Tag Archives: Drug-Drug Interactions

Is Your Child on Multiple Meds? He May Be at Increased Risk for Adverse Events

When we think of drug interactions and adverse effects, we worry more about adults — and particularly seniors — who are often on a cocktail of drugs. But new research shows that children and teens are also at risk for adverse effects – some quite serious – from being on multiple drugs.

The study, published in September in the journal Pediatrics, found that one in five children is on regular prescription medication, and one in twelve is potentially at risk for serious side effects from two or more drugs interacting with each other. In particular, teen girls have a higher risk than boys.

In many cases, this happens when a child is on a chronic long-term medication, such as an antidepressant, birth control or an ADHD (attention-deficit/hyperactivity disorder) stimulant. He or she falls ill and is given an antibiotic, a short-term medication. At that point, there is the potential for those two drugs to interact and cause adverse effects.

The Risks of Using Multiple Drugs in Children

About 200,000 children (age 17 and younger) go to the ER each year as a result of an adverse drug event, according to the CDC. What wasn’t known before was how many children and teens were on prescription drugs, and how many were taking two or more at the same time — called concurrent use — and the risk from drug-to-drug interaction.

The researchers found that boys age six to 12 years old had the highest use of concurrent prescription drugs at 12%, followed by teen boys and girls at 10%.

Significantly, the risk of drug-to-drug interactions for teen girls on antidepressants was much higher at 18%, than for boys at almost 7%, because more teen girls were given antibiotics for infections.

The most common side effect seen with drug-drug interactions in the study was abnormal heart rhythm, with a risk of its leading to sudden death. It also found that the most commonly used combinations of drugs were associated with effects such as suicidal tendencies or depressive symptoms. These combinations include taking an antidepressant with at least one other psychotropic medication or a birth control pill.

What Parents Need to Know

Over-the-counter (OTC) pain and fever medicines and antacids can also potentially interact with antidepressants and other chronic drugs, the study authors pointed out.

“Parents need to be aware of these adverse effects, which are not typical but could happen for many reasons,” said Dima Qato, PharmD, MPH, PhD, associate professor of pharmacy at the University of Illinois, Chicago, and lead study author. “They need to be aware of the drugs that can cause it, which are not limited to prescription medicines, but can also be [OTC] analgesics and acid reflux drugs used to treat heartburn.”

If children see more than one doctor and they’re given different prescription drugs by different providers, parents need to inform their physicians and pharmacists about all drugs they’re on.

About 200,000 children (age 17 and younger) go to the ER each year as a result of an adverse drug event.

Sudden cardiac deaths are under-reported in children, but are more common among those who are athletes, have asthma or are on antidepressants.

“It’s a concern that children are taking medications that expose them to higher risk,” Qato cautioned. “We may not know, as physicians, pharmacists and school nurses, that this could happen.”

“We hope people will be more vigilant about giving children multiple medications, particularly teen girls,” she added.

Communication Key to Avoid Risk

“The study brings up some really good points,” said Siyi Yung, MD, a pediatrician and attending physician at the University of California, Los Angeles Mattel Children’s Hospital. “It shows how many kids are at risk for drug interactions. It’s definitely a problem, even if it’s not as prevalent as in elderly people. We need to be aware of it because of how often children go to the emergency room for adverse effects.”

But she cautioned that the study looked at potential interactions, not actual events that took place and were reported. These potential adverse effects are not common, but could happen.

“The potential is high, but in pediatrics, when we prescribe for a chronic period of time, we usually follow them very closely, especially if it’s an antidepressant, via phone or in-person,” Yung said. “When patients are already on chronic medication, and we are the ones prescribing an antibiotic, that is when it gets trickier.”

When an outside prescriber such as a psychiatrist writes up a prescription for an antidepressant, and communication between the doctor, the parents and the pediatrician is not clear, this can lead to gaps in knowledge which can complicate things, especially when the child is put on two or more drugs. Intake forms at clinics and hospitals always ask about current medications, but patients and caregivers can slip up and forget to list them all.

“Someone could come in for a urinary tract infection, forget to tell the doctor they’re also on antidepressants, and get antibiotics for their UTI, which could lead to a drug interaction,” Yung explained. “For many patients, their parents give us an oral report, but often can’t remember the name of the medicine, its potency, etc.”

System Improvements Needed

Part of the problem also lies with unnecessary prescriptions for antibiotics, which Yung said are often doled out when children are brought to the ER or urgent care, and seen by unfamiliar doctors. Antibiotics are only effective for bacteria-based infections. More than 60,000 children end up at the ER as a result of an adverse drug event from an antibiotic each year, according to the CDC.

“I think it drives home the need to improve our healthcare system so patients are not forced to go to the ER when they could be served by their normal clinic or primary care provider,” Yung said.

Similarly, for ADHD, when a parent raises concerns, there may be an explanation for a child’s behavior when physicians investigate, and maybe even contact the teachers, before prescribing drugs.

Parents also often start a child on OTC medicines without being aware of how they might interact with the chronic drugs the child is on, so it’s important to ask the doctor what medicines and supplements (including vitamins) should be avoided every time you meet with the doctor about the chronic drug, she said.

Opioid-Related Complications Sending More Seniors to Hospital

Despite efforts to reduce the use of prescription opioids, a significant number of seniors continue to take them, and an increasing number of seniors are landing in the hospital because of opioid-related complications.

Between 2010 and 2015, the number of emergency room (ER) visits among seniors related to taking opioids more than doubled, while hospitalizations increased by 54%, according to a new report from the Agency for Healthcare Research and Quality (AHRQ). In 2015, there were more than 124,000 hospitalizations and 36,000 ER visits as a result of complications from opioids.

Researchers said that as seniors tend to be prescribed more drugs than younger adults, they are more susceptible not only to adverse events from opioids themselves because of body changes, but from the opioids interacting with other medications. Many seniors also have mental health issues, cognitive decline and dementia that, compounded with taking opioids, puts them at increased risk for adverse events such as falls or delirium that can lead to a hospital visit.

An associated AHRQ report found that between 2015 and 2016, about 20% of seniors – around 10 million – filled at least one opioid prescription and 7% – about 4 million – received four or more.

AHRQ Center for Evidence and Practice Director Arlene Bierman, MD, who worked on the first report, told HealthDay that healthcare providers can address the situation by using non-opioid pain medications or even non-drug treatments before opioids. And if opioids are deemed necessary, the lowest possible dose should be prescribed.

More Older People Use Marijuana – I’m Concerned

When I think of a typical marijuana user, I admit I tend to stereotype. I see a young person, at home or with friends, smoking a large joint and having a good time. I don’t picture a grandma toking. Yet new research indicates that older people, in fact, are using cannabis more and more.

A new study found that the number of middle-aged and older adults using marijuana is on the rise. The analysis, based on the National Survey on Drug Use and Health, found that about 9% of adults between 50 and 65 had used cannabis in the last year, and about 3% of those 65 and older had. In 2013, those figures were, respectively, 7% and 1.4%.

Laws allowing for marijuana use – either recreationally or for medical purposes – are on the rise and can explain the increase. There is some medical evidence that marijuana can be used for a variety of medical conditions, such as pain, nausea from chemotherapy, multiple sclerosis, epilepsy and seizures, and this may also help to explain the increase in the older population.

Why Worry?

So what’s the big deal, you might ask? Since older people tend to take multiple medications, there is a risk of marijuana potentially interacting with those drugs and undermining their effectiveness. Yet because marijuana research is limited in the US, thanks to strict restrictions from the government, it’s hard to know exactly what those impacts are.

If older individuals – or any people, for that matter – are using marijuana for medical purposes, hopefully their doctors are aware of the medications being taken. However, if you are using marijuana and your doctors don’t know, you should tell them as soon as possible. They may be aware of potential marijuana-drug interactions.

Despite the lack of research on marijuana-drug interactions, there are certain classes of drugs that don’t mix well with cannabis. Because marijuana is very calming on the body, taking drugs that have sedating effects is a big no-no. For example, taking benzodiazepines such as Valium (diazepam) and Xanax (alprazolam), which are used for anxiety and insomnia, or muscle relaxants can lead to central nervous system depression. The same goes with using cannabis and alcohol.

Cannabidiol (CBD), one of the chemicals found in marijuana, is a big culprit for problems. Why? It can inhibit an enzyme in the liver that is used to break down medicines. When this happens, the medication ends up staying in the body longer, which can enhance the effects of drugs. CBD can even slow the breakdown of statin medications, used to lower cholesterol. That can increase the chances of side effects associated with statins, such as muscle pain.

There is also evidence that marijuana can impact the effectiveness of antidepressants. This is because marijuana may speed up metabolism of the antidepressant in the body. As a result, a person may need higher doses in order to get the same effect from the antidepressant.

More research is needed not only on the benefits and risks of marijuana as a medical treatment, but on cannabis-drug interactions. The trend in older people using marijuana makes the research all the more urgent. It’s time for the federal government to loosen restriction of cannabis research.

Quick Hits: FDA Threatens E-Cig Manufacturers, Elderly Polypharmacy and Falls & More

Saying youth smoking of e-cigarettes is reaching “epidemic proportions,” the FDA has ordered the manufacturers of the 5 top e-cigarettes to come up with plans on how to curb use by teens. The agency also threatened to pull flavored e-cigarettes – which are especially appealing to young people – from the market if they can’t demonstrate how they can keep the devices away from children. The manufacturers receiving letters are Juul Labs Inc., Vuse, MarkTen XL, Blu and Logic. Data from Nielsen Research indicates that Juul has more than two-thirds of the e-cigarette market. About 2.1 million middle and high school students used e-cigarettes last year, according to the CDC. Over the summer, the FDA said it issued more than 1,300 warning letters and fines to retailers who illegally sold e-cig products to minors as part of an undercover operation, the largest coordinated enforcement effort in the agency’s history. Posted September 12, 2018. Via FDA.

Elderly people that take several medications for sleeping, pain or incontinence are twice as likely to fall and suffer broken bones compared to those not taking any drugs. Researchers analyzed data on more than 70,000 older adults living in New Zealand. Those who were taking more than 3 Drug Burden Index medications – drugs that sedate or affect one’s cognition – were twice as likely to break their hip than those on no drugs, researchers reported in the Journals of Gerontology. Between 20% and 30% of those who broke their hip died within a year. Lead author Hamish Jamieson, PhD, of the University of Otago, Christchurch, New Zealand, said that multiple medications can cause falls in the elderly because of side effects in each of the medications and drug-drug interactions than can create additional side effects. Posted September 11, 2018. Via University of Otago.

The FDA has issued warning letters to 2 companies for making unsubstantiated medical claims in selling products containing the herb kratom. The agency says that Chillin Mix Kratom and Mitra Distributing make claims that their kratom products can relieve opioid withdrawal and treat conditions including depression, anxiety and high blood pressure. The FDA noted that kratom may contain substances that contain opioids and the plant may have a high potential for abuse. Over the last year, the FDA has issued several public warnings about potential dangers associated with kratom. In February, the agency said it identified 44 deaths associated with the use of kratom. Posted September 11, 2018. Via FDA.

Many Children At Risk for Serious Drug-Drug Interactions

Nearly 20% of children have taken at least 1 prescription medication in the last month, and 7.5% took 2 or more, according to a new study. Researchers note that many children taking multiple drugs are at risk for major drug-drug interactions.

The study looked at data from the 2013-14 period of the National Health and Nutrition Examination Survey. The data was based on prescriptions for more than 23,000 children and adolescents. Prescription drug use was highest in adolescent girls (28%) followed by boys between the ages of 6 and 12 years old (26.5%), the researchers reported in the journal Pediatrics.

Overall, in adolescents between 13 and 19 years old, about 23% had taken a prescription drug in the last 30 days. In the 6-to-12 age group, 21% of children reported using a medication.

Respiratory drugs, such as those used for asthma and allergies, were the most commonly prescribed to children, followed by psychotherapeutic agents, which include drugs such as stimulants for ADHD (attention deficit/hyperactivity disorder) and antidepressants.

Researchers noted that 8.2% of children and adolescents taking more than 1 drug were at risk for a potentially serious drug-drug interaction, and the majority of those interactions were because of antidepressants. Put another way, 1 in 12 children face a potentially dangerous drug-drug interaction.

Data indicated that the percentage of children taking a prescription drug in the last 30 days has actually been declining since the 2005-06 period, when it was just over 25%.

McKnight’s Senior Living: 6 Meds To Handle With Care

Older adults taking five or more medications per week, plus an aging body system, equals problems for home and senior living caregivers. Polypharmacy can leave senior residents uniquely vulnerable to side effects and adverse events. That leaves caregivers worried and frustrated because there is little they can do. However, in the daily care of your clients, you can be aware of those drugs that are most likely to lead to potential health issues and be ready. Read here. 

Why Opioids Are More Dangerous for Seniors

One of the most fascinating aspects of learning about side effects of drugs has been to discover that many side effects are predictable based on how the a drug works in the body — what is called “method of action.”

Opioids, for example, work by slowing pain receptors and increasing dopamine, a chemical that controls the brain’s reward and pleasure center, which is an effective way of inhibiting the body’s ability to feel pain and makes you feel great.

This colorful and informative video explains how opioids work (there’s no sound).

However, opioids not only go to the brain but also move throughout the entire body affecting (and most often, slowing) all body systems. The most obviously inhibited one, after pain, is the digestive system. Hence the well-known problem of “opioid-induced constipation.”

And Then There’s Aging

Aging bodies add another dimension. Medicines accumulate more easily in a body (especially in the kidneys) where all systems are naturally slowing down from age. If you’re a senior, ask your doctors to give you the lowest effective dose of the lowest level of pain med, which is good advice at any age. The choice of pain killer should be very different for a healthy 40-year-old who plays squash weekly than for an 80-year-old with high blood pressure who walks a few blocks a day and has a delicate stomach.

Elderly adults taking opioid painkillers have 4 times as many bone fractures, are 68% more likely to be hospitalized and are 87% more likely to die as those taking over-the-counter pain medication.

Side effects from most drugs, and especially opioid drugs, are more pronounced in seniors. Falls, dizziness, headaches, sedation, worse constipation and slow reaction times are much more common when using opioids. (Should you be driving while using even a mild opioid?)

Elderly adults taking opioid painkillers have 4 times as many bone fractures, are 68% more likely to be hospitalized and are 87% more likely to die as those taking over-the-counter pain medication, according to the National Safety Council.

When Options Become Limited

Why take any opioid if you’re a senior who isn’t in end-of-life care? Your options become limited as your stomach becomes more sensitive, your kidneys and liver process more slowly and you take other medicines that might interact badly with some meds. Some of the less extreme painkillers, like Aleve or Tylenol, aren’t tolerated well. For example, aspirin and NSAIDs can upset stomachs. Note that some studies indicate that opioid drugs are just as upsetting to stomachs.

Weaker opioids like codeine don’t work for many people. The next step up, morphine, is hard on the kidneys, an organ that is commonly compromised in old age. Hydromorphine is easier on the kidneys but much more potent, stronger than might be needed with stronger side effects. Opioid choices get stronger and affect the body more from there.

What to do if your doctor recommends an opioid-based drug? Consider refusing them. They are NOT RECOMMENDED for headaches or migraines, and the benefits of using them for fibromyalgia or chronic back pain probably don’t outweigh their very significant risks, the AAN (American Academy of Neurology) states.

Work with your doctor on a multifaceted approach to pain management, as recommended by the AAN. Cognitive-behavioral therapy and activity coaching have been very successful not only at lowering pain but increasing the ability to function.

Fix the source of the pain and take opioids for the shortest time period possible. Do your best to make sure a temporary severe pain doesn’t turn into a chronic one.

Watch for Drug Interactions

If you’re a senior and taking drugs for high blood pressure, cardio issues, diabetes, etc., prescribing is complicated and risky. Drug-to-drug interactions are not only possible, they are likely. Assume any new symptom is a side effect and call your doctor before it becomes life threatening or limiting. This is one of the many reasons that we at MedShadow encourage you to discuss thoroughly your options for alternatives to drugs wherever possible — this way, when you need drugs your doctors have more options.

Opioids are known for being highly addictive. And as discussed in our recent article, 3 Steps from Pain Management to Heroin, seniors are not immune to addiction.

Whether you are a senior, care for a senior or expect to become a senior one day, it’s always important to discuss with your health care provider why you are taking a drug, how long you can expect to take it and what the effect of it will be on your entire body, not just the problem area.

Are Seniors Being Overmedicated?

How many medicines do you take? It’s a question that stumps many seniors and people with chronic illnesses. That’s because more people today take 5, 6 or more medicines simultaneously — and they take some of those drugs for years.

Doctors call this polypharmacy. For some people it’s essential to maintaining health and thus can’t be avoided. But evidence suggests and experts agree that millions of people — and you may be one — are taking more medications than needed. Not only is that a waste of money, it adds significantly to the risk of side effects and adverse drug events due to both the cumulative and synergistic impact of the drugs.

Indeed, polypharmacy is one of those persistent problems that beset the health system. Everyone knows it exists and is getting worse, but no one quite knows what to do about it. We have all these great drugs, and we pretty much just pile them on. And few studies specifically examine the interaction of even the most commonly used drugs.

“The FDA doesn’t require a realistic look at this and thus the companies don’t really probe it,” says Dr. Mark Helfand, prescription drug expert at Oregon Health & Sciences University and an internist at the Portland Veteran’s Administration Hospital. “In fact, in many of the studies drug companies do to get a drug approved, patients taking multiple medicines are excluded. But when you get out in the real world, people taking many medicines has become the norm.”

Fortunately, there are some straightforward steps you can take, working with your doctor, to identify whether you’re taking too many medicines, taking any unnecessarily, or suffering the ill effects of polypharmacy. I’ll discuss those below. But first, some numbers and explanation:

Between 30% and 40% of people aged 65 and over take 5 or more medicines regularly, according to Express Scripts, which manages pharmacy benefits for large employers, and Health USA 2013, a report from the Department of Health and Human Services published last year. Of that group, about 10% took 10 or more drugs.

This excellent overview piece from the NIH cites similar data from the mid-2000s for people aged 75 to 85, including a survey indicating that about half the people in that age group also report regularly taking either an over-the-counter medicine or vitamin supplement, or both. The American Society of Consultant Pharmacists report that 15% to 25% of seniors’ drug use is considered unnecessary or inappropriate.

“I think this problem is mostly because people see so many specialists and those specialists don’t then coordinate with each other or with a patient’s primary care provider about what drugs they are prescribing,” says Marvin Lipman, MD, a primary care physician and endocrinologist in Scarsdale, NY, and medical director for Consumer Reports. “So it’s left to the patient to track it all, and some older people just can’t do that well.”

For example, it’s problematic to take an anti-anxiety drug, an antidepressant, an insomnia medicine, a beta-blocker and an antipsychotic drug all at once. Yet some combinations of these meds are quite common among seniors. The danger with this particular mix is that the combination will almost certainly yield a heavily sedated, cognitively impaired person who, if not bedridden from the sedation, is prone to falls.

Next: How Seniors Are Most Affected by Polypharmacy >>