Transcript Identifying and Managing Alcohol and Medication

Identifying and Managing Alcohol and
Medication Interactions in Older Adults
Patricia W. Slattum, PharmD, PhD, CGP
Virginia Commonwealth University
AAAG Northern Virginia Regional Conference 2011
Objectives
• Identify medications that may interact with
alcohol and potential outcomes in older adults.
• Describe risk factors for adverse events from
alcohol and medication interactions among older
adults.
• Discuss treatment issues in pain, falls, depression
and insomnia when alcohol and medication
interactions play a role.
• Using case studies, develop strategies to manage
alcohol and medication interactions in older
adults.
The Aging Body and Medications
• Our bodies experience
physical changes as we
age.
• These changes can
impact
– How well medications
get into and out of the
body.
– How the body responds
to medications.
Changes in Body Composition with Aging
• Body fat increases and
body water decreases as a
percent of body weight.
• Example: Alcohol
– Alcohol goes into body
water.
– With less water, blood
alcohol concentrations are
higher.
Delafuente JC. Consult Pharm 2008, 23:324-34.
Changes in the Kidney and Liver
With Aging
• Most drugs leave the
body through the liver
and kidney.
– Liver and kidney
function decline with
aging.
– Drugs take longer to get
out of the body.
– Older adults may need
lower doses or a longer
time between doses.
Delafuente JC. Consult Pharm 2008, 23:324-34.
Changes in Drug Response with Aging
• Older adults may
– Have decreased functional
ability before taking the
medication.
– Be more sensitive to
medications.
– Be less able to compensate for
the effects of medications.
• This may result in unwanted
effects of medications.
Bowie M, Slattum P. J Geriatr Pharmacother 2007;5: 263-303
Atypical Presentation of Adverse
Drug Events in Older Adults
• Altered mental status/confusion
• Fatigue
• Falling
• Constipation
• Urinary Incontinence
• Depression
• Dizziness
Adverse events often mistaken for normal aging!
Tangiisuran B, et al. Age and Ageing 2009;38:358-359.
Weingart SN, et al. Arch Intern Med 2005;165:234-240.
Schmader KE, et al. Am J Med 2004;116:394-401.
Drug-Drug Interactions
• Patient groups at increased risk:
– Older adults taking multiple medications
– Those seeing more than one doctor
– Those being infrequently or
inadequately monitored
– Those with impaired liver or kidney
function
• Warfarin (Coumadin®) is a high-risk
medication for drug interactions.
• Dietary supplements, herbal products
and over-the –counter medications
must also be considered.
• Pharmacists look for drug interactions
when filling prescriptions.
Mallet L, et al. Lancet 2007;370:185-91.
Drug-Alcohol Interactions
• Mixing certain medications with
alcohol can cause adverse events
– Mixing alcohol with sedatives, pain
medications or other drugs acting on the
brain can result in increased sedation,
unsteadiness or falls.
– Mixing alcohol with aspirin, ibuprofen,
naproxen or similar drugs can increase
risk of gastrointestinal bleeding.
– Mixing alcohol with blood pressure
lowering medications can cause blood
pressure to go too low.
Harmful interactions: Mixing alcohol with Medicines Brochure
https://pubs.niaaa.nih.gov/publications/Medicine/medicine.htm
Alcohol and Acetaminophen
• Acetaminophen is found in many combination
pain products.
• Recommendations for maximum dose/day
recently decreased to 3,000 mg/day.
• When taken during or right after drinking
increases the risk of liver damage.
• Chronic drinking may increase the production
of toxic metabolites of acetaminophen.
http://www.rochester.edu/uhs/healthtopics/Alcohol/interactions.html
https://webapps.ou.edu/alcohol/docs/13EtohandMedicationInteractions4054.pdf
Treatment Issues
• Pain
• Depression
• Insomnia
Pain
• Many medications recommended to manage
pain in older adults interact with alcohol:
– Acetaminophen
– Nonsteroidal Anti-inflammatory Drugs
– Opiate analgesics
• Some patients may be using alcohol to selftreat pain.
Case LR
LR is an 86-year-old female whose primary complaint is dry
mouth. LR lives alone in her own home, but is increasingly
having difficulty with instrumental activities of daily living
such as paying her bills and shopping for groceries. She
dozes off frequently during the day and seems unsteady on
her feet. When her daughter tries to discuss this with her,
she claims that this is “normal” for someone her age and to
stop worrying her. LR brings up the issue of dry mouth with
each of her three doctors, but the only recommendations
she has received is to suck on hard candy and drink more
fluids. She doesn’t feel that these measures really help. Her
daughter requests a medication assessment to determine if
her medications may be contributing to her dry mouth.
Her current medication regimen:
Morning
1 Calcium 600mg
1 Gabapentin (Neurontin®) 800mg
1 Potassium chloride 20mEq
1 Furosemide (Lasix®) 20mg
1 digoxin (Lanoxin®) 0.125 mg
½ metoprolol 25mg
Noon
1 Duloxetine (Cymbalta®) 60mg
1 Gabapentin (Neurontin®) 800mg
2 Oxaprozin (Daypro®) 600mg
Night
2 Quetiapine (Seroquel®) 25mg
1 Amitriptyline 50mg
1 Temazepam (Restoril®) 15mg
1 Gabapentin (Neurontin®) 800mg
½ metoprolol 25mg
PRN: Mylanta, Gas X, and Tylenol
started 3 years ago
started 2 years ago
started 4 years ago
started 4 years ago
started 3 years ago
started 8 years ago
started 3 weeks ago
started 2 years ago
started 1.5 years ago
started 1 year ago
started 3 months ago
started 10 years ago
started 2 years ago
started 8 years ago
During an interview, LR admitted to changing
the administration times of some of her
medications and to consuming “some” alcohol
most days of the week. She also takes 1000
mg of acetaminophen in the morning and
before going to bed in the evening each day.
• What are the signs that LR may be
experiencing medication-related problems?
• What are your concerns about LR’s medication
use?
• What are your recommendations?
Depression
• Alcohol interacts with all classes of
antidepressants.
• Major depression and alcohol use disorder:
either doubles the chance of having the other.
• There appears to be a causal link between
alcohol use disorder and major depression.
• Best treatment approaches for the older adult
are still unknown.
Boden and Fergussen. Addiction 2011;106:906-914.
Case SP
SP is an 82 year old white female who suffers
from chronic obstructive pulmonary disorder
(COPD). She had a medical history of aortic
aneurysm which was treated surgically, and was
diagnosed with depression in the past for which
she was treated with antidepressants. She was
a smoker for the last 40 years and a moderate
alcohol-drinker. After moving to a senior
congregate living center, she started drinking
more heavily leading to incidences of falls and
fractured arm.
Mohanty M, Slattum PW. Age in Action 2011; Summer
Her prescriptions consisted of 11 medications:
• Advair (combination of fluticasone & salmeterol),
tiotropium, albuterol, montelukast, and Mucinex
(guaifenesin and pseudoephedrine) for COPD
• paroxetine for depression
• simvastatin for cholesterol
• supplements (iron and calcium)
• She was also taking digoxin for congestive heart failure
and primodine for tremor. However, during the
interview she did not mention a history of tremor or
heart failure.
After checking for potential drug interactions,
it was found that primidone and ethanol have
a moderate interaction, while paroxetine and
ethanol have a minor level of drug interaction.
SP decided to abstain from drinking and
smoking following the three sessions of
counselling with her physician. After quitting
alcohol consumption, she has not reported
any incidence of fall or other forms of injury.
Mohanty M, Slattum PW. Age in Action 2011; Summer
• What were the signs that SP might be
experiencing a medication-related problem?
• What recommendations do you have for SP?
Insomnia
• Alcohol interacts significantly with sedatives
used to treat insomnia.
• Alcohol worsens sleep disorders.
• Options:
– Treat underlying health conditions
– Evaluate medications as a contributor
– Sleep hygiene: daytime exercise, limit caffeine,
exposure to natural light during day, limit napping
during the day, etc.
Case OP
OP is an 80 year old WF living in an assisted living
community. At the time of her medication review by a
pharmacist, her family expressed concerns that she had
been “loopy and out of it” recently. She also experienced a
fall in the evening but was not injured. There hadn’t been
any recent changes in her medications, but during the
pharmacist’s interview, OP mentioned drinking wine in the
evening. The medication technician, who often works on
OP’s floor, stated that OP “stays up all night drinking wine
and watching TV then sleeps throughout the day.” The
medication technician was not sure how much she drinks
nightly or whether she was drinking more than usual. OP
was taking 16 scheduled prescription medications and 5 as
needed medications.
Mohanty M, Slattum PW. Age in Action 2011; Summer
Her scheduled prescriptions included:
–
–
–
–
–
–
–
–
–
–
–
lisinopril, nadolol, and amlodipine for hypertension
furosemide for edema
levothyroxine for thyroid replacement
albuterol for asthma
pantoprazole for gastroesophageal reflux disease (GERD)
solifenacin for urinary incontinence
citalopram, bupropion, and quetiapine for depression
trazodone for insomnia and depression
tramadol for pain
supplements of potassium and Vitamin D
Additionally, trazodone (sleep-inducer), promethazine (for
nausea and vomiting), docusate (for constipation),
acetaminophen and cholestyramine (for loose stool) were
prescribed as needed.
Mohanty M, Slattum PW. Age in Action 2011; Summer
• What are the signs that OP may be
experiencing a medication-related problem?
• What recommendations do you have?
Evaluation of her medication regimen indicated that
bupropion, quetiapine, trazodone, and tramadol have
the potential to interact with alcohol increasing her
CNS depression and risk for fall. The pharmacist
recommended to the physician to changing trazodone
to use only when needed, and to discontinue
quetiapine, if possible. OP was educated about the
potential risk of mixing alcohol and her medications
and was advised to stop consuming alcohol by her
pharmacist, physician and family. OP stopped
consuming alcohol and some changes in her drug
regimen were instituted, after which her functional and
cognitive status improved.
Mohanty M, Slattum PW. Age in Action 2011; Summer
Summary
• Falls and other problems may be a
consequence of medication and alcohol
interactions in older adults.
• Depression, insomnia and pain present
difficult treatment decisions when alcohol is
consumed concurrently.
• Consider medication discontinuation in
patients who continue to consume alcohol.
Improving the Quality of Medication Use in
Elderly Patients: A Not-So-Simple Prescription
“Putting the pieces of the puzzle together to
create a solution remains a formidable, but
not insurmountable task….All the pieces of
the puzzle lie before us; it remains for us to
find a way to fit them together”
Jerry H. Gurwitz, M.D.
Gurwitz JH, Arch Intern Med 2002; 162:1670-3
Gurwitz JH, Arch Intern Med 2002; 162:1670-3