Professional Documents
Culture Documents
Mystified
• “The arrival of a good clown exercises a more
beneficial influence on the health of a town
than 20 asses laden with drugs.”
• Dr. Thomas Sydenham (1624-1689)
The Numbers…
• 30 years ago there were 900 drugs to choose
from in the PDR
• Today there are over 11,000…
• Plus….
The numbers….
• Over 600 herbals products —many of which interact with
prescribed drugs including cardiac drugs and
antidepressants
• St. John’s Wort is the number one herbal product that
interacts with over 60 percent of all prescription drugs. The
interaction is to make the drugs LESS effective:
Cyclosporine, tamoxifen, HAART (highly active anti-
retroviral therapy) for AIDS patients, and Combined Oral
Contraceptives
• Side effect?
Vitamins and herbal supplements….
• Vitamin supplements—A (liver toxicity), B6
(peripheral neuropathy), C (doesn’t work to prevent
colds but is an excellent way to help absorb iron
when iron supplements are necessary), D for bones,
balance, boosting immune system, E (no extra
benefit on hearts, and in the very old may actually
exacerbate heart failure)…but vitamin E reduces fat
in the liver in patients with fatty liver disease (800
IU)
• Calcium supplements, iron supplements, soy
supplements interfere with levothyroxine
(Synthroid)
Speaking of levothyroxine…
• Nighttime dosing may be more efficacious
than daytime dosing
• Most important—take at the same time of day
• Adjust doses as the patient ages—why?
• Levothyroxine RX can also cause atrial fib if
the dose is too high; levothyroxine doses
DECREASE with aging; some patients only
need 0.5 mcg/kg/day vs. younger adults with
1.7 mcg/kg/day (Prescriber’s Letter July 2011)
The Gs and platelet aggregation
• How about the “Gs”??
• Garlic vs. garlic supplements (interfere with all sorts of
drugs)
• Gingko—not beneficial for dementia, but is beneficial for
PAD
• grapeseed extract—EAT GRAPES
• ginseng –whatever ails ya’; side effects?
• Glucosamine--??
• green tea** (a potentially harmful interaction is with green
tea and simvastatin—the higher the dose of simvastatin the
greater the risk of rhabdomyolysis with green tea)
Plus…
• Over 10,000 over-the-counter (OTC) drugs that can
wreak havoc—examples:
1) cimetidine (Tagamet)—for heartburn
2) acetaminophen (Tylenol) is in over 300 over-the-
counter products (Tylenol)—inadvertent overdoses
(narrow therapeutic index—toxic dose is not much
higher than therapeutic dose)
….as well as numerous prescription analgesics…
Fioricet, Lorcet, Percocet, Propacet, Roxicet,
Ultracet (limit “cets” to 325/mg per tab to reduce
toxicity)
Acetaminophen/Tylenol
• Afferent arteriole
( ↑ vasodilation by
( ↑ prostaglandins)
• Blood entering
glomerulus
• Glomerulus→filter
• Efferent arteriole
( ↑ vasoconstriction via
( ↑ angiotensin II)
• Blood exiting
glomerulus
PRILS inhibit ATII/vasodilate the efferent arteriole Microalbuminuria
**
To summarize…ACE inhibitors are used
for:
• Hypertension (*night time dosing of anti-
hypertensive drugs—dippers (10% decline @ night)
vs. non-dippers)
(American Journal of Kidney Diseases December
2007)
• A new, interesting theory of hypertension—CMV
infection in epithelial cells results in excess release of
renin and angiotensin II, excess production of
proinflammatory cytokines, and development of
intimal hyperplasia and athersclerosis
To summarize…ACE inhibitors are used
for:
• Decrease the remodeling of the heart in heart failure
patients and post-MI patients (clearly beneficial in MI
patients 65-74 years of age, but not so clear in patients
older than 75)
• Beneficial in patients with anterior ST-elevation MIs
and in patients with MIs complicated by HF or
significant LV systolic dysfunction with LV ejection
fractions less than 40%
• Decrease the risk of 1st and 2nd myocardial infarctions
in high-risk patients due to anti-inflammatory effects
• Stroke prevention
• Prevention of diabetic nephropathy
• Decrease insulin resistance and reduce the risk of
progression to type 2 diabetes
Side effects, of course…
• Hypotension—start low and go slow
• Hypoglycemia (low blood sugar)—only in
diabetics on antiglycemic agents; not a
problem in normoglycemic patients
Side effects, of course…
• Hyperkalemia (high potassium) (excreting sodium
and water and retaining potassium)
• Add a thiazide diuretic to the ACE inhibitor
• Capozide (captopril + thiazide)
• Vaseretic (enalapril +thiazide)
• Prinizide (lisinopril + thiazide)
• Zestorectic (as above)
• Lotensin HCT (benazepril + hydrochlorothiazide)
What about K+ containing foods?
