Patient Profile for Mary Doe
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General Information
ID: 071420044md
Prescriber: John Q. Public, M.D.
Name: Mary Doe
Address: 123 Main Street
City: Anywhere
State: Georgia
Zip: 30224
Country: USA
Phone: (770) 123-4567
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Current Conditions
• anxiety
• arterial thromboembolism prophylaxis
• bradycardia
• females
• hypertension
• nutritional supplementation
• ocular pain
• osteoarthritis
• osteoporosis prophylaxis
• renal impairment
• urticaria
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Current Allergies
• Angiotensin-converting enzyme inhibitors (ACE inhibitors)
• Codeine
• Hydrochlorothiazide, HCTZ
• Hytrin®
• Penicillins
• Sulfonamides
• Tenormin®
• Vioxx®
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Current Medications
• Medication
• Aldactone® Dosage: 25mg Sig: Tab 2 AM and tab 1 PM
• Bayer® Childrens Aspirin Dosage: 81mg Sig: tab 1 daily
• Centrum® Silver® Sig: tab 1 daily
• Effexor® XR Dosage: 75mg Sig: cap 1 HS
• GNC Glucosamine; Chrondroitin Dosage: 250/1500mg Sig: tab 1 twice a day
• Mobic®
• Tums® Ultra Sig: three times a day
• Ultracet® Sig: tab 1 q 8hr as needed for pain
• Voltaren® Dosage: Opthalmic solution Sig: drop 1 in Left Eye three time a day
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Dosing Parameters
Gender: Female
Birthdate: 4/30/1918
Weight: 83.64 kgs
Height: 165.1 cm
Ideal Body Weight: 58.6 kgs
Body Surface Area: 1.96 m²
Serum Creatinine: 0.9 mg/dL
Creatinine Clearance: 41.51 mL/min
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Notes:
Title: Evaluation and Recommendations 07162004
Date: 7/17/2004 2:59:56 PM
This 86 year old female is in relatively good health, has excellent laboratory values and is cognitively very alert. Problems discussed are dizzy spells, falls, back pain (probably due to falls and general osteoarthritis), long list of allergies and uncontrollable hypertension due to allergies to drugs listed in this report. Pulse rates low at times but there is a mean pulse of 63 and mean blood pressure of 152/94. This hypertension must be treated and controlled immediately. Problems with dizziness and erratic pulse rate may subside once the blood pressure can stabilize. Currently on medications that are not friendly to female geriatric patients or can exacerbate other undesirable conditions. The current antihypertensive (Aldactone) is not the drug of choice and may exacerbate more health problems. Several of the over-the-counter drugs should be changed or stopped. I encouraged the patient to continue the Effexor XR 75mg at bedtime and this dose should be increased to 150mg at bedtime in about 30 days. After a long visit with the patient, it appears that anxiety and depression play a big role in the hypertension and pulse problems.. Allergies consistent with blood pressure medicines have made the patient uneasy about trying new products. Review of past trials is confusing since four (4) different ACE Inhibitors, two (2) Beta Blockers and two (2) Alpha Blockers were tried. After the first sign of allergy in the first agent in a category, others should not have been tried.
Calcium Channel Blockers are more friendly in geriatric patients, and should have been the initial treatment for this patient. Diltiazem CD 180mg daily should be tried and monitored closely for the first two weeks to determine if any skin rashes or allergy problems occur. Continuous monitoring of blood pressures on arising and at bedtime should be recorded in the log provided, along with pulse values. Any changes in normal blood pressure should be recorded in the space provided.
NSAID drug therapy in geriatrics is not advised. Mobic in the geriatric female increases the AUC (activity under the curve) allowing for drug buildup and more risk for adverse events. Since the patient has been taking Ultracet with no problems, then a move from as necessary to TID (three times a day) and every six hours as needed for pain. Although this report may mention some side effects observed in patients taking Ultracet and Effexor XR, dosing in this patient is not high enough for those problems to occur.
Glucosamine/Chondrotin continuance is fine and may provide some support for the osteoarthritis but should only contain the Chondrotin and Glucosamin. Use of the CVS or EKERDS's brand of Glucosamine/Chondrotin "Double Strength" is the one I recommend.
In place of the TUMS (Calcium Carbonate which can cause constipation) Citracal 950mg Tablets should be used. This is the Citrate salt and is much less constipating and will provide the necessary Calcium as long as the Centrum Silver is continued which will provide the needed 400 units of Vitamin D necessary for Calcium absorption.
Voltaren Ophthalmic Drops is another NSAID. This is not friendly with geriatric patients. Patanol Ophthalmic drops will provide better relief and offers less risk for adverse events. I would recommend use in both eyes twice a day, but this is only if the condition persists.
It is probably necessary to address fluid retention problems so a small dose of Demadex should be initiated to see if the patient can tolerate this drug. I have never seen an allergic response to this drug. Advantages of this loop diuretic is that it has a 24 hour half life, so there will not be the antidiuretic rebound you see in the short half life Lasix. This will ensure that dosing does not increase and that the patient can enjoy normal voiding times.
Suggestions in Drug Therapy Management that are needed quickly and long term
Stop Aldactone
Start Cardizem CD 180mg each morning
Stop Glucosamine/Chondrotin GNC
Start CVS brand Glucosamine/Chondrotin double strength. Take one tablet
three times a day
Stop Mobic
Start Ultracet - take one tablet three times a day and every 6 hours as needed for pain
Stop Tums
Start Citracal 950mg - take one tablet three times a day
Continue Centrum Silver take one tablet daily
Continue Effexor XR 75mg at bedtime for 10 more days, then increase dosing to Effexor XR 150mg at bedtime
Stop Voltaren Ophthalmic drops
Start Patanol Ophthalmic drops place 1 drop in each eye every morning and at bedtime (continued use for Patanol is optional, consistent with condition)
Continue Baby Aspirin daily
Start Vitamin E 400 Units - take one capsule daily
Start Demadex 2.5mg daily
NEW DRUG REGIMEN.......
Cardizem CD 180mg ... Take one (1) capsule each morning
Chondrotin/Glucosamine (double strength) from CVS.... Take one (1) tablet three times a day
Ultracet tablets..... Take one (1) tablet three times a day.... and if needed for breakthrough pain you may take an additional dose every 6 hours.
Citracal 950mg tablets.... Take one (1) tablet three times a day
Centrum Silver tablets..... Take one (1) tablet daily
Effexor XR 75mg capsule.... Take one (1) capsule at bedtime for 10 days then two (2) capsules (150mg) at bedtime.... You may want to have your refill contain the 150mg capsules
Patanol Ophthalmic drops..... put one (1) drop in each eye in the morning and at bedtime (optional)
Baby Aspirin 81mg tablet... Take one (1) tablet daily
Vitamin E 400mg capsule.... Take one (1) capsule daily
Demadex 5mg tablet.... Take one-half tablet (2.5mg) each morning.
