and provides a wide variety of information about prescription and over-the-counter drugs. To get to the site, you need to have access to a computer connected to the Internet (all local library branches have these computers available for public use). The FDA’s Home Web site is www.fda.gov. At this site click on Drugs in the left hand column on the screen. Then click on Drugs@FDA. Once you are at the Drugs@FDA screen you can search for drug information by entering at least 3 characters of the drug name (generic or trade name). At this site you can obtain a wealth of information about most FDA approved drug products, including Consumer Information Sheets, Medication Guides, and product labeling. You can also find information about generic drug products that are available for brand name drugs. In addition, information can be obtained to help identify therapeutically equivalent drugs for prescription medicines, and alternative nonprescription drug products with the same active ingredient. It should be noted, however, that the Drugs@FDA site does not include information about dietary supplements (because they do not require FDA approval), drugs for animals, or prescription drugs sold in countries other than the U.S. This drug information site is updated daily. More information about this new information source can be obtained by calling 1-888-INFO-FDA (1-888-463-6332) or via e-mail at [e-mail].

QUESTION: I heard about a new FDA web site for drug safety information. What can you tell me about it?

ANSWER: The FDA recently created a new web page with drug safety information for patients and health care professionals. You can now go to a single page on the U.S. Food and Drug Administration’s web site to find a wide variety of safety information about prescription drugs. This web page, http://www.fda.gov/cder/drugSafety.htm, provides links to information in the following categories:

• Drug labeling, including patient labeling, professional labeling, and patient package inserts;

• Drugs that have a Risk Evaluation and Mitigation Strategy (REMS) to ensure that their benefits outweigh their risks;

• A searchable database of postmarket studies that are required from, or agreed to by, drug companies to provide the FDA with additional information about a drug’s safety, efficacy, or optimal use;

• Clinicaltrials.gov, a searchable database of clinical trials, including information about each trial’s purpose, who may participate, locations, and useful phone numbers;

• Drug-specific safety information, including safety sheets with the latest information about the drug as well as related FDA press announcements, fact sheets, and drug safety podcasts;

• Quarterly reports that list certain drugs that are being evaluated for potential safety issues, based on a review of information in the FDA’s Adverse Event Reporting System (AERS);

• Warning Letters, Import Alerts, Recalls, Market Withdrawals, and Safety Alerts;

• Regulations and guidance documents;

• Consumer information about using medications safely and disposing of unused medicines;

• Instructions how to report problems to the FDA through its MedWatch program;

• Consumer articles on drug safety; and

• The FDA’s response to the Institute of Medicine’s 2006 report on the future of drug safety.

By providing these