• May also contribute to hyperkalemia and
cardiac arrhythmias but usually only in
patients with renal insufficiency so or in
patients who are also on K+ sparing
diuretics such as spironolactone
(Aldactone) and eprelrenone (Inspra)
• Avoid excessive potassium intake when on
the above drugs or with renal insufficiency
• Advise patients to decrease potassium
intake until they can get their potassium
checked
High K+ containing foods
• Potatoes
• Prunes
• Raisins
• Apricots
• Bananas
• Halibut
• Canteloupe
• Oranges
• Pasta sauce
• Health.harvard.edu/heartextra for K+ content
of 1,200 foods
Side effects, of course…
• Cough (gender differences)
• ACE inhibitors block angiotensin converting enzyme; but as
ACE is inhibited, bradykinin goes UP…bradykinin is a potent
bronchoconstrictor
• Women have more bradykinin to begin with, therefore the
gender disparity in the cough
• Rx? Stop drug; can try a nonspecific antitussive; consider
indocin, baclofen, aspirin, or sulindac (Clinoril) if the cough
persists (Rose BD)
Side effects, of course…
• Cough (gender differences)
• Life-threatening angioedema (“Does my
voice sound funny to you?”)
And ONE OTHER THING:ACE inhibitors (category
D) throughout pregnancy
• Why?
• Angiotensin 2 boosts growth factors
• ACE inhibitors inhibit AT2 and inhibit growth;
ACE inhibitors are teratogenic
• More sex
• No pregnancy worries
• Swingin’ singles
• Who cares what the neighbors think?
• Swimming pools and golf courses
• Can you have a heart attack during sex?
• Only if…
Drugs and reducing the size of the
“prostrate”
• Alpha-one blockers
Tamsulosin (Flomax)
Silodosin (Rapaflo)
Doxazosin (Cardura)
• Testosterone blockers
Dutasteride (Avodart)
Finasteride (Proscar)
Parietal cell
Basilar surface
H2 receptors H2
• Acyclovir (Zovirax)(4000/d)
• Famciclovir (Famvir)(750/d)
• Valacyclovir (Valtrex)(3000/d)
Tx must be started within 48-72 hours after the
first signs of a rash appear.
• +Prednisone
• PREVENTION?
SHINGLES PREVENTION
• Zostavax (Merck) to reduce the incidence of
Herpes Zoster (shingles/Hell’s fire) in people
over 50 (14 x stronger than Varivax)(risk
reduction—50%); reduces severity and
decreases post-herpetic neuralgia
DEPRESSION
“The FDA this week approved the first-ever
transdermal patch for the treatment of
depression. Simply remove the backing and
press the patch firmly over your mother’s
mouth.” Tina Fey, on Saturday Night Live (March 2006)
Drugs for depression
• Serotonin Reuptake Inhibitors (SRIs)—
fluoxetine (Prozac), sertraline (Zoloft),
paroxetine (Paxil), citalopram (Celexa),
escitalopram (Lexapro)
• Serotonin Norepinephrine Reuptake
Inhibitors (SNRIs)—venlafaxine (Effexor),
desvenlafaxine (Pristiq), duloxetine
(Cymbalta)
Drugs for depression
• The “other” category—mirtazapine (Remeron),
buproprion (Wellbutrin)
• “old” antidepressants—Tricyclic
Antidepressants (TCAs) such as amitriptyline
(Elavil), nortriptyline (Norpramin, Pamelor)—are
actually SNRIs as they inhibit the re-uptake of
both serotonin and norepinephrine;
• Drugs that block the reuptake of serotonin and
norepinephrine can be used for neuropathic
pain (duloxetine/Cymbalta and amitriptyline
(Elavil) are commonly used for neuropathic pain
Is there a better SSRI?
• Top two are sertraline and escitalopram (Lancet, Jan. 09)
• Sertraline/Zoloft—short half life; great for use in the elderly;
few drug interactions—(cheapest)
• Escitalopram/Lexapro—few drug interactions, not as many as
Paxil
• Citalopram/Celexa (not to be confused with Celebrex)—very
few drug interactions
• Fluoxetine/Prozac—half-life is too long for elderly
• Paroxetine/Paxil—many, many drug interactions and not
good for use in the elderly; is the most anti-cholinergic of all
(interferes with cholinesterase inhibitors used for Alzheimer’s
disease) and can cause anti-cholinergic side effects in elderly
(see next slide)
SSRIs—a major side effect
• Boost serotonin
• Makes ya’ happy
• Blocks dopamine
though and dopamine in
the brain is responsible
for sexual functioning
(among other things)
• Decreases libido,
anorgasmia (50-75% of
patients)
• However, if premature
ejaculation is your
problem, the SSRIs are
for you
I’m here for my SSRI prescription…