I believe that this regimen will meet the patient’s medication management needs and allow for a better quality of life.
Continuing the Effexor XR is essential for you to feel better and have your blood pressure become stable.. Even though you may not believe you are depressed and anxious, all the signs during your assessment indicated that you are.
Remember, it takes time for the new drugs to reach total therapeutic levels. With this in mind, be patient for 7 to 10 days before evaluating your feelings and progress.
Notes:
Title: Follow-up on changes and condition
Date: 8/2/2004 10:30AM
Follow up this morning was disappointing since the physician was so negative in comments made about consultant pharmacist. Check of BP this AM shows 122/51 with pulse of 83BPM. Mean blood pressure for the past eight day is 148/78. Doctor prescribed Norvasc 2.5mg twice a day with Aldactone 25mg each AM. A calcium channel blocker, the drug group that I wanted to use, was tried and has been successful in lowering the blood pressure. The fact remains that the need for the Aldactone is doubtful and a further increase in the Norvasc will probably cause pedal edema something we don’t want. The calcium channel blocker diltiazem is much more friendly in the geriatric. With the CD dosage form once a day, dosing is possible and compliance is more assured. Use of Aldactone for diuretic makes for additional adverse events that may not occur with use of Demadex, as I have already indicated. The more natural action of the Demadex may provide better compliance.
Suggestions…
Go back to initial recommendations but with initial dosing of 120mg Diltiazem CD. Monitoring blood pressure AM and PM is essential to observe mean blood pressure- it is not just a snapshot in time. It is hard to believe the doctor said not to take your blood pressure. Without comprehensive monitoring and averaging of blood pressures, it is difficult to tell whether your drug therapy is working.
I will contact a referring physician who is more receptive to advancements in medicine, to examine this patient.
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Drug Interactions
Spironolactone (Aldactone®) and Aspirin, ASA (Bayer® Childrens Aspirin)
Severity: Moderate
Salicylates can increase the risk of renal toxicity in patients receiving diuretics because salicylates inhibit renal prostaglandin synthesis, which can lead to fluid retention and increased peripheral vascular resistance. Concomitant use of salicylates and spironolactone, may cause hyperkalemia. Aspirin, ASA has been shown to inhibit the active tubular secretion of canrenone, the active metabolite of spironolactone, however, this effect on canrenone pharmacokinetics did not compromise the clinical action of spironolactone significantly.
Salicylates can increase the risk of renal insufficiency in patients receiving diuretics secondary to the effects of salicylates on renal blood flow. Salicylates may decrease the hyperuricemic effect of hydrochlorothiazide and furosemide. Concomitant use of salicylates and potassium-sparing drugs, such as triamterene or spironolactone, may cause hyperkalemia.
Spironolactone (Aldactone®) and Diclofenac (Voltaren®)
Severity: Moderate
NSAIDs can cause sodium and fluid retention as well as increase peripheral vascular resistance. NSAIDs can decrease the diuretic, natriuretic, and antihypertensive actions of diuretics, possibly through inhibition of renal prostaglandin synthesis. Concomitant administration of NSAIDs with diuretics can also increase the risk for renal insufficiency secondary to decreased renal blood flow. Patients should be monitored for changes in the effectiveness of their diuretic therapy and for signs and symptoms of renal impairment. Among NSAIDs, indomethacin, naproxen, and piroxicam may have the greatest pressor effect, while the effects of sulindac and nabumetone may be significantly less. Concomitant use of NSAIDs and potassium-sparing drugs, such as spironolactone, can cause hyperkalemia.
NSAIDs, to varying degrees, have been associated with an elevation in blood pressure (approximately 5 mm Hg) when given over a period of weeks. This effect is most significant in patients receiving concurrent antihypertensive agents and long-term NSAID therapy. NSAIDs may decrease the effect of antihypertensive agents through various mechanisms, including renal and peripheral vasoactive pathways.NSAIDs have been shown to attenuate the effects of diuretics, beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs), vasodilators, central alpha-2 agonists, peripheral alpha-1 blockers, and angiotensin II blockers. Doses of antihypertensive medications may require adjustment in patients receiving concurrent NSAIDs.[4087] Elderly patients may be at increased risk of adverse effects from combined long-term NSAID therapy and antihypertensive agents, especially diuretics, due to age-related decreases in renal function and an increased risk of stroke and coronary artery disease.[3154]
Spironolactone (Aldactone®) and Meloxicam (Mobic®)
Severity: Moderate
NSAIDs can cause sodium and fluid retention as well as increase peripheral vascular resistance. NSAIDs can decrease the diuretic, natriuretic, and antihypertensive actions of diuretics, possibly through inhibition of renal prostaglandin synthesis. Concomitant administration of NSAIDs with diuretics can also increase the risk for renal insufficiency secondary to decreased renal blood flow. Patients should be monitored for changes in the effectiveness of their diuretic therapy and for signs and symptoms of renal impairment. Among NSAIDs, indomethacin, naproxen, and piroxicam may have the greatest pressor effect, while the effects of sulindac and nabumetone may be significantly less. Concomitant use of NSAIDs and potassium-sparing drugs, such as spironolactone, can cause hyperkalemia.
NSAIDs, to varying degrees, have been associated with an elevation in blood pressure (approximately 5 mm Hg) when given over a period of weeks. This effect is most significant in patients receiving concurrent antihypertensive agents and long-term NSAID therapy. NSAIDs may decrease the effect of antihypertensive agents through various mechanisms, including renal and peripheral vasoactive pathways.NSAIDs have been shown to attenuate the effects of diuretics, beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs), vasodilators, central alpha-2 agonists, peripheral alpha-1 blockers, and angiotensin II blockers. Doses of antihypertensive medications may require adjustment in patients receiving concurrent NSAIDs.[4087] Elderly patients may be at increased risk of adverse effects from combined long-term NSAID therapy and antihypertensive agents, especially diuretics, due to age-related decreases in renal function and an increased risk of stroke and coronary artery disease.[3154]
Spironolactone (Aldactone®) and Potassium Salts (found in Centrum® Silver®)
Severity: High
Spironolactone should not be used concomitantly with other potassium-sparing diuretics (amiloride or spironolactone) or with eplerenone because of the increased risk of developing hyperkalemia. Simultaneous use of cyclosporine or tacrolimus with spironolactone can also increase the risk of hyperkalemia, and is generally not recommended. In addition, ACE inhibitors, angiotensin II receptor antagonists, trimethoprim, heparin, potassium supplements, potassium-containing medications (e.g., penicillin G potassium), and any substance containing potassium salts (e.g., blood, salt substitutes, low-salt milk) can increase the risk of hyperkalemia developing in patients receiving spironolactone, especially in the presence of renal impairment (renal disease, elderly patients). These agents should be used with caution and serum potassium levels monitored when the substances are concurrently administered with spironolactone.
Potassium salts should be used with caution in patients taking drugs that may increase serum potassium levels, such as ACE inhibitors; angiotensin II receptor antagonists; NSAIDs; beta-blockers; eplerenone; potassium-sparing diuretics (amiloride, spironolactone, or triamterene); high-doses of IV potassium penicillin G; trimethoprim (especially high dose); or heparin. Concurrent use can cause hyperkalemia, especially in elderly patients or patients with impaired renal function. Conversely, potassium supplements should be discontinued when hypokalemia-causing agents are discontinued or re-evaluated to avoid the possibility of developing hyperkalemia. Examples of hypokalemia-causing agents include: thiazide diuretics and loop diuretics; amphotericin B; high-dose beta-agonists; and high doses of extended-spectrum penicillins (carbenicillin, mezlocillin, piperacillin, and ticarcillin).
Aspirin, ASA (Bayer® Childrens Aspirin) and Calcium Carbonate (Tums® Ultra)
Severity: Low
Concurrent administration of high doses of antacids (e.g., sodium bicarbonate 4 g or aluminum and magnesium hydroxide 60—120 ml) or other urinary alkalinizers (e.g., citrates) may increase urine pH and decrease serum salicylate levels by decreasing renal tubular reabsorption of salicylic acid. Antacids do not appear to affect the bioavailability of aspirin, but may cause earlier release of aspirin from enteric-coated products.
By increasing urinary pH, calcium carbonate can decrease the urinary excretion of quinidine or increase the urinary excretion of salicylates. In addition, increased urinary pH can antagonize the actions of either ammonium chloride or methenamine. Staggering the administration times will not prevent this interaction. Calcium carbonate should not be used with urinary acidifiers.
Aspirin, ASA (Bayer® Childrens Aspirin) and Diclofenac (Voltaren®)
Severity: High
Corticosteroids or NSAIDs should be used cautiously in patients receiving aspirin, ASA. While there is controversy regarding the ulcerogenic potential of corticosteroids (e.g., prednisone and others) alone, concomitant administration of corticosteroids with aspirin may increase the GI toxicity of aspirin. Although studies involving aspirin were not included, a meta-analysis published in 1991 revealed that concomitant use of corticosteroids increased the risk of adverse GI events due to NSAIDs.[1162] Combinations of aspirin with corticosteroids may be just as likely as combinations of non-salicylate NSAIDs with corticosteroids to cause gastric mucosal injury since aspirin has been shown to cause more gastropathy than non-salicylate NSAIDs independent of a contributing effect of corticosteroids.[1163] The use of aspirin together with non-salicylate NSAIDs (e.g., indomethacin and others) can lead to additive GI toxicity. Concurrent use of chronic ibuprofen therapy (800 mg three times daily) seems to antagonize the inhibition of platelet cyclooxygenase (COX)-1 activity and impairment of platelet aggregation by low-dose aspirin (81 mg once daily) per an ex vivo analysis.[4062] Interestingly in this study, diclofenac or rofecoxib therapy, agents with less activity at COX-1 than ibuprofen, did not affect inhibition of platelet aggregation by aspirin.[4062] An in vitro study has shown that the antagonism of aspirin platelet inhibition probably involves competition at platelet-derived COX-1 and is related to the NSAIDs' ability to inhibit COX-1 mediated thromboxane B2 production in platelets.[4063] However, whether this interference with aspirin's activity leads to adverse clinical consequences or occurs with NSAIDs other than ibuprofen has not been determined.
Because NSAIDs can cause GI bleeding, inhibit platelet aggregation, and prolong bleeding time, additive effects may be seen in patients receiving platelet inhibitors (including aspirin, ASA), anticoagulants, or thrombolytic agents. Increased adverse gastrointestinal effects (GI) are possible if diclofenac is used with salicylates. In addition, diclofenac is displaced from its binding sites by aspirin resulting in increased clearance and lower plasma concentrations, peak plasma levels, and AUC values; however, this interaction does not appears to be clinically important. A clinically significant interaction between diclofenac and warfarin has not been observed, although a prolongation of prothrombin time has been reported with concurrent administration of warfarin and other NSAIDs. Therefore, close monitoring of patients is recommended.
Aspirin, ASA (Bayer® Childrens Aspirin) and Meloxicam (Mobic®)
Severity: High
Meloxicam appears to lack platelet inhibitory effects and has minimal gastric ulceration or hemorrhagic potential. However, additive adverse gastrointestinal effects are possible if meloxicam is used with other NSAIDs, ethanol, corticosteroids or salicylates. Although some patients may need to be given corticosteroids and NSAIDs concomitantly, which can be done successfully for short periods of time without sequelae, prolonged concomitant administration should be avoided. Concomitant administration of aspirin, ASA (3000 mg/day) to healthy volunteers increased the meloxicam AUC by 10% and increased the meloxicam peak plasma concentrations by 24%. Concomitant administration of aspirin with meloxicam may result in an increased rate of GI ulceration or other complications, compared to the use of meloxicam alone. Because of its lack of platelet effects, meloxicam is not a substitute for aspirin for cardiovascular prophylaxis. Although meloxicam does not inhibit platelet aggregaton, an increased risk of bleeding may be seen in patients receiving platelet inhibitors, anticoagulants, or thrombolytic agents. In healthy subjects receiving daily doses of warfarin, meloxicam did not alter warfarin pharmacokinetics or the average anticoagulant effect of warfarin as determined by prothrombin time. However, one subject showed an increase in INR from 1.5 to 2.1. Anticoagulant activity and signs and symptoms of GI bleeding should be monitored, particularly in the first few days, after initiating or changing meloxicam therapy in patients receiving warfarin or similar agents, since these patients are at an increased risk of bleeding complications.
Corticosteroids or NSAIDs should be used cautiously in patients receiving aspirin, ASA. While there is controversy regarding the ulcerogenic potential of corticosteroids (e.g., prednisone and others) alone, concomitant administration of corticosteroids with aspirin may increase the GI toxicity of aspirin. Although studies involving aspirin were not included, a meta-analysis published in 1991 revealed that concomitant use of corticosteroids increased the risk of adverse GI events due to NSAIDs.[1162] Combinations of aspirin with corticosteroids may be just as likely as combinations of non-salicylate NSAIDs with corticosteroids to cause gastric mucosal injury since aspirin has been shown to cause more gastropathy than non-salicylate NSAIDs independent of a contributing effect of corticosteroids.[1163] The use of aspirin together with non-salicylate NSAIDs (e.g., indomethacin and others) can lead to additive GI toxicity. Concurrent use of chronic ibuprofen therapy (800 mg three times daily) seems to antagonize the inhibition of platelet cyclooxygenase (COX)-1 activity and impairment of platelet aggregation by low-dose aspirin (81 mg once daily) per an ex vivo analysis.[4062] Interestingly in this study, diclofenac or rofecoxib therapy, agents with less activity at COX-1 than ibuprofen, did not affect inhibition of platelet aggregation by aspirin.[4062] An in vitro study has shown that the antagonism of aspirin platelet inhibition probably involves competition at platelet-derived COX-1 and is related to the NSAIDs' ability to inhibit COX-1 mediated thromboxane B2 production in platelets.[4063] However, whether this interference with aspirin's activity leads to adverse clinical consequences or occurs with NSAIDs other than ibuprofen has not been determined.
Aspirin, ASA (Bayer® Childrens Aspirin) and Ascorbic Acid, Vitamin C (found in Centrum® Silver®)
Severity: Low
Agents that acidify the urine should be avoided in patients receiving high-dose salicylates. Urine acidifying agents (e.g., ammonium chloride, ascorbic acid, vitamin C, potassium chloride, or phosphate salts) may increase renal tubular reabsorption of salicylic acid and possibly increase salicylic acid levels. However, if the urine is acidic prior to administration of an acidifying agent, the increase in salicylic acid concentrations should be minimal. Increases in salicylic acid levels are more likely in patients receiving acidifying agents with a baseline urinary pH > 6.5.
Agents that acidify the urine should be avoided in patients receiving high-dose salicylates. Urine acidifying agents (e.g., ammonium chloride, ascorbic acid, vitamin C, potassium salts, or phosphate salts) may increase renal tubular reabsorption of salicylic acid and possibly increase salicylic acid levels. However, if the urine is acidic prior to administration of an acidifying agent, the increase in salicylic acid concentrations should be minimal. Increases in salicylic acid levels are more likely in patients with a urinary pH > 6.5.
Ergocalciferol, Vitamin D2 (found in Centrum® Silver®) and Calcium Carbonate (Tums® Ultra)
Severity: Moderate
Calcium is often combined with vitamin D in nutritional supplementation products to supply the recommended RDA/RDI in the general population and to promote optimum bone health. The concurrent use of vitamin D with calcium carbonate or other calcium salts is generally beneficial; in some patients, however, this combination may result in hypercalcemia.
The concurrent use of vitamin D analogs with calcium-containing antacids or other calcium salts may contribute to vitamin D-induced hypercalcemia. Calcium replacement or use of calcium-based phosphate binders may be required in patients receiving vitamin D analogs, but careful monitoring of serum calcium and phosphorus levels is needed.
Phosphorus Salts (found in Centrum® Silver®) and Aspirin, ASA (Bayer® Childrens Aspirin)
Severity: Moderate
Phosphates acidify the urine which may interfere with the excretion of salicylates. Use of phosphorus salts in patients stabilized on salicylates may increase serum concentrations of the salicylate to toxic levels.
Phosphorus Salts (found in Centrum® Silver®) and Spironolactone (Aldactone®)
Severity: High
Concurrent use of potassium-containing phosphorus salts with the following medications may predispose a patient to develop hyperkalemia, especially in patients with renal impairment: potassium-sparing diuretics, heparin (chronic therapy), ACE inhibitors, cyclosporine, potassium salts, or potassium-containing medications such as high doses of potassium penicillin G. Also, patients using salt substitutes or low-salt milk may develop hyperkalemia if given potassium-containing phosphorus salts.
Phosphorus Salts (found in Centrum® Silver®) and Calcium Carbonate (Tums® Ultra)
Severity: High
Orally administered phosphorus salts should normally not be coadministered with sevelamer, calcium salts (including calcium carbonate), or antacids containing calcium carbonate or aluminum hydroxide or other aluminum salts. In some instances the administration of sevelamer, calcium carbonate, or an aluminum hydroxide product is used therapeutically (e.g., uremia) to decrease serum phosphorus levels, so the administration of phosphorus would counteract the intended use of these drugs in these settings. In addition, the administration of calcium salts to patients receiving phosphorus salts may increase the risk of calcium deposition in soft-tissues. An interaction between calcium and phosphorus may also occur in parenteral admixtures; such admixtures should be observed carefully for precipitation and specialized resources on compatibility should be consulted. Precipitation in the admixture is dependent primarily on the concentration of calcium and phosphate in the solution, the pH and temperature of the solution, however, other factors such as amino acid concentration and the presence of other additives must also be observed (see Intravenous Products).
Potassium Salts (found in Centrum® Silver®) and Diclofenac (Voltaren®)
Severity: Low
Potassium salts should be used with caution in patients taking drugs that may increase serum potassium levels, such as ACE inhibitors; angiotensin II receptor antagonists; NSAIDs; beta-blockers; eplerenone; potassium-sparing diuretics (amiloride, spironolactone, or triamterene); high-doses of IV potassium penicillin G; trimethoprim (especially high dose); or heparin. Concurrent use can cause hyperkalemia, especially in elderly patients or patients with impaired renal function. Conversely, potassium supplements should be discontinued when hypokalemia-causing agents are discontinued or re-evaluated to avoid the possibility of developing hyperkalemia. Examples of hypokalemia-causing agents include: thiazide diuretics and loop diuretics; amphotericin B; high-dose beta-agonists; and high doses of extended-spectrum penicillins (carbenicillin, mezlocillin, piperacillin, and ticarcillin).
Potassium Salts (found in Centrum® Silver®) and Meloxicam (Mobic®)
Severity: Low
Potassium salts should be used with caution in patients taking drugs that may increase serum potassium levels, such as ACE inhibitors; angiotensin II receptor antagonists; NSAIDs; beta-blockers; eplerenone; potassium-sparing diuretics (amiloride, spironolactone, or triamterene); high-doses of IV potassium penicillin G; trimethoprim (especially high dose); or heparin. Concurrent use can cause hyperkalemia, especially in elderly patients or patients with impaired renal function. Conversely, potassium supplements should be discontinued when hypokalemia-causing agents are discontinued or re-evaluated to avoid the possibility of developing hyperkalemia. Examples of hypokalemia-causing agents include: thiazide diuretics and loop diuretics; amphotericin B; high-dose beta-agonists; and high doses of extended-spectrum penicillins (carbenicillin, mezlocillin, piperacillin, and ticarcillin).
Magnesium Salts (found in Centrum® Silver®) and Calcium Carbonate (Tums® Ultra)
Severity: Moderate
Calcium and magnesium salts are often combined together in nutritional supplement and vitamin products. Oral calcium-containing medications may increase serum calcium or magnesium concentrations in susceptible patients, primarily in patients with renal insufficiency.
Concurrent use of magnesium salts with other magnesium-containing products (e.g., magnesium citrate, magnesium hydroxide or other magnesium-containing antacids) may result in magnesium toxicity, especially in patients with renal impairment. Single use of magnesium citrate solution for bowel cleansing or magnesium hydroxide as a laxative may warrant caution if significant renal impairment exists. Magnesium citrate should not be used chronically as a laxative due to the risk of hypermagnesemia.
Magnesium Salts (found in Centrum® Silver®) and Spironolactone (Aldactone®)
Severity: Moderate
Diuretics may interfere with the kidneys ability to regulate magnesium concentrations. Long-term use of loop diuretics or thiazide diuretics may impair the magnesium-conserving ability of the kidneys and lead to hypomagnesemia. Conversely, long-term use of potassium-sparing diuretics has been found to increase renal tubular reabsorption of magnesium which may cause hypermagnesemia in patients also receiving magnesium supplements, especially in patients with renal insufficiency.
Magnesium Salts (found in Centrum® Silver®) and Venlafaxine (Effexor® XR)
Severity: Low
Because of the CNS-depressant effects of magnesium sulfate, additive central-depressant effects can occur following concurrent administration with barbiturates, opiate agonists, sedating H1-blockers, antidepressants, benzodiazepines, general anesthetics, local anesthetics, and phenothiazines.
Niacin, Niacinamide (found in Centrum® Silver®) and Spironolactone (Aldactone®)
Severity: Moderate
Clonidine has been shown to inhibit niacin-induced flushing. This interaction is harmless unless niacin augments the hypotensive actions of clonidine. Finally, clinicians should keep in mind that cutaneous vasodilation induced by niacin may become problematic if high-dose niacin is used concomitantly with other antihypertensive agents, especially peripheral vasodilators such as epoprostenol, nitrates, calcium-channel blockers, or others, particularly in the setting of acute myocardial infarction, unstable angina, or other acute hemodynamic compromise.
Niacin, Niacinamide (found in Centrum® Silver®) and Aspirin, ASA (Bayer® Childrens Aspirin)
Severity: Low
Niacin is known to induce the release of prostacyclin, which may be the mechanism of niacin-induced flushing, especially after immediate-release dosage forms. Aspirin, ASA has been shown to offset this adverse reaction if administered 30 minutes before the niacin dose. Concomitant administration of aspirin is reported to decrease the metabolic clearance of nicotinic acid according to manufacturer's data, but the clinical relevance of this finding is not known. In general, the interaction between ASA or and niacin is beneficial, although clinicians should note that both drugs, when administered in high doses, are potentially hepatotoxic. A recently published study demonstrated that niacin dosage forms that are more likely to produce flushing are less likely to be hepatotoxic.[221] Ibuprofen has also been reported to minimize niacin-induced flushing.
Meloxicam (Mobic®) and Diclofenac (Voltaren®)
Severity: High
In vitro studies indicate that the M1 metabolite of leflunomide inhibits cytochrome P450 2C9, the enzyme responsible for the metabolism of many NSAIDs. Leflunomide has inhibited the metabolism of diclofenac in vitro. Leflunomide also altered protein binding, increasing the free fraction of both ibuprofen and diclofenac by 13—50%. The clinical significance of these interactions with NSAIDs is unknown. There was extensive concomitant use of NSAIDs in phase III clinical studies of leflunomide in the treatment of rheumatoid arthritis and no clinical differential effects were observed. However, because some NSAIDs have been reported to cause hepatotoxic effects, some caution may be warranted in their use with leflunomide.
In general, NSAID therapy can decrease the clearance of methotrexate, resulting in elevated and prolonged serum methotrexate levels. Nonsteroidal antiinflammatory drugs (NSAIDs) should not be administered prior to, concomitantly, or following intermediate or high doses of methotrexate. Concomitant administration of NSAIDs with high-dose methotrexate therapy has been reported to elevate and prolong serum concentrations of methotrexate resulting in deaths from severe hematologic and gastrointestinal toxicity. However, meloxicam has not been studies with high-dose methotrexate therapy. Caution should be used when NSAIDs are administered concurrently with lower doses of methotrexate. Multiple dose meloxicam did not have a significant effect on the pharmacokinetics of methotrexate in a limited study of 13 rheumatoid arthritis patients receiving a single dose (15 mg) of methotrexate IV. When meloxicam is administered to patients receiving methotrexate, renal function and potential for methotrexate accumulation and toxicity should be monitored. In vitro, methotrexate does not displace meloxicam from its human serum binding sites. It should be noted that the doses of methotrexate used in rheumatoid arthritis are lower than those used in psoriasis or malignant disease; these higher doses may lead to unexpected toxicity in combination with NSAIDs. Concurrent use of NSAIDs may lead to an increased risk of GI bleeding in patients with methotrexate-induced thrombocytopenia or mask fever, pain, swelling and other signs and symptoms of an infection.
In general, NSAID therapy can decrease the clearance of methotrexate, resulting in elevated and prolonged serum methotrexate levels. Nonsteroidal antiinflammatory drugs (NSAIDs) should not be administered prior to, concomitantly, or following intermediate or high doses of methotrexate. Concomitant administration of NSAIDs with high dose methotrexate therapy has been reported to elevate and prolong serum concentrations of methotrexate resulting in deaths from severe hematologic and gastrointestinal toxicity. Caution should be used when NSAIDs are administered concurrently with lower doses of methotrexate. In patients with rheumatoid arthritis, methotrexate has been given concurrently with NSAIDs without apparent problems. It should be noted that the doses of methotrexate used in rheumatoid arthritis are lower than those used in psoriasis or malignant disease; these higher doses may lead to unexpected toxicity in combination with NSAIDs. Concurrent use of NSAIDs may lead to an increased risk of GI bleeding in patients with methotrexate-induced thrombocytopenia or mask fever, pain, swelling and other signs and symptoms of an infection.
Acetaminophen; Tramadol (Ultracet®) and Aspirin, ASA (Bayer® Childrens Aspirin)
Severity: Moderate
Prolonged concurrent use of acetaminophen and salicylates is not recommended. High-dose, chronic administration of the combined analgesics significantly increases the risk of analgesic nephropathy, renal papillary necrosis, and end-stage renal disease. Do not exceed the recommended individual maximum doses when these agents are given concurrently for short-term therapy, such as may occur with acetaminophen; tramadol.
Acetaminophen; Tramadol (Ultracet®) and Calcium Carbonate (Tums® Ultra)
Severity: Low
Antacids or food can delay and decrease the oral absorption of acetaminophen.
Acetaminophen; Tramadol (Ultracet®) and Venlafaxine (Effexor® XR)
Severity: High
The combination of SSRIs and tramadol has been associated with serotonin syndrome and an increased risk of seizures. SSRIs inhibit the formation of the active metabolite of tramadol by inhibiting cytochrome P450 2D6. The inhibition of this metabolite may decrease the analgesic effectiveness of tramadol but increase the level of the serotonergic parent compound. Although clinical data are lacking, other medications that decrease the reuptake of serotonin (e.g., duloxetine, nefazodone, St. John's wort, Hypericum perforatum, venlafaxine) may cause similar reactions in patients taking tramadol. One case report details a fatal seizure reaction in an alcoholic adult concomitantly taking tramadol, acetaminophen, venlafaxine, trazodone, quetiapine, promethazine and acetaminophen.[3347]
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Adverse Reactions
• abdominal pain (Bayer® Childrens Aspirin | Voltaren® | Aldactone® | Mobic® | GNC Glucosamine; Chrondroitin | Ultracet®)
• acute generalized exanthematous pustulosis (AGEP) (Ultracet®)
• agitation (Ultracet®)
• agranulocytosis (Bayer® Childrens Aspirin | Voltaren® | Aldactone® | Mobic®)
• akathisia (Effexor® XR)
• alopecia (Mobic® | GNC Glucosamine; Chrondroitin)
• amenorrhea (Aldactone®)
• anaphylactic shock (Ultracet®)
• anaphylactoid reactions (Bayer® Childrens Aspirin | Voltaren® | Mobic® | Ultracet®)
• anemia (Voltaren® | Mobic® | Ultracet®)
• angioedema (Bayer® Childrens Aspirin | Mobic® | Ultracet®)
• anorexia (Aldactone® | Effexor® XR | Mobic® | GNC Glucosamine; Chrondroitin | Ultracet®)
• anxiety (Effexor® XR | Ultracet®)
• aplastic anemia (Bayer® Childrens Aspirin | Voltaren®)
• aseptic meningitis (Voltaren® | Mobic®)
• asthenia (Effexor® XR | Ultracet®)
• ataxia (Aldactone®)
• azotemia (Bayer® Childrens Aspirin | Voltaren® | Aldactone® | Mobic®)
• bleeding (Bayer® Childrens Aspirin | Effexor® XR)
• blurred vision (Voltaren® | Effexor® XR)
• bronchospasm (Bayer® Childrens Aspirin | Mobic® | Ultracet®)
• bullous rash (Mobic®)
• colitis (Mobic®)
• confusion (Bayer® Childrens Aspirin | Voltaren® | Aldactone® | Ultracet®)
• conjunctivitis (Voltaren®)
• constipation (Bayer® Childrens Aspirin | Tums® Ultra | Voltaren® | Effexor® XR | Mobic® | GNC Glucosamine; Chrondroitin | Ultracet®)
• contact dermatitis (Ultracet®)
• corneal edema (Voltaren®)
• corneal erosion (Voltaren®)
• dehydration (Bayer® Childrens Aspirin)
• diaphoresis (Bayer® Childrens Aspirin | Effexor® XR | Mobic® | Ultracet®)
• diarrhea (Bayer® Childrens Aspirin | Voltaren® | Aldactone® | Mobic® | GNC Glucosamine; Chrondroitin |
Ultracet®)
• disseminated intravascular coagulation (DIC) (Bayer® Childrens Aspirin)
• dizziness (Bayer® Childrens Aspirin | Voltaren® | Effexor® XR | Mobic® | Ultracet®)
• drowsiness (Bayer® Childrens Aspirin | Aldactone® | Effexor® XR | GNC Glucosamine; Chrondroitin | Ultracet®)
• dyspepsia (Bayer® Childrens Aspirin | Voltaren® | Mobic® | GNC Glucosamine; Chrondroitin | Ultracet®)
• dysphagia (Bayer® Childrens Aspirin | Voltaren® | Mobic®)
• dyspnea (Mobic®)
• ecchymosis (Effexor® XR)
• edema (Mobic® | GNC Glucosamine; Chrondroitin | Ultracet®)
• ejaculation dysfunction (Effexor® XR)
• elevated hepatic enzymes (Bayer® Childrens Aspirin | Voltaren® | Mobic® | Ultracet®)
• emotional lability (Ultracet®)
• encephalopathy (Bayer® Childrens Aspirin | Ultracet®)
• eructation (Tums® Ultra | Mobic®)
• erythema (Aldactone® | Mobic® | Ultracet®)
• erythema multiforme (Voltaren® | Mobic®)
• erythema nodosum (Bayer® Childrens Aspirin)
• esophageal stricture (Bayer® Childrens Aspirin | Voltaren® | Mobic®)
• esophageal ulceration (Bayer® Childrens Aspirin | Voltaren® | Mobic®)
• esophagitis (Bayer® Childrens Aspirin | Voltaren® | Mobic®)
• euphoria (Ultracet®)
• exfoliative dermatitis (Ultracet®)
• fatigue (GNC Glucosamine; Chrondroitin)
• fetal death (Ultracet®)
• fever (Bayer® Childrens Aspirin | Aldactone® | Mobic® | Ultracet®)
• flatulence (Tums® Ultra | Ultracet®)
• fluid retention (Voltaren®)
• flushing (Ultracet®)
• gastric hypersecretion (Tums® Ultra)
• gastritis (Bayer® Childrens Aspirin | Voltaren® | Aldactone® | Mobic®)
• gastroesophageal reflux (Mobic®)
• GI bleeding (Bayer® Childrens Aspirin | Voltaren® | Mobic®)
• GI perforation (Bayer® Childrens Aspirin | Voltaren® | Mobic®)
• gynecomastia (Aldactone®)
• hallucinations (Bayer® Childrens Aspirin | Ultracet®)
• headache (Bayer® Childrens Aspirin | Voltaren® | Aldactone® | Mobic® | GNC Glucosamine; Chrondroitin |
Ultracet®)
• hearing loss (Bayer® Childrens Aspirin)
• heart failure (Voltaren® | Mobic®)
• hematemesis (Mobic®)
• hematuria (Voltaren®)
• hemolysis (Ultracet®)
• hemolytic anemia (Bayer® Childrens Aspirin | Voltaren® | Ultracet®)
• hemorrhoids (Bayer® Childrens Aspirin)
• hepatic failure (Mobic®)
• hepatic necrosis (Bayer® Childrens Aspirin | Voltaren® | Ultracet®)
• hepatitis (Bayer® Childrens Aspirin | Voltaren®)
• hirsutism (Aldactone®)
• hyperbilirubinemia (Bayer® Childrens Aspirin | Mobic®)
• hypercalcemia (Tums® Ultra)
• hypercholesterolemia (Effexor® XR)
• hyperglycemia (Bayer® Childrens Aspirin)
• hyperkalemia (Aldactone®)
• hypernatremia (Bayer® Childrens Aspirin)
• hypertension (Effexor® XR | Ultracet®)
• hyperuricemia (Bayer® Childrens Aspirin)
• hyperventilation (Bayer® Childrens Aspirin)
• hypoglycemia (Bayer® Childrens Aspirin)
• hypokalemia (Bayer® Childrens Aspirin)
• hyponatremia (Aldactone® | Effexor® XR)
• hypophosphatemia (Tums® Ultra)
• hypoprothrombinemia (Bayer® Childrens Aspirin | Ultracet®)
• hypotension (Ultracet®)
• impotence (Aldactone® | Effexor® XR)
• infection (Voltaren® | Mobic®)
• infertility (Aldactone®)
• insomnia (Effexor® XR | GNC Glucosamine; Chrondroitin | Ultracet®)
• interstitial nephritis (Bayer® Childrens Aspirin | Voltaren® | Mobic® | Ultracet®)
• intracranial bleeding (Bayer® Childrens Aspirin)
• iritis (Voltaren®)
• jaundice (Bayer® Childrens Aspirin | Voltaren® | Mobic® | Ultracet®)
• keratitis (Voltaren®)
• laryngeal edema (Bayer® Childrens Aspirin)
• lethargy (Aldactone®)
• leukocytosis (Bayer® Childrens Aspirin)
• leukopenia (Bayer® Childrens Aspirin | Mobic® | Ultracet®)
• libido decrease (Aldactone® | Effexor® XR)
• maculopapular rash (Bayer® Childrens Aspirin | Aldactone® | Mobic® | Ultracet®)
• mania (Effexor® XR)
• mastalgia (Aldactone®)
• melena (Bayer® Childrens Aspirin | Voltaren® | Mobic®)
• menstrual irregularity (Aldactone®)
• metabolic acidosis (Bayer® Childrens Aspirin | Aldactone®)
• metabolic alkalosis (Tums® Ultra)
• methemoglobinemia (Ultracet®)
• milk-alkali syndrome (Tums® Ultra)
• mydriasis (Effexor® XR)
• nausea/vomiting (Bayer® Childrens Aspirin | Tums® Ultra | Voltaren® | Aldactone® | Effexor® XR | Mobic® | GNC
Glucosamine; Chrondroitin | Ultracet®)
• neonatal abstinence syndrome (Ultracet®)
• nephrotic syndrome (Voltaren®)
• neutropenia (Ultracet®)
• ocular irritation (Voltaren®)
• ocular pain (Voltaren®)
• odynophagia (Bayer® Childrens Aspirin | Voltaren® | Mobic®)
• oliguria (Ultracet®)
• oral ulceration (Mobic®)
• palpitations (GNC Glucosamine; Chrondroitin)
• pancreatitis (Voltaren® | Mobic®)
• pancytopenia (Bayer® Childrens Aspirin | Voltaren® | Ultracet®)
• peptic ulcer (Bayer® Childrens Aspirin | Tums® Ultra | Voltaren® | Mobic®)
• peripheral edema (Voltaren® | Mobic®)
• pharyngitis (Mobic®)
• photophobia (Voltaren®)
• photosensitivity (Mobic®)
• physiological dependence (Ultracet®)
• platelet dysfunction (Bayer® Childrens Aspirin | Voltaren®)
• polyuria (Aldactone®)
• porphyria (Voltaren®)
• postmenopausal bleeding (Aldactone®)
• priapism (Effexor® XR)
• prolonged bleeding time (Bayer® Childrens Aspirin)
• proteinuria (Voltaren®)
• pruritus (Voltaren® | Mobic® | Ultracet®)
• psychological dependence (Ultracet®)
• pulmonary edema (Bayer® Childrens Aspirin)
• purpura (Bayer® Childrens Aspirin | Voltaren® | Mobic® | Ultracet®)
• pyrosis (heartburn) (Voltaren® | Mobic® | GNC Glucosamine; Chrondroitin)
• QT prolongation (Effexor® XR)
• rash (unspecified) (Mobic® | GNC Glucosamine; Chrondroitin | Ultracet®)
• renal failure (unspecified) (Bayer® Childrens Aspirin | Voltaren® | Aldactone® | Mobic® | Ultracet®)
• renal papillary necrosis (Bayer® Childrens Aspirin | Voltaren® | Ultracet®)
• renal tubular necrosis (Bayer® Childrens Aspirin | Ultracet®)
• respiratory depression (Bayer® Childrens Aspirin | Ultracet®)
• Reye's syndrome (Bayer® Childrens Aspirin)
• rhinitis (Bayer® Childrens Aspirin)
• secondary malignancy (Aldactone®)
• seizures (Bayer® Childrens Aspirin | Effexor® XR | Ultracet®)
• serotonin syndrome (Effexor® XR | Ultracet®)
• SIADH (Effexor® XR)
• sinus bradycardia (Aldactone®)
• sinus tachycardia (Effexor® XR | GNC Glucosamine; Chrondroitin | Ultracet®)
• Stevens-Johnson syndrome (Bayer® Childrens Aspirin | Voltaren® | Mobic® | Ultracet®)
• stomatitis (Mobic®)
• suicidal ideation (Effexor® XR)
• thrombocytopenia (Bayer® Childrens Aspirin | Mobic® | Ultracet®)
• tinnitus (Bayer® Childrens Aspirin | Voltaren®)
• tolerance (Ultracet®)
• toxic epidermal necrolysis (Bayer® Childrens Aspirin | Mobic® | Ultracet®)
• tremor (Effexor® XR | Ultracet®)
• urinary retention (Ultracet®)
• urticaria (Bayer® Childrens Aspirin | Voltaren® | Aldactone® | Mobic® | Ultracet®)
• visual impairment (Bayer® Childrens Aspirin | Voltaren® | Ultracet®)
• weakness (Aldactone® | Effexor® XR)
• weight gain (Mobic®)
• weight loss (Effexor® XR)
• wheezing (Bayer® Childrens Aspirin)
• withdrawal (Effexor® XR | Ultracet®)
• xerophthalmia (Voltaren®)
• xerostomia (Effexor® XR | Mobic® | Ultracet®)
________________________________________________________________________________
Indication Alerts
Drugs that can be used to treat current conditions:
• Aldactone® can be used to treat hypertension
• Bayer® Childrens Aspirin can be used to treat arterial thromboembolism prophylaxis, and osteoarthritis
• Centrum® Silver® can be used to treat hypertension, nutritional supplementation, and osteoporosis prophylaxis
• Effexor® XR can be used to treat anxiety
• GNC Glucosamine; Chrondroitin can be used to treat osteoarthritis
• Mobic® can be used to treat osteoarthritis
• Tums® Ultra can be used to treat nutritional supplementation, and osteoporosis prophylaxis
• Ultracet® can be used to treat osteoarthritis
• Voltaren® can be used to treat ocular pain, and osteoarthritis
Conditions not currently being treated:
• bradycardia
• renal impairment
• urticaria
________________________________________________________________________________
Precautions
Precaution: Aldactone® in renal impairment
Spironolactone is contraindicated in patients with hyperkalemia (serum potassium greater than 5.5 mEq/L) or who are receiving other potassium-sparing agents. Patients receiving spironolactone should not receive potassium supplementation or increase their dietary intake of potassium unless they have refractory hypokalemia; serum potassium, creatinine, and BUN levels should be monitored. Spironolactone-induced hyperkalemia can cause life-threatening cardiac arrhythmias, and it is more likely to occur in patients with impaired renal function, diabetes mellitus, or in elderly patients; these patients should have periodic serum electrolyte, creatinine, and BUN levels monitored. Spironolactone should be used with caution in these patients. The precaution for spironolactone in patients with diabetes mellitus is primarily due to the risk of hyperkalemia and not the risk of inducing hyperglycemia, which may occur with thiazide or loop diuretics. Elderly patients also may be more sensitive to the hypotensive and diuretic effects of spironolactone. Spironolactone is also contraindicated in patients with anuria, diabetic nephropathy or any renal disease associated with severe renal impairment (CrCl < 10 ml/min) or renal failure. The dose of spironolactone should be adjusted in patients with moderate renal impairment (CrCl 10—50 ml/min). Serum potassium, creatinine, and BUN levels should be monitored in patients receiving spironolactone.=
Precaution: Bayer® Childrens Aspirin in hypertension
Sodium-restricted patients or patients with hypovolemic states (e.g., ascites, dehydration, heart failure, hypertension, or hypovolemia) may be more susceptible to adverse renal effects of salicylate therapy. Buffered aspirin contains a high sodium content. In patients with carditis, high doses of salicylates may precipitate congestive heart failure or pulmonary edema.
Precaution: Bayer® Childrens Aspirin in renal impairment
Salicylates should be used with caution in patients with renal impairment and with extreme caution, if at all, in patients with advanced, chronic renal failure since salicylic acid and its metabolites are excreted in the urine. In addition, these patients may be at increased risk of developing salicylate-induced nephrotoxicity. In a case-controlled study of patients with early renal failure, the regular use of aspirin (without acetaminophen) was associated with a risk of chronic renal failure that was 2.5-times as high as that for non-aspirin users.[4064] The risk increased significantly with increasing cumulative lifetime dose and increasing average dose during periods of regular use; duration of therapy was not associated with increased risk. When aspirin was given regularly in analgesic doses (> 500 g per year during periods of regular use) the odds ratio for chronic renal failure was 3.5 (95% confidence interval 1.4 to 8.0). Low-dose aspirin use for cardiovascular prophylaxis was not significantly associated with the development of renal failure. In this study, it appears that pre-existing renal disease or systemic disease is a required precursor to the development of analgesic-induced renal failure; patients without preexisting renal disease who used analgesics had only a small risk of developing end-stage renal disease. Renal function should be monitored periodically in patients receiving prolonged or high-dose salicylate therapy. Salicylates should be used cautiously in patients with renal disease or systemic lupus erythematosus (SLE) due to the risk of decreased glomerular filtration rate in these patients.
Precaution: Bayer® Childrens Aspirin in urticaria
Patients with a tartrazine dye hypersensitivity or salicylate hypersensitivity should avoid aspirin. The risk of cross-sensitivity with other nonsteroidal antiinflammatory drugs is significantly greater with aspirin than other salicylates; avoid use in patients with a known NSAID hypersensitivity. Patients with nasal polyps or with allergic reactions (e.g. urticaria) to aspirin are at risk of developing bronchoconstriction or anaphylaxis and should not receive aspirin. Patients with asthma are at risk of developing severe and potentially fatal exacerbations of asthma after taking aspirin. Aspirin should be avoided in asthmatics with a history of aspirin-induced acute bronchospasm.
Precaution: Centrum® Silver® in hypertension
Phosphorus salts should be administered cautiously to patients who have conditions which may be associated with hyperphosphatemia and/or hypocalcemia. These conditions include hypoparathyroidism, chronic renal disease, rhabdomyolysis, osteomalacia (rickets), or acute pancreatitis. Due to the possibility of developing hyperkalemia and subsequent cardiac arrest, potassium-containing phosphorus salts should be used cautiously in patients with cardiac disease, severe adrenal insufficiency (Addison's disease), acute dehydration, pancreatitis, severe renal impairment (< 30% of normal), rhabdomyolysis, strenous physical exercise (especially unconditioned persons), or extensive tissue breakdown (i.e., severe burns). Sodium-containing phophorus salts may exacerbate conditions such as heart failure, severe hepatic disease, peripheral edema, pulmonary edema, hypernatremia, hypertension, or toxemia of pregnancy (e.g., preeclampsia). In addition, patients on sodium-restricted diets should not receive sodium-containing phosphorus salts. Children with abnormal colonic motility (e.g., megacolon) or anatomic abnormalities of the colon are at the most risk of developing possible life-threatening fluid and electrolyte disturbances and altered acid-base balances during therapy with phosphate laxatives.
Precaution: Centrum® Silver® in renal impairment
Phosphorus salts should be administered cautiously to patients who have conditions which may be associated with hyperphosphatemia and/or hypocalcemia. These conditions include hypoparathyroidism, chronic renal disease, rhabdomyolysis, osteomalacia (rickets), or acute pancreatitis. Due to the possibility of developing hyperkalemia and subsequent cardiac arrest, potassium-containing phosphorus salts should be used cautiously in patients with cardiac disease, severe adrenal insufficiency (Addison's disease), acute dehydration, pancreatitis, severe renal impairment (< 30% of normal), rhabdomyolysis, strenous physical exercise (especially unconditioned persons), or extensive tissue breakdown (i.e., severe burns). Sodium-containing phophorus salts may exacerbate conditions such as heart failure, severe hepatic disease, peripheral edema, pulmonary edema, hypernatremia, hypertension, or toxemia of pregnancy (e.g., preeclampsia). In addition, patients on sodium-restricted diets should not receive sodium-containing phosphorus salts. Children with abnormal colonic motility (e.g., megacolon) or anatomic abnormalities of the colon are at the most risk of developing possible life-threatening fluid and electrolyte disturbances and altered acid-base balances during therapy with phosphate laxatives.
Precaution: Centrum® Silver® in females
Phytonadione is classified as FDA pregnancy risk category C. Adequate, well-controlled studies in humans have not been conducted; however, placental transfer is minimal. Usually, supplementation of vitamin K during pregnancy is not required. The recommended Adequate Intake (AI) values for pregnant females are the same as non-pregnant females (see Dosage).
Precaution: Centrum® Silver® in hypertension
Potassium supplements should be monitored closely in patients with cardiac arrhythmias (e.g., atrial fibrillation, atrial flutter, digitalis toxicity (except due to documented hypokalemia), and ventricular arrhythmias including ventricular fibrillation and ventricular tachycardia), including patients receiving digoxin or other antiarrhythmic therapy. Based on a multidisciplinary review of literature and clinical practice trends, the National Council on Potassium in Clinical Practice recommends that serum potassium concentrations >= 4 mEq/L be achieved and maintained in patients with hypertension, heart failure, and cardiac arrhythmias to minimize complications of potassium depletion.[3085] In addition, the Council recommends potassium supplementation for patients at risk for developing hypokalemia and associated complications. Potassium supplementation is specifically recommended for patients with potential for diuretic-induced potassium loss (e.g., receiving thiazide or loop diuretics), patients with high sodium intake (unwilling to reduce salt intake), and patients with reduced GI intake (e.g., GI disturbances, laxative abuse).[3085]
Precaution: Centrum® Silver® in renal impairment
Potassium supplements are contraindicated in patients with hyperkalemia since a further increase in serum potassium concentration in such patients can produce cardiac arrest. Due to the risk of developing hyperkalemia, potassium supplementation should be used with caution in patients with adrenal insufficiency (untreated Addison's disease); acute dehydration; systemic metabolic acidosis such as diabetic ketoacidosis; diarrