Herbals, Drugs and Aging….

Are these compatible?Are these compatible?

2015 CPS

I do not have a vested interest or an affiliation with any corporation or organization offering financial support or grant monies for this seminar.

I do not have an affiliation with any organization whose philosophy

could potentially bias this presentation.

Speaker Disclosure

Speaker Background

Norm Tomaka– Pharmacist– Consultant Pharmacist

– Licensed Health Care Risk ManagerLicensed Health Care Risk Manager

– Affiliation-Consultant Pharmacy Services

-Outpatient /Ambulatory Healthcare Facilities

Objectives

• Become familiar with the risks to patient safety when combining conventional medication therapy with alternative products (nutraceuticals)

• Evaluate the lack of standardization and regulation of herbals and other nutraceuticals

• Gain an understanding of the complex interactions presented by drug therapy and nutraceuticals in geriatric patients

• Review herbal-medication anti-coagulants interactions supported by clinical evidence

Medication Safety

• Misuse of “over-the counter” (OTC) products has lead to increased hospitalizations

• Ask your pharmacist before adding ANY herbal, OTC or vitamin

https://www.ismp.org/tools/use-medicine-safely-campaign/Americas_Medicine_Cabinet_11.pdf

Unintentional medication misuse

can lead to patient harm and additional

health care costs

CDC Grand Rounds: Prescription Drug Overdoses- U.S. Epidemic. Jan 13, 2012pp. 10-13. http://www.cdc.gov/mmwr/pdf/wk/mm6101.pdf

Medication “Balance”

• Desired effects• Standard vs Individualized dosing

– Weight – Age – Other medications– Race– Health Condition

• Side effects– Not always desirable

• Start low, go slow…

Homeostasis

Are consumers/patients accurately informed about the “alternative products” they’re purchasing?

Poll

Patient visitAmbulatory

Medical Clinic

December2014

Patient requested to bring in all “medications” from home

http://top-herbals.com/

Can I take herbal supplements if I am taking other medicines?

“A key concern for older adults is whether an herb will interact with prescription medications- resulting in adverse effects.”

Sunny Linnebur, PharmD, FCCP, BCPS, CGP Associate Professor University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences University of Colorado Anschutz Medical Camp

http://www.healthinaging.org/resources/resource:herbal-remedies-ask-the-experts/

The New York State attorney general’s office accused four national retailers of selling dietary supplements that were fraudulent and in many cases contaminated with unlisted ingredients - 02/03/2015, page A1 of the New York Times™, NY edition with the headline: 4 Retailers Told to Stop Selling Supplements

What’s in those supplements?

http://well.blogs.nytimes.com/2015/02/03/sidebar-whats-in-those-supplements/?ref=todayspaper&_r=0

2015 Class action lawsuit* over ‘herbal’ supplements

Investigators analysis found French bean, asparagus, pea, wild carrot, rice, wheat/grass, and daisy, in addition to the herbal supplements Gingko Biloba, St. John’s Wort, ginseng, garlic, echinacea, and saw palmetto

*John Hollis is lead plaintiff in a class action lawsuit filed against Walgreens by Bailey & Glasser LLP in Washington, D.C. Hollis claims the Walgreens brand Ginkgo Biloba he purchased for years was composed of rice and other substitutes not Ginkgo Biloba. www.baileyandglasser.com

“Some of the substituted fillers and contaminants are allergens posing considerable health risks that should have been disclosed to consumers,” the attorneys stated.

“These supplements are expensive, and consumers should have confidence that they are buying something beneficial, not worthless products that might actually contain allergens and other contaminants.”

http://drugtopics.modernmedicine.com/drug-topics/news/walgreens-facing-class-action-lawsuit-over-herbal-supplements?page=0,0

Pharmacist as a resource

Are patients and caregivers asking important questions?

http://www.rc-hr.com/pharmacy/

Donna Apostal, RPh

Definitions• Complementary and alternative medicine (CAM)

o “A group of diverse medical practices and products that are not presently considered to be part of conventional medicine”

o Ranges from medicinal herbs to acupuncture to massage• Dietary supplement

o “Any product (besides tobacco) that contains a vitamin, mineral, herb, or amino acid and that is intended as a supplement to the normal diet”

• Nutraceuticalo “Food, or parts of food, that provide medical or health

benefits, including the prevention and treatment of disease”

o More recent, general termPharmacy and Therapeutics, vol. 35, no. 8, pp. 461–468, 2010.

Epidemiology

• 36% to 62% of the adult by population use at least one form of alternative/nutraceutical “treatment”

• 76% physicians and pharmacists surveyed said that they were “poorly informed” about herbal medicines

Natural Medicines Comprehensive Database: Unbiased, Scientific Clinical Information on Complementary, Alternative, and Integrative Therapies. Pharmacy and Therapeutics, vol. 35, no. 8, pp. 461–468, 2010.

Case: MedicationsSertraline 50 mg 1 tablet by mouth at bedtime

Quetiapine 25 mg 1 tablet by mouth at 8AM, 2PM, and 10 PM

Trazodone 50 mg 1 tablet by mouth at 6AM and 2PM

Trazodone 100 mg 1 tablet by mouth at bedtime

Spironolactone 25 mg 1 tablet by mouth daily

Furosemide 20 mg 1 tablet by mouth daily

Acetaminophen 325 mg 1 to 2 tablets every 8 hours as needed for pain (must ask for)

Docusate-Senna 50-8.6 mg 1 tablet by mouth twice daily for laxative

Guaifenesin 100 mg/5 mL, 10 ml by mouth every 4 hours as needed for phlegm

Ipratropium-Albuterol 0.5-2.5 mg/3 mL inhale 1 vial via nebulizer every 6 hours as needed for cough or shortness of breath

Florastor™ 250 mg 1 capsule by mouth twice daily

Ultimate Probiotic Critical Care™ 1 capsule by mouth daily

Vitamin B-12 1,000 mcg/mL 1 mL by mouth daily

Vitamin B complex 1 tablet by mouth daily

L-Taurine 850 mg 6 capsules 1 time daily 1 hour before or after food or other supplements

Coenzyme Q10 75 mg 1 capsule by mouth daily

Prosta-Glan™ Dietary Supplement 3 capsules by mouth twice daily with meals

GC-MSM 3550 (glucosamine, chondroitin, hyaluronic acid) 4 tablets by mouth daily

Nattokinase with Vitamin E 3 capsules by mouth twice daily

Phosphatidylserin E complex 1,000 mg 1 tablet by mouth daily

Bladder Control Advantage™ 1 capsule by mouth twice daily

100% Protein Powder Mix 1 scoop with 8 oz and drink by mouth daily

Mega EPA Omega-3 EPA and DHA 2,126 mg 1 softgel by mouth daily

Bruise Free™ 3 capsules by mouth daily

Twilight-Time™ dietary supplement 1-2 capsules by mouth at bedtime for sleep

Acetyl L-Carnitine 500 mg 1 capsule by mouth twice daily between meals

Same Case: Nutraceuticals

Physiologic Effects of Aging

●Alters pharmacokinetics ■ GI Absorption, distribution,

metabolism, elimination of medications■ Muscle mass, kidney function, bone

mineral density

Hajjar ER, Gray SL, Guay DR, Starner CI, Handler SM, Hanlon JT. Chapter 11. Geriatrics. In: Talbert RL, DiPiro JT, Matzke GR, by mouthsey LM, Wells BG, Yee GC, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York: McGraw-Hill; 2011.

Effects of Aging on Metabolism

http://jap.physiology.org/content/95/6/2598

Aging and Human Temperature RegulationW. Larry Kenney , Thayne A. MunceJournal of Applied Physiology Published 1 December 2003 Vol. 95 no. 6, 2598-2603 DOI: 10.1152/japplphysiol.00202.2003

Anticoagulants and Nutraceuticals

http://www.nycva.org/wp-content/uploads/2012/11/4664193_f520.jpg

http://www.blood-thinners.org/files/5213/1060/5279/Blood_Thinners_Blood_Cells.jpg

Natural Medicines and….

Platelet AggregationName Potential Drug Interactions/Comments Andrographis Anticoagulants, antiplatelets, antihypertensive drugs,

immunosuppressants1,2

Black tea (Contains caffeine)

Anticoagulants, antiplatelets, benzodiazepines, beta-adrenergic agonists, diuretics, warfarin1,2

Boldo Warfarin1,2

Chamomile Warfarin (interferes with metabolizing enzymes)3,4

Chondroitin Warfarin1,2

Coenzyme Q10 Warfarin (alters gut vitamin K synthesis or contains vitamin K)3,4

Cranberry Warfarin (interferes with coagulation cascade and metabolizing enzymes)3,4

Danshen Warfarin1,2

Dong quai Warfarin1,2

Fenugreek Warfarin1,2

Fish oil (High doses)

Garlic Warfarin (interferes with metabolizing enzymes and platelet function)1,2,3,4

Natural Medicines and…..

Platelet AggregationGinger Warfarin (interferes with platelet function)1,2,3,4

Ginkgo biloba Warfarin (interferes with metabolizing enzymes)3,4

Ginseng Warfarin (interferes with metabolizing enzymes and platelet function)3,4

Glucosamine Warfarin1,2

Grapefruit Warfarin (interferes with metabolizing enzymes)3,4

Green tea Warfarin (alters gut vitamin K synthesis or contains vitamin K)3,4

Guarana (Contains caffeine)

Horse chestnut Nattokinase Policosanol Resveratrol Saw palmetto St. John’s Wort Warfarin (interferes with metabolizing enzymes)3,4 Vitamin E (High doses)

Poll

Which of the following is correctly matched with its “pharmacological” activity?

a. Glucosamine Antiplatelet activityb. Coenzyme Q10 Decreased blood

pressurec. Green tea Antiplatelet activityd. St. John’s wort Serotonergic

activitye. All of the above

Answer

Which of the following is correctly matched with its pharmacological activity?

a. Glucosamine Antiplatelet activityb. Coenzyme Q10 Decreased blood

pressurec. Green tea Antiplatelet activityd. St. John’s wort Serotonergic

activitye.e. All of the aboveAll of the above

• The use of dietary supplements is extensive and growing

o Global nutraceutical market is estimated as $117 billion• Dietary supplements are not without adverse effects

o Those at highest risk include older adults and all patients perioperatively

• All caregivers should play an active role in recognizing potentially harmful from dietary supplements

• Examples of outcomes through interventions include:o Reduce adverse drug event (e.g. hypoglycemic episode, falls)o Prevent medication-nutraceutical interactiono Reduce hospital readmissions

Talk with Your Pharmacist• Pharmacy technicians verbally offer the opportunity to

talk to the pharmacist (FL Law)– Prepare questions ahead of interaction

• Side effects?• Is the dose appropriate for condition treated?• Will this prescription mix with other products?• Does the medication have the by potential to affect behavior?

-Know what you are signing if you decline consultation

Prescription Medications

• Is this your medicine?• Check your address and date of

birth; do you match the information on the prescription?

• At the pharmacy- ask to open the bag and compare the name on the receipt with the name on the prescription label

Talk with YOUR Pharmacist

• Improve medication management– for every $1 spent on Rx

medication, there is $4 decrease in hospital costs.

– for every $3 spent on asthma medication, there is a $17 decrease in emergency room spending.

Source: NACDS Practice Memo. It’s time to talk about value. Available online at: http://www.practicememo.com/Archives/html/2006/Nov06.html

Pharmacistsimproving medication use…advancing patient care

Just ASK your pharmacist

RXRXOTCOTC

HerbalsHerbals

http://www.secondscount.org/heart-resources/heart-resources-detail-2/secondscounts-med-minder#.VQBIttLF_WI

Additional References1) TOP Herbals (2015, March 3) Retrieved from http://top-herbals.com2) Institute for Safe Medication Practices, “America’s Medicine Cabinet” presentation. (Accessed 2014, Dec. 10) www.ismp.org3) Healthy.Net (2015, March 2) Retrieved from www.healthy.net4) Natural Medicines Comprehensive Database: Unbiased, Scientific Clinical Information on Complementary, Alternative, and

Integrative Therapies. The Perioperative Use of Natural Medicines. (Referenced 2015, February 12-14) http://naturaldatabase.therapeuticresearch.com/ce/ceCourse.aspx?s=ND&cs=UFL&pc=12-102&cec=1&pm=5#references

5) Health in Aging.Org “Herbal Remedies Topic Review” ( 2015, February 13) http://www.healthinaging.org/resources/resource:herbal-remedies-ask-the-experts

6) Natural Standard: The Authority on Integrative Medicine. https://naturalmedicines.therapeuticresearch.com/7) Ge B, Zhang Z, Zuo Z. Updates on the clinical evidenced herb-warfarin interactions. Evid Based Complement Alternat Med.

2014: 9573628) Heck AM, DeWitt BA, Lukes AL. Potential interactions between alternative therapies and warfarin. Am J Health Syst Pharm.

2000 Jul 1;57(13):1221-7.9) Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health-Care Professionals, The Pharmaceutical Press,

London 1996, p.283.10) Hajjar ER, Gray SL, Guay DR, Starner CI, Handler SM, Hanlon JT. Chapter 11. Geriatrics. In: Talbert RL, DiPiro JT, Matzke GR,

Posey LM, Wells BG, Yee GC, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York: McGraw-Hill; 201111) Rozenfeld V, Crain JL, Callahan AK. Possible augmentation of warfarin effect by glucosamine-chondroitin. Am J Health Syst

Pharm. 2004 Feb 1;61(3):306-7.12) Cooper K1, Squires H, Carroll C, Papaioannou D, et al. Chemoprevention of colorectal cancer: systematic review and economic

evaluation. Health Technol Assess. 2010 Jun;14(32):1-206. doi: 10.3310/hta14320.13) C. L. Ventola, “Current issues regarding complementary and alternative medicine (CAM) in the United States—part 1: the

widespread use of CAM and the need for better-informed health care professionals to provide patient counseling,” Pharmacy and Therapeutics, vol. 35, no. 8, pp. 461–468, 2010.

14) SecondsCount.Org, SCAI™ ‘My Med Minder” Dose Chart Template. http://www.secondscount.org/heart-resources/heart-resources-detail-2/secondscounts-med-minder#.VQBKENLF_WJ

Herbals, Drugs and Aging….Are these compatible?Are these compatible?

Questions?

2015 CPS