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
 Keep all of your healthcare providers informed of any
changes to your health
 Keep an updated medication list
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
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
•T Y L E N O L
•N S A I D S ( M O T R I N / A D V I L / A L E V E / A S P I R I N )
•C O U G H A N D C O L D
•A N T I - D I A R R H E A L S A N D L A X A T I V E S
•H E R B A L R E M E D I E S
Tylenol
• 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:
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–
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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
NSAIDs
• 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
 Antihistamines: Benadryl, Claritin, Zyrtec
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
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)
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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)
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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
Anti-diarrheals
 Metamucil (fiber)
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Laxatives

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:
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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)
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
Stool Softeners: Docusate, Colace


Safest and most natural way relieve symptoms of
constipation
Can take hours to days for effect
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

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Glycerin suppositories are the safest treatment for
small children and newborns
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 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 Remedies
Herbal
Supplement
Class
Medical
Use
Comments
Melatonin
A
Jet Lag
Do not mix with prescription sleep aids
Do not use if pregnant or breastfeeding
Cranberry
B
Urinary Tract
Infection
Can interact with blood thinners and increase
risk of bleeding
Caution use of juices for diabetics
Aloe Vera
C
Skin burns
Generally safe when used topically
Glucosamine and
Chondroitan
A
Knee
osteoarthritis
Do not use if pregnant or breastfeeding
Do not use with shellfish allergies
Fish Oil
A
Cholesterol
High blood
pressure
Do not use if pregnant or breastfeeding
Do not use in children < 18 years old
Do not take more than 3 grams per day
Tea Tree Oil
C
Acne
Dandruff
Do not use on open burns or wounds
Do not use on dry skin
Topical oil – not for oral ingestion
Coenzyme Q 10
A
Coenzyme Q 10
deficiency
May lower blood sugar – caution in diabetics
Many drug interactions exists
Herbal Remedies
• Caution: ‘G-herbs’ = increased risk of bleeding
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–
–
–
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
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–
–
–
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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)
 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 (GERD)
 Histamine2- receptor antagonists
Drug
How available
Famotidine (PEPCID)
OTC: 10, 20mg
Rx: 20, 40mg
Ranitidine (ZANTAC)
OTC: 75, 100mg
Rx: 300mg
Nizatidine (AXID)
OTC: 75mg
Rx: 150, 300mg
Cimetidine (TAGAMET)
OTC: 200mg
Rx: 300, 400, 800mg
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 (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
Clopidogrel
(Plavix)
Dofetilide
(Tikosyn)
Thioridazine
Amiodarone
Phenytoin
Carbamazepine
Quinidine
Theophylline
Citalopram
Gastroesophageal Reflux Disease (GERD)
 Proton Pump Inhibitors
Medication
Omeprazole (Prilosec)
Available OTC
Omeprazole- Sodium
Bicarbonate (Zegerid)
Available OTC
Pantoprazole (Protonix)
Lansoprazole (Prevacid)
Dexlansoprazole (Dexilant)
Esomeprazole (Nexium)
Rabeprazole (Achiphex)
Available OTC
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 (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
 “Statin” medications
 Atorvastatin (LIPITOR)
 Simvastatin (ZOCOR)
 Rosuvastatin (CRESTOR)
 Pravastatin (PRAVACHOL)
 Lovastatin (MEVACOR, ALTOPREV)
 Fluvastatin (LESCOL)
 Pitavastatin (LIVALO)
High Cholesterol
 Possible side effects of statins:
 Digestive problems:
Nausea
 Gas
 Diarrhea
 Constipation
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Blood sugar increases
Memory loss or confusion
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Usually reversible when medication is stopped
Increased risk of cataracts
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
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Liver damage
Unusual tiredness or
weakness
 Loss of appetite
 Abdominal pain
 Dark-colored urine
 Yellowing of the skin or
eyes

High Cholesterol
 Statin drug
interactions
Shapiro and Brown, RxPrep CourseBook 2013 ed.
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 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)
 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 (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 (COUMADIN)
 Other important side
effects:
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Hives, rash, itching
Chest pain, pressure
Nausea, vomiting
Fever or flu-like symptoms
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Joint or muscle aches
Diarrhea
Tingling or numbness in any
part of the body
Warfarin (COUMADIN)
 Less serious side effects:
 Gas
 Feeling cold
 Fatigue
 Pale skin
 Changes in the way food tastes
 Hair loss
Warfarin (COUMADIN)
 Drug interactions
 Warfarin interacts with MANY medications
Carbamazepine
Phenobarbital
Phenytoin
Rifampin
St. John’s Wort
Amoxicillin
Cephalosporins
Fluoroquinolones
Tetracyclines
Amiodarone
Bactrim
Antifungal
medications
Fluvastatin
Fluvoxamine
Macrolide
antibiotics
Flagyl
Tigecycline
NSAIDs
SSRIs
SNRIs
Warfarin (COUMADIN)
 Common Interactions
 NSAIDs
Aspirin, ibuprofen, naproxen, etc.
 Use with warfarin can increase bleeding risk
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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
Common Brands
Generic
 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

Toprol-XL,
Lopressor
Metoprolol
Tenormin
Atenolol
Coreg
Carvedilol
Zebeta
Bisoprolol
Normodyne,
Trandate
Labetalol
Inderal
Propranolol
High Blood Pressure– ACE Inhibitors
Common Brands
Generic
Zestril, Prinivil
Lisinopril
Altace
Ramipril
Vasotec
Enalapril
Capoten
Captopril
Accupril
Quinapril
Lotensin
Benazepril
 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 NSAIDsMotrin, Aleve, Advil, etc.
High Blood Pressure– Diuretics (Water Pills)
Common
Brands
Generic
Maxzide
Hydrochlorothiazide
(HCTZ)
Thalitone
Chlorthalidone
Dyrenium
Triamterene
Aldactone
Spironolactone
Lasix
Furosemide
Bumex
Bumetanide
 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
 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 - Insulin
Type/Names
Tips
Short-acting
Take 15-30 minutes before you eat a
meal to avoid low blood sugar
Aspart (Novolog)
Lispro (Humalog)
Regular (Humulin R, Novolin R)
Longer-acting
Glargine (Lantus)
Detemir (Levemir)
Some people find improved control of
blood sugar by taking at night
If dose is larger than 50 U, splitting into
two injections can increase efficacy
Be aware of your signs of low blood sugar and have a plan to get control
Keep track of daily blood sugar as directed by your healthcare provider
Diabetes- Other Drugs
Drug
Common Interactions
and Side Effects
Sulfonylureas
• Low blood sugar– take with food and
be cautious with alcohol
• May cause some weight gain
Glipizide
Glimepiride
Glyburide
Metformin
Exenatide (Byetta)
• Diarrhea/stomach cramps – usually
get better if you build up to target
dose.
• Caution must be used in patients
with kidney problems
• Can slow down the absorption of
other drugs – keep in mind if rapid
relief needed (pain or nausea
medication)
Diabetes- Low Blood Sugar
 Blood sugar level <70 mg/dL
 What do you do?
 Take in 15 grams of quick
acting carbohydrate/sugar
source
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

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
 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!
Questions