from grapefruit to glaucoma: interactions and side effects you should be aware of from grapefruit to...
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From Grapefruit to From Grapefruit to Glaucoma:Glaucoma:
Interactions and Side Interactions and Side Effects You Should Be Effects You Should Be
Aware OfAware OfRichard L. Ogletree, Jr,
Pharm.D.
ScopeScope
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 PatientsHospitalized 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
DefinitionsDefinitions
ADR - FDAADR - 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 - WHOADR - 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 ADE - Adverse Drug EventEvent
Includes medical errors
Categories of ADR’sCategories of ADR’s
Predictable or Type A (augmented) side effects toxic effects
Non-predictable or Type B (bizarre) hypersensitivity responses idiosyncratic effects
Side EffectsSide Effects
A result other than the one desired from the agent diphenhydramine - drowsiness nitroglycerin - headache prazosin - nasal stuffiness
Toxic EffectsToxic Effects
Direct cellular function alteration or damage colchicine - GI upset, myopathy digoxin - heart block aminoglycosides - nephrotoxicity
HypersensitivityHypersensitivity
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)
HypersensitivityHypersensitivity
Could range from rash to anaphylaxis sulfonamide allergies penicillin allergies many hepatotoxicities
Idiosyncratic EffectsIdiosyncratic 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’sAssessment of ADR’s
Temporal relationship Dechallenge Rechallenge Confounders
Can Influence ADR’sCan Influence ADR’s
Age Weight Race Sex Pregnancy Concomitant diseases Other drugs or food
Drug interactionsDrug 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...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 ...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:Important:
Drug interactions could be desirable multiple mechanisms of action decreasing necessary dose decreasing side effects antidotes
Types of Drug InteractionsTypes of Drug Interactions
Pharmaceutical Pharmaceutical incompatibility - incompatibility - including including in vivo bindingin 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
vitamins?
Receptor site Receptor site interactioninteraction
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 Influence of same physiological systemphysiological system
Warfarin and NSAIDS Aminoglycosides and
neuromuscular blockers Beta blockers, digoxin, verapamil,
diltiazem Multiple anti-hypertensives
Changes in electrolytes Changes in electrolytes or fluid balanceor fluid balance
ACE inhibitors and K+ Lithium and high sodium intake Lithium and low sodium diet Ampho B and diuretics
Absorption interactionsAbsorption interactions
Antacids and drugs Grapefruit juice Doxycycline and digoxin Erythromycin and sulfasalazine Omeprazole and ketoconazole Binding in GI tract
DistributionDistribution
Protein binding mostly theoretical generally transient warfarin and phenytoin
Tissue binding quinidine and digoxin
Drug metabolism - Drug metabolism - inductioninduction
Inducers phenytoin phenobarbital carbamazepine rifampin cigarette smoke St. John’s wort
Drug metabolism - Drug metabolism - inductioninduction
Be careful with oral contraceptives HRT cyclosporine
Drug metabolism - Drug metabolism - inhibitioninhibition
Inhibitors azole antifungals
ketoconazole itraconazole
macrolide antibiotic erythromycin clarithromycin
cimetidine
Drug metabolism - Drug metabolism - inhibitioninhibition
More inhibitors SSRI’s
fluvoxamine paroxetine fluoxetine
nefazodone fluoroquinolones amiodarone
Grapefruit JuiceGrapefruit Juice
Caused by furanocoumarin fractions
Takes place in GI tract Inhibition of CYP450 1A2 & 3A4 Prevents GI metabolism Increases absorption Increased peak
Grapefruit Juice Grapefruit Juice InteractionsInteractions
Calcium channel blockers (felodipine, nisoldipine, nifedipine, verapamil)
Cyclosporine Midazolam (oral) Cisapride Simvastatin, lovastatin
Predicting Grapefruit Predicting Grapefruit Juice InteractionsJuice Interactions
Absorption Bioavailability CYP 450 esp. 3A4 metabolism Look on insert
HMG - CoA Reductase HMG - CoA Reductase Inhibitors (“statins”)Inhibitors (“statins”)
Lovastatin (Mevacor®) Pravastatin (Pravachol®) Simvastatin (Zocor®) Fluvastatin (Lescol®) Atorvastatin (Lipitor®) Rosuvastatin (Crestor®)
HMG - CoA Reductase HMG - CoA Reductase Inhibitors (“statins”)Inhibitors (“statins”)
Lower cholesterol Inhibit rate limiting reaction in
mevalonate pathway Other mevalonic acid products
dilochol (liver, retina) ubiquinone (muscles)
Concerns with “Statins”Concerns with “Statins”
Liver problems Concern with ALT or AST > 3X ULN
Muscle problems Concern with CK > 10X ULN
Consider ubiquinone supplementation in selected patients
Liver Monitoring with Liver Monitoring with “Statins”“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/yearNote: This is with initiation and with each dose increase. Pravastatin (Pravachol®) bl, prior to dose increase and
when “clinically indicated”
HMG - CoA Reductase HMG - CoA Reductase Inhibitors (“statins”)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 HMG - CoA Reductase Inhibitors (“statins”)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 HMG - CoA Reductase Inhibitors (“statins”)Inhibitors (“statins”)
Concerns unexplained muscle pain accident hospitalization?
Theoretical concerns Metformin Stavudine and other NRTI’s weight-lifting?
Zocor (simvastatin): Label Zocor (simvastatin): Label Change - New Restrictions, Change - New Restrictions, Contraindications, and Dose Contraindications, and Dose
LimitationsLimitations
Posted:06/08/2011
FDA notified healthcare professionals that it is recommending limiting the use of the highest approved dose of the cholesterol-lowering 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 simvastatin-related 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.
SimvastatinSimvastatin
• Contraindicated Itraconazole Ketoconazole Posaconazole Erythromycin Clarithromycin Telithromycin HIV protease inhibitors Nefazodone Gemfibrozil Cyclosporine Danazol
SimvastatinSimvastatin
• Contraindicated Itraconazole Ketoconazole Posaconazole Erythromycin Clarithromycin Telithromycin HIV protease inhibitors Nefazodone Gemfibrozil Cyclosporine Danazol
SimvastatinSimvastatin
10 mg/day Diltiazem Verapamil
20 mg/day Amiodarone Amlodipine Ranolazine
Grapefruit juice Avoid > 1 quart/day
Lovastatin - Feb. 28, Lovastatin - Feb. 28, 20122012
Strong CYP3A4 inhibitors are contraindicated• Avoid
Cyclosporine Gemfibrozil
• 20 mg/ day Danazol Diltiazem Verapamil
• 40 mg amiodarone
Grapefruit juice Avoid > 1 quart/day
Also from Feb. 28, 2012Also 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 PravaRosuv
aVytori
n*Simva
%↓ LDL-C
----- 40 mg 1 mg 20 mg 20 mg ----- ----- 10 mg 30%
10 mg 80 mg 2 mg40 or 80 mg
40 mg ----- ----- 20 mg 38%
20 mg ----- 4 mg 80 mg 80 mg 5 mg10/10
mg40 mg 41%
40 mg ----- ----- ----- 10 mg10/20
mg80 mg 47%
80 mg ----- ----- ----- 20 mg10/40
mg----- 55%
----- ----- ----- 40 mg10/80
mg----- 63%
*No incremental benefit of Vytorin on cardiovascular morbidity and mortality over and above that demonstrated for simvastatin has been established.
QuinolonesQuinolones Photosensitivity Drug interactions Rash Dizziness Seizure Insomnia Loss of glycemic control Tendon rupture
Quinolones - Tendon Quinolones - Tendon RuptureRupture
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 Quinolones - Tendon DisorderDisorder
Case-control study - n = 46,766 Adjusted relative risk > 60 years old
current use OR 3.5 (2.3 - 5.3)
concurrent steroids OR 6.2 (3.0 - 12.8)
recent or past use ns < 60 years old ns
van der Linden, et al. BMJ 2002;324:1306-1307
TetracyclinesTetracyclines
Photosensitivity Interaction with polyvalent cations Tooth staining Increased intracranial pressure (ICP) Also called BIH (Benign Intracranial
Hypertension) or Psuedotumor Cerebri
Tetracyclines - Tooth Tetracyclines - Tooth StainingStaining
Tetracycline - during tooth formation
Binds to calcium Cervical third of tooth (gingival
margin) Avoid during pregnancy Avoid in children
Tetracyclines - Tooth Tetracyclines - Tooth StainingStaining
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 Minocycline - Tooth StainingStaining
PreventionPrevention Give an antioxidant Give lower doses 100 mg/day for 2 weeks, then 50
mg/day
Tetracyclines - BIHTetracyclines - 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 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 - BIHTetracyclines - 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 - BIHTetracyclines - BIH
Ask about headaches tinnitis blurred vision double vision
Check for papilledema
LevothyroxineLevothyroxine 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 Levothyroxine interactionsinteractions
Calcium Iron (including prenatal vitamins or
other vitamin/mineral preps) Soy protein
all decrease absorption separate by at least 2 hours
SSRI’sSSRI’s Anxiety Insomnia Sexual dysfunction Withdrawal Interaction with DM cough preps Tooth grinding GI bleeds
SSRI withdrawalSSRI withdrawal
Disequilibrium dizziness vertigo ataxia swimming or spaced out feeling impaired coordination
SSRI withdrawalSSRI withdrawal GI disturbances
nausea vomiting diarrhea anorexia
Flu-like symptoms
SSRI withdrawalSSRI withdrawal Sensory disturbances
auditory hallucinations paresthesias electrical shock sensations
CNS symptoms agitation confusion headache lethargy
SSRI withdrawalSSRI withdrawal Sleep disturbances
insomnia nightmares vivid dreams
relapse of depression
SSRI withdrawal -SSRI withdrawal -most commonmost common
Dizziness Nausea Lethargy Headache
SSRI withdrawal 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 interactionSSRI - DM interaction
Dextromethorphan D-isomer of levorphanol Cough suppressant NMDA antagonist Decreases glutamate excitability
DextromethorphanDextromethorphan
Cough/cold preps Adjuvant for pain management
(including neuropathic pain) Decrease opioid tolerance Interacts with MOAI’s Interacts with SSRI’s
Serotonin syndromeSerotonin syndrome
Mental status changes Tremor Restlessness Incoordination Shivering Increased temperature
Serotonin syndromeSerotonin syndrome
Diaphoresis Hyperreflexia Myoclonus Diarrhea Convulsions Could be fatal
SSRI - DM interactionSSRI - DM interaction
If needing a cough suppressant use:
Benzonatate Carbetapentane combinations
SSRI Induced BruxismSSRI 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 BruxismSSRI Induced Bruxism
Ask about/look for muscle tension headache joint pain (tmj) muscle pain (chewing muscles) masseter hypetrophy
SSRI Induced Bruxism - SSRI Induced Bruxism - ManagementManagement
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 BleedsSSRI’s and GI Bleeds
SSRI antidepressants OR 3.0 (2.1 - 4.4) most likely - trazodone
Non SSRI antideps OR 1.4 (1.1 - 1.9)
Abajo, et al. BMJ 1999;319:1106-1109
SSRI’s and GI BleedsSSRI’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
8/24/20128/24/2012Abnormal heart rhythms Abnormal heart rhythms
associated with high doses associated with high doses of Celexa (citalopram of Celexa (citalopram
hydrobromide)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.
ZyvoxZyvox
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).
LinezolidLinezolid 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 cases D/C 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 Serotonergic Psychiatric MedicationsMedications
SSRIs SNRIs Tricyclics MAOIs
Other: Amoxapine Maprotiline Nefazodone Trazodone Buproprion Buspirone Vilazodone
Serotonin Syndrome Serotonin Syndrome SymptomsSymptoms
Tremor Altered mental status Clonus Muscular hypertonicity hyperthermia
7/26/20117/26/2011Serious CNS reactions Serious CNS reactions
possible when methylene possible when methylene blue is given to patients blue is given to patients
taking certain psychiatric taking certain psychiatric medicationsmedications
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 blueMethylene blue
Monoamine oxidase inhibitor properties
Urgent treatment of: Methemoglobinemia Ifosfamide-induced encephalopathy Cyanide poisoning
AlsoAlso
Urinary medications UTA Urogesic blue
Antihistamine/Antihistamine/DecongestantDecongestantCombinationsCombinations
Newer antihistamines Less sedation Long duration of activity Good safety profiles
Antihistamine/Antihistamine/DecongestantDecongestantCombinationsCombinations Same decongestants (usually
pseudoephedrine) Increased heart rate Increased blood pressure Prostate disturbance Decreased appetite Anxiety Insomnia
Decongestant ProfilesDecongestant Profiles
050
100150
200250300
350400
450500
3.9 4.4 5 7
Claritin D 12Zyrtec DAllegra DClaritin D 24
3/12/20133/12/2013Azithromycin (Zithromax Azithromycin (Zithromax or Zmax) and the risk of or Zmax) and the risk of potentially fatal heart potentially fatal heart
rhythmsrhythms
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
6/25/20146/25/2014 FDA warns of rare but FDA warns of rare but
serious hypersensitivity serious hypersensitivity reactions with certain reactions with certain
over-the-counter topical over-the-counter topical acne productsacne products
The U.S. Food and Drug Administration (FDA) is warning that certain over-the-counter (OTC) topical acne products can cause rare but serious and potentially life-threatening 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 DrugsAnticholinergic Drugs
Toxidrome mneumonic Blind as a bat Dry as a bone Mad as a hatter Hot as a hare Red as a beet
Counseling pointsCounseling 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 pointsCounseling points
Hot as a hare Red as a beet
Both are associated with heat intolerance
Counsel about heat precautions
Anticholinergics - usesAnticholinergics - uses
GI dicyclomine hyoscyamine
Overactive Bladder oxybutynin tolterodine darefenacin solefenacin
Anticholinergics - usesAnticholinergics - uses
Excessive salivation glycopyrrolate atropine scopolamine
Antipsychotic induced EPS benztropine trihexyphenidyl
Anticholinergic DrugsAnticholinergic 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 Other agents with potential for heat potential for heat intoleranceintolerance
Amphetamines Pseudoephedrine Phenylepherine Zonisamide Topiramate
Other Side Effects with Other Side Effects with TopiramateTopiramate
Taste disturbance Confusion Word-finding difficulties Loss of appetite Visual disturbance
Lotrisone®Lotrisone®
Antifungal/Corticosteroid Often for “jock itch” or diaper rash Skin thinning Functional “occlusive dressing” Systemic side effects “Addictive”
Glucocorticoids - Glucocorticoids - SystemicSystemic
Increased blood glucose HPA axis suppression Decreased bone mineral density Skin thinning Withdrawal Glaucoma
GlaucomaGlaucoma
Or increased intraocular pressure Most common with ophthalmic dosing
- use special care after LASIK Also seen with systemic therapy What about inhaled steroids?
Inhaled GlucocorticoidsInhaled Glucocorticoids
Glaucoma or IOP risk Family history OR 2.6 (1.2 - 5.8) High doses and fam hx OR 6.3 (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’sReport ADR’s
Larger patient populations Open-ended time frame Not limited to “healthy adults” JCAHO requires an institutional
policy
Check UpdatesCheck Updates Clin-Alert Australian Adverse Drug Reaction
Bulletin http://www.health.gov.au/tga/adr/aadrb.htm
Med-Safe (New Zealand) http://www.medsafe.govt.nz/profs.htm
Dear Doctor letters Institutional newsletter
LactuloseLactuloseA 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.
How do you say you’re How do you say you’re sorry?sorry?
KABOOM!
Brooke Tullos Infectious Disease Travis KingMary Wooten Infectious Disease Travis KingBrooke Tullos Infectious Disease Travis KingMary Wooten Infectious Disease Travis King
FDA AlertsFDA Alerts
7/09/20157/09/2015FDA strengthens warning FDA strengthens warning
that non-aspirin that non-aspirin nonsteroidal anti-nonsteroidal anti-
inflammatory drugs inflammatory drugs (NSAIDs) can cause heart (NSAIDs) can cause heart
attacks or strokesattacks or strokes
The U.S. Food and Drug Administration (FDA) is strengthening an existing label warning that non-aspirin 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 non-aspirin NSAID Drug Facts labels.
7/01/20157/01/2015FDA evaluating the FDA evaluating the
potential risks of using potential risks of using codeine cough-and-cold codeine cough-and-cold
medicines in childrenmedicines in children