Transcript Grapefruit to Glaucoma

From Grapefruit to Glaucoma:
Interactions and Side Effects You
Should Be Aware Of
Richard L. Ogletree, Jr, Pharm.D.
Scope
 Drug
related morbidity and mortality estimated yearly cost in ambulatory
setting of $76.6 billion.
 Most
of this is due to hospitalization
 8.76
million admissions
 $47.4 billion
 28%
of hospitalizations due to drug
related causes
Arch Int Med 1995;155:1949
Hospitalized Patients
 1994
- estimated 33.1 million hospital
admissions
 Estimated 2.2 million serious ADR’s (1
in 15 patients)
 Estimated 106,000 fatal ADR’s (1 in 315
patients)
 4th to 6th leading cause of death in U.S.
Lazarou, et al. JAMA 1998;279(15):1200
Definitions
ADR - FDA
 Any
adverse event associated with the
use of a drug in humans, whether or not
considered related, including an
adverse event occurring with the use in
professional practice; from accidental or
intentional overdose, from abuse, from
withdrawal, or a failure of expected
activity
ADR - WHO
 Any
response to a drug that is noxious
and unintended and that occurs at
doses used in humans for prophylaxis,
diagnosis, or therapy of disease, or for
the modification of physiological
function
ADE - Adverse Drug Event
 Includes
medical errors
Categories of ADR’s
 Predictable
or Type A (augmented)
 side
effects
 toxic effects
 Non-predictable
 hypersensitivity
or Type B (bizarre)
responses
 idiosyncratic effects
Side Effects
A
result other than the one desired from
the agent
 diphenhydramine
- drowsiness
 nitroglycerin - headache
 prazosin - nasal stuffiness
Toxic Effects
 Direct
cellular function alteration or
damage
 colchicine
- GI upset, myopathy
 digoxin - heart block
 aminoglycosides - nephrotoxicity
Hypersensitivity
 Reacting
to substances in amounts not
causing the reaction in most individuals
 prior
exposure is necessary
 often independent of dose
 often associated with cell bound IgE
antibodies
 often associated with elevated eosinophil
counts (>300)
Hypersensitivity
 Could
range from rash to anaphylaxis
 sulfonamide
allergies
 penicillin allergies
 many hepatotoxicities
Idiosyncratic Effects
 “Abnormal
susceptibility to some drug,
protein, or other agent that is peculiar
to the individual”
 Prior exposure not necessary
 Often genetic
 acetylator
status (INH, procainamide)
 Glucose 6PD deficiency
 agranulocytosis with chloramphenicol
Assessment of ADR’s
 Temporal
relationship
 Dechallenge
 Rechallenge
 Confounders
Can Influence ADR’s
 Age
 Weight
 Race
 Sex
 Pregnancy
 Concomitant
diseases
 Other drugs or food
Drug interactions
 Pharmacological
or clinical response to
the administration of a combination of
drugs is different from that anticipated
when drugs are given alone
More simply put...
 When
the effects of one drug are
changed by presence of another drug,
food, drink, or environmental chemical
agent
Net effect could be ...
 Enhanced
response to one or more of
the components
 Antagonism of effect of one or more of
the components
 Idiosyncratic effect
Important:
 Drug
interactions could be desirable
 multiple
mechanisms of action
 decreasing necessary dose
 decreasing side effects
 antidotes
Types of Drug Interactions
Pharmaceutical
incompatibility - including
in vivo binding
 IV
admixture incompatibility
 Tetracyclines and Ca++ or iron
 Fluoroquinolones and aluminum or
iron
 Phenytoin suspension and NG tube
feedings
 Olestra or orlistat and fat soluble
Receptor site interaction
 Alpha
blockers and nasal decongestants
 Naloxone and opioids
 Clonidine in opiate withdrawal
 Vitamin k and coumadin
 Epinephrine and beta blockers
 Flumazenil and benzodiazepines
Influence of same
physiological system
 Warfarin
and NSAIDS
 Aminoglycosides and neuromuscular
blockers
 Beta blockers, digoxin, verapamil,
diltiazem
 Multiple anti-hypertensives
Changes in electrolytes or
fluid balance
 ACE
inhibitors and K+
 Lithium and high sodium intake
 Lithium and low sodium diet
 Ampho B and diuretics
Absorption interactions
 Antacids
and drugs
 Grapefruit juice
 Doxycycline and digoxin
 Erythromycin and sulfasalazine
 Omeprazole and ketoconazole
 Binding in GI tract
Distribution
 Protein
binding
 mostly
theoretical
 generally transient
 warfarin and phenytoin
 Tissue
binding
 quinidine
and digoxin
Drug metabolism - induction
 Inducers
 phenytoin
 phenobarbital
 carbamazepine
 rifampin
 cigarette
smoke
 St. John’s wort
Drug metabolism - induction
 Be
careful with
 oral
contraceptives
 HRT
 cyclosporine
Drug metabolism - inhibition
 Inhibitors
 azole
antifungals
 ketoconazole
 itraconazole
 macrolide
antibiotic
 erythromycin
 clarithromycin
 cimetidine
Drug metabolism - inhibition
 More
inhibitors
 SSRI’s
 fluvoxamine
 paroxetine
 fluoxetine
 nefazodone
 fluoroquinolones
 amiodarone
Grapefruit Juice
 Caused
by furanocoumarin fractions
 Takes place in GI tract
 Inhibition of CYP450 1A2 & 3A4
 Prevents GI metabolism
 Increases absorption
 Increased peak
Grapefruit Juice Interactions
 Calcium
channel blockers (felodipine,
nisoldipine, nifedipine, verapamil)
 Cyclosporine
 Midazolam (oral)
 Cisapride
 Simvastatin, lovastatin
Predicting Grapefruit Juice
Interactions
 Absorption
 Bioavailability
 CYP
450 esp. 3A4 metabolism
 Look on insert
HMG - CoA Reductase
Inhibitors (“statins”)
 Lovastatin
(Mevacor®)
 Pravastatin (Pravachol®)
 Simvastatin (Zocor®)
 Fluvastatin (Lescol®)
 Atorvastatin (Lipitor®)
 Rosuvastatin (Crestor®)
HMG - CoA Reductase
Inhibitors (“statins”)
 Lower
cholesterol
 Inhibit rate limiting reaction in
mevalonate pathway
 Other mevalonic acid products
 dilochol
(liver, retina)
 ubiquinone (muscles)
Concerns with “Statins”
 Liver
problems
 Concern
 Muscle
with ALT or AST > 3X ULN
problems
 Concern
 Consider
with CK > 10X ULN
ubiquinone supplementation
in selected patients
Liver Monitoring with
“Statins”
 Fluvastatin
(Lescol®)
bl, 12 wks
 Simvastatin (Zocor®)
bl, 3 mo. (80 mg), 6 mo. 12 mo.
 Atorvastatin (Lipitor®) bl, 12 wks, 2X/year
 Lovastatin (Mevacor®) bl, 6 wks, 12 wks, 2X/year
 Rosuvastatin (Crestor®) bl, 12 wks, 2X/year
Note: This is with initiation and with each dose increase.
 Pravastatin (Pravachol®) bl, prior to dose increase and
when “clinically indicated”
HMG - CoA Reductase
Inhibitors (“statins”)
Drugs which increase levels can increase
the chance of myopathy or
rhabdomyolysis
 Cyclosporin
 Gemfibrozil
 Niacin
 Erythromycin,
Clarithromycin
 Itraconazole
 Nefazodone
(Serzone®)
HMG - CoA Reductase
Inhibitors (“statins”)
Situations which predispose to myopathy
could increase the chance of myopathy
or rhabdomyolysis
 major
surgery
 severe acute infection
 trauma
 seizures
 electrolyte disturbances
 hypotension
HMG - CoA Reductase
Inhibitors (“statins”)
 Concerns
 unexplained
muscle pain
 accident
 hospitalization?
 Theoretical
concerns
 Metformin
 Stavudine
and other NRTI’s
 weight-lifting?
Zocor (simvastatin): Label Change - New
Restrictions, Contraindications, and Dose
Limitations
Posted:06/08/2011
FDA notified healthcare professionals that it is recommending
limiting the use of the highest approved dose of the cholesterollowering medication simvastatin (80 mg) because of increased risk
of muscle damage. Patients taking simvastatin 80 mg daily have
an increased risk of myopathy compared to patients taking lower
doses of this drug or other drugs in the same class. This risk
appears to be higher during the first year of treatment, is often the
result of interactions with certain medicines, and is frequently
associated with a genetic predisposition toward simvastatinrelated myopathy. The most serious form of myopathy, called
rhabdomyolysis, can damage the kidneys and lead to kidney
failure which can be fatal. FDA is requiring changes to the
simvastatin label to add new contraindications (should not be
used with certain medications) and dose limitations for using
simvastatin with certain medicines.
Simvastatin
•
Contraindicated











Itraconazole
Ketoconazole
Posaconazole
Erythromycin
Clarithromycin
Telithromycin
HIV protease inhibitors
Nefazodone
Gemfibrozil
Cyclosporine
Danazol
Simvastatin
•
Contraindicated











Itraconazole
Ketoconazole
Posaconazole
Erythromycin
Clarithromycin
Telithromycin
HIV protease inhibitors
Nefazodone
Gemfibrozil
Cyclosporine
Danazol
Simvastatin

10 mg/day
 Diltiazem
 Verapamil

20 mg/day
 Amiodarone
 Amlodipine
 Ranolazine

Grapefruit juice
 Avoid
> 1 quart/day
Lovastatin - Feb. 28, 2012

•
Strong CYP3A4 inhibitors are contraindicated
Avoid


•
20 mg/ day



•
Danazol
Diltiazem
Verapamil
40 mg


Cyclosporine
Gemfibrozil
amiodarone
Grapefruit juice

Avoid > 1 quart/day
Also from Feb. 28, 2012
 Added
to warnings
 memory
problems
 new onset diabetes
 Removed
- recommendation for routine
liver enzymes Liver injury from statins is rare, and
monitoring does not seem to be
effective in predicting or preventing
such damage.
Atorva
Fluva
Pitava
Lova
Prava
Rosuva
Vytorin
*
Simva
%↓
LDL-C
-----
40 mg
1 mg
20 mg
20 mg
-----
-----
10 mg
30%
10 mg
80 mg
2 mg
40 or 80
mg
40 mg
-----
-----
20 mg
38%
20 mg
-----
4 mg
80 mg
80 mg
5 mg
10/10
mg
40 mg
41%
40 mg
-----
-----
-----
10 mg
10/20
mg
80 mg
47%
80 mg
-----
-----
-----
20 mg
10/40
mg
-----
55%
-----
-----
-----
40 mg
10/80
mg
-----
63%
*No incremental benefit of Vytorin on cardiovascular morbidity
and mortality over and above that demonstrated for simvastatin
Quinolones
 Photosensitivity
 Drug
interactions
 Rash
 Dizziness
 Seizure
 Insomnia
 Loss
of glycemic control
 Tendon rupture
Quinolones - Tendon Rupture
 More
common in 60 y/o and older
 Median of 6 days until onset
 Achilles most common
 Often bilateral
 Most recover by 2 months
 Stop at first sign of tendon pain
inflammation, or weakness
 Use care in weightlifters?
Quinolones - Tendon Disorder
 Case-control
study - n = 46,766
 Adjusted relative risk
 > 60 years old
 current
use
 concurrent steroids
12.8)
 recent or past use
<
60 years old
OR
3.5
OR
(2.3 - 5.3)
6.2 (3.0 -
ns
ns
van der Linden, et al. BMJ 2002;324:1306-1307
Tetracyclines
 Photosensitivity
 Interaction
with polyvalent cations
 Tooth staining
 Increased intracranial pressure (ICP)
 Also called BIH (Benign Intracranial
Hypertension) or Psuedotumor Cerebri
Tetracyclines - Tooth Staining
 Tetracycline
- during tooth formation
 Binds to calcium
 Cervical third of tooth (gingival
margin)
 Avoid during pregnancy
 Avoid in children
Tetracyclines - Tooth Staining
 Minocycline
- after tooth eruption
 Incisional edge, middle third
 Binds to iron?
 Binds to glycoproteins oxidizing to form
quinone?
 > 100 mg/day
 > 1 month duration
 3 – 6 % incidence
Minocycline - Tooth Staining
Prevention
 Give
an antioxidant
 Give lower doses
 100 mg/day for 2 weeks, then 50
mg/day
Tetracyclines - BIH
 Most
common with minocycline
 Also seen with tetracycline and
doxycycline
 More common in normal weight
(idiopathic more common in obese)
 More common in adolescent and
young adult women
BIH
 The
diagnostic criteria are:
 Increased
intracranial pressure (> 200 mm water)
 Normal neurological examination except for
papilledema and/or sixth nerve palsy
 No mass or ventricular enlargement on imaging
 Normal CSF protein and white cell count
 No clinical or imaging evidence of venous sinus
thrombosis
 There may be decreased visual acuity and visual field
defects.
Tetracyclines - BIH
 Not
associated with dose
 Often occurs in first 2 to 4 weeks of
therapy
 Other drugs causing BIH
 Vitamin
A analogs (isotretinoin)
 Steroids (esp in withdrawal)
Tetracyclines - BIH
 Ask
about
 headaches
 tinnitis
 blurred
vision
 double vision
 Check
for papilledema
Levothyroxine
 Very
commonly used
 Hypothyroidism
 primary
 secondary
 Weight
loss - not a good idea
 Anemia predisposes to intolerance
 watch
for tachycardia, palpitations, nervousness
 correct low Hct (esp if below 28) before starting
 start low 25 mcg or less
Levothyroxine interactions
 Calcium
 Iron
(including prenatal vitamins or other
vitamin/mineral preps)
 Soy protein
 all
decrease absorption
 separate by at least 2 hours
SSRI’s
 Anxiety
 Insomnia
 Sexual
dysfunction
 Withdrawal
 Interaction with DM cough preps
 Tooth grinding
 GI bleeds
SSRI withdrawal
 Disequilibrium
 dizziness
 vertigo
 ataxia
 swimming
or spaced out feeling
 impaired coordination
SSRI withdrawal
 GI
disturbances
 nausea
 vomiting
 diarrhea
 anorexia
 Flu-like
symptoms
SSRI withdrawal
 Sensory
disturbances
 auditory
hallucinations
 paresthesias
 electrical shock sensations
 CNS
symptoms
 agitation
 confusion
 headache
 lethargy
SSRI withdrawal
 Sleep
disturbances
 insomnia
 nightmares
 vivid
 relapse
dreams
of depression
SSRI withdrawal most common
 Dizziness
 Nausea
 Lethargy
 Headache
SSRI withdrawal
 Onset
- 1 to 5 days after disruption
(longer for fluoxetine)
 Duration - 1 to 3 weeks
 Prevention - slow taper of meds
 Ginger has been helpful with nausea
and vertigo
SSRI - DM interaction
 Dextromethorphan
 D-isomer
of levorphanol
 Cough suppressant
 NMDA antagonist
 Decreases glutamate excitability
Dextromethorphan
 Cough/cold
preps
 Adjuvant for pain management
(including neuropathic pain)
 Decrease opioid tolerance
 Interacts with MOAI’s
 Interacts with SSRI’s
Serotonin syndrome
 Mental
status changes
 Tremor
 Restlessness
 Incoordination
 Shivering
 Increased
temperature
Serotonin syndrome
 Diaphoresis
 Hyperreflexia
 Myoclonus
 Diarrhea
 Convulsions
 Could
be fatal
SSRI - DM interaction
If needing a cough suppressant use:
 Benzonatate
 Carbetapentane
combinations
SSRI Induced Bruxism
 Often
nocturnal
 More common in women
 Probably dopaminergic (similar to
neuroleptics)
 2 to 4 weeks from starting therapy
(reported range - 1 week to 11 months)
 Sometimes, first noticed by dentist
SSRI Induced Bruxism
 Ask
about/look for
 muscle
tension
 headache
 joint pain (tmj)
 muscle pain (chewing muscles)
 masseter hypetrophy
SSRI Induced Bruxism Management
 Changing
agents - probably not helpful
 Decrease dose of SSRI
 Buspirone
5
- 30 mg
 usually hs dosing
 should have an effect in 1 to 4 weeks
SSRI’s and GI Bleeds
 SSRI
antidepressants
 most
 Non
1.9)
OR 3.0 (2.1 - 4.4)
likely - trazodone
SSRI antideps
OR 1.4 (1.1 -
Abajo, et al. BMJ 1999;319:1106-1109
SSRI’s and GI Bleeds
Not adjusted for NSAID use
 SSRI antidepressants
OR 2.6 (1.7 - 3.8)
 NSAID’s
OR 3.7 (3.2 - 4.4)
 SSRI + NSAID
OR 15.6 (6.6 - 36.6)
Abajo, et al. BMJ 1999;319:1106-1109
8/24/2012
Abnormal heart rhythms
associated with high doses of
Celexa (citalopram hydrobromide)
The U.S. Food and Drug Administration (FDA)
is informing healthcare professionals and
patients that the antidepressant Celexa
(citalopram hydrobromide; also marketed as
generics) should no longer be used at doses
greater than 40 mg per day because it can cause
abnormal changes in the electrical activity of
the heart. Studies did not show a benefit in the
treatment of depression at doses higher than 40
mg per day.
 Maximum
dose - 40 mg/day due to prolongation of QT
interval
 Max of 20 mg/day
 60
YO and older
 liver impairment
 poor CYP2C19 metabolizers
 taking cimetidine (Tagamet)
 Not
recommended for
 CHF
patients
 bradyarrhythmias,
 concomitant use of medications that prolong the QT interval
Monitor ECGs and electrolytes
 Discontinue if patient has persistent QTc measurements
of > 500 ms.

Zyvox
The U.S. Food and Drug Administration
(FDA) has received reports of serious
central nervous system (CNS) reactions
when the antibacterial drug linezolid
(marketed as Zyvox) is given to patients
taking psychiatric medications that work
through the serotonin system of the brain
(serotonergic psychiatric medications).
Linezolid
 Inhibits
monoamine oxidase A
 Results in decreased serotonin metabolism
 Serotonin toxicity = Serotonin syndrome
 Should avoid linezolid in patients taking
serotonergic drugs unless treating:
 VRE
 Noscomial pneumonia
 Complicated skin and skin structure infections
(including MRSA)
 Emergent
cases
 Use
alternate therapy for linezolid
 Stop serotonergic drug and monitor patient
for CNS toxicity for:
 Two
weeks (five with fluoxetine)
 24 hours after last dose of linezolid
 whichever comes first
 Non-emergent
 D/C
cases
serotonergic drug 2 weeks before
starting linezolid (5 weeks for fluoxetine)
 Resume serotonergic drug 24 hours after
last dose of linezolid
 Educate patient of signs and symptoms of
Serotonin Syndrome
 Report adverse events to FDA MedWatch
Serotonergic Psychiatric
Medications
 SSRIs
 SNRIs
 Tricyclics
 MAOIs
 Other:
 Amoxapine
 Maprotiline
 Nefazodone
 Trazodone
 Buproprion
 Buspirone
 Vilazodone
Serotonin Syndrome
Symptoms
 Tremor
 Altered
mental status
 Clonus
 Muscular
hypertonicity
 hyperthermia
7/26/2011
Serious CNS reactions possible
when methylene blue is given to
patients taking certain
psychiatric medications
The U.S. Food and Drug Administration (FDA)
has received reports of serious central nervous
system (CNS) reactions when the drug
methylene blue is given to patients taking
psychiatric medications that work through the
serotonin system of the brain (serotonergic
psychiatric medications). Methylene blue is
commonly used in diagnostic procedures and
is also used to treat a number of medical
conditions.
Methylene blue
 Monoamine
oxidase inhibitor
properties
 Urgent treatment of:
 Methemoglobinemia
 Ifosfamide-induced
 Cyanide
poisoning
encephalopathy
Also
 Urinary
medications
 UTA
 Urogesic
blue
Antihistamine/Decongestant
Combinations
 Newer
antihistamines
 Less sedation
 Long duration of activity
 Good safety profiles
Antihistamine/Decongestant
Combinations
 Same
decongestants (usually
pseudoephedrine)
 Increased heart rate
 Increased blood pressure
 Prostate disturbance
 Decreased appetite
 Anxiety
 Insomnia
Decongestant Profiles
500
450
400
350
300
250
200
150
100
50
0
Claritin D 12
Zyrtec D
Allegra D
Claritin D 24
3.9
4.4
5
7
3/12/2013
Azithromycin (Zithromax or
Zmax) and the risk of potentially
fatal heart rhythms
The
U.S. Food and Drug Administration
(FDA) is warning the public that
azithromycin (Zithromax or Zmax) can
cause abnormal changes in the electrical
activity of the heart that may lead to a
potentially fatal irregular heart rhythm.
Patients
at particular risk for developing
this condition include those with known
risk factors such as:
existing QT interval prolongation
low blood levels of potassium or
magnesium
a slower than normal heart rate
use of certain drugs used to treat
abnormal heart rhythms
arrhythmias
6/25/2014
FDA warns of rare but serious
hypersensitivity reactions with
certain over-the-counter topical
acne products
The
U.S. Food and Drug Administration
(FDA) is warning that certain over-thecounter (OTC) topical acne products can
cause rare but serious and potentially lifethreatening allergic reactions or severe
irritation.
The
hypersensitivity reactions may occur
within minutes to a day or longer after
product use.
 The
OTC topical acne products of concern are
marketed under various brand names such as:
Proactiv
Neutrogena
MaxClarity
Oxy
Ambi
Aveeno
Clean & Clear
 They
are available as gels, lotions, face washes,
solutions, cleansing pads, toners, face scrubs, and
other products.
Anticholinergic Drugs
Toxidrome mneumonic
 Blind
as a bat
 Dry as a bone
 Mad as a hatter
 Hot as a hare
 Red as a beet
Counseling points
 Blind
as a bat –
 blurry
vision
 dilated pupils
 caution with driving
 recommend sunglasses
 Dry
as a bone
 decreased
saliva
 increased risk of cavities
 recommend dental exams
 Mad
as a hatter
 confusion
 memory
loss
Counseling points




Hot as a hare
Red as a beet
Both are associated with heat intolerance
Counsel about heat precautions
Anticholinergics - uses
 GI
 dicyclomine
 hyoscyamine
 Overactive
Bladder
 oxybutynin
 tolterodine
 darefenacin
 solefenacin
Anticholinergics - uses
 Excessive
salivation
 glycopyrrolate
 atropine
 scopolamine
 Antipsychotic
induced EPS
 benztropine
 trihexyphenidyl
Anticholinergic Drugs
A drug interaction of note
All solid oral dosage forms of potassium
chloride are contraindicated in any patient in
whom there is structural, pathological (e.g.,
diabetic gastroparesis), or pharmacologic (use
of anticholinergic agents or other agents with
anticholinergic properties at sufficient doses to
exert anticholinergic effects) cause for arrest or
delay in tablet passage through the
gastrointestinal tract.
Prepare an aqueous (water) suspension as follows:
 Place
the whole tablet(s) in approximately one-half glass of water (4
fluid ounces).
 Allow approximately 2 minutes for the tablet(s) to disintegrate.
 Stir for about half a minute after the tablet(s) has disintegrated.
 Swirl the suspension and consume the entire contents of the glass
immediately by drinking or by the use of a straw.
 Add another one fluid ounce of water, swirl, and consume
immediately.
 Then, add an additional one fluid ounce of water, swirl, and
consume immediately.
Other agents with potential
for heat intolerance
 Amphetamines
 Pseudoephedrine
 Phenylepherine
 Zonisamide
 Topiramate
Other Side Effects with
Topiramate
 Taste
disturbance
 Confusion
 Word-finding difficulties
 Loss of appetite
 Visual disturbance
Lotrisone®
 Antifungal/Corticosteroid
 Often
for “jock itch” or diaper rash
 Skin thinning
 Functional “occlusive dressing”
 Systemic side effects
 “Addictive”
Glucocorticoids - Systemic
 Increased
blood glucose
 HPA axis suppression
 Decreased bone mineral density
 Skin thinning
 Withdrawal
 Glaucoma
Glaucoma
 Or
increased intraocular pressure
 Most common with ophthalmic dosing use special care after LASIK
 Also seen with systemic therapy
 What about inhaled steroids?
Inhaled Glucocorticoids
 Glaucoma
 Family
or IOP risk
history
OR
 High doses and fam hx OR
2.6
6.3
(1.2 - 5.8)
(1.0 - 38.6)
 No
association when no fam. Hx
 Ask about family history of glaucoma or
IOP when prescribing inhaled steroids
Mitchell, et al Ophthalmology 1999;106:2301-2306
Report ADR’s
 Larger
patient populations
 Open-ended time frame
 Not limited to “healthy adults”
 JCAHO requires an institutional policy
Check Updates
 Clin-Alert
 Australian
Adverse Drug Reaction
Bulletin
http://www.health.gov.au/tga/adr/aad
rb.htm
 Med-Safe (New Zealand)
http://www.medsafe.govt.nz/profs.htm
 Dear Doctor letters
 Institutional newsletter
Lactulose
A theoretical hazard may exist for patients being
treated with lactulose solution who may be required
to undergo electrocautery procedures during
proctoscopy or colonoscopy. Accumulation of H2 gas
in significant concentration in the presence of an
electrical spark may result in an explosive reaction.
Although this complication has not been reported
with lactulose, patients on lactulose therapy
undergoing such procedures should have a thorough
bowel cleansing with a non-fermentable solution.
Insufflation of CO2 as an additional safeguard may be
pursued but is considered to be a redundant measure.
Brooke Tullos
Mary Wooten
Infectious Disease
Infectious Disease
Travis King
Travis King
KABOOM
!
How do you say you’re sorry?
FDA Alerts
7/09/2015
FDA strengthens warning that
non-aspirin nonsteroidal antiinflammatory drugs (NSAIDs) can
cause heart attacks or strokes
 The
U.S. Food and Drug Administration (FDA) is
strengthening an existing label warning that nonaspirin nonsteroidal anti-inflammatory drugs
(NSAIDs) increase the chance of a heart attack or
stroke.
 Based
on our comprehensive review of new safety
information, the FDA is requiring updates to the
drug labels of all prescription NSAIDs.
 The
FDA will also request updates to the OTC nonaspirin NSAID Drug Facts labels.
7/01/2015
FDA evaluating the potential
risks of using codeine cough-andcold medicines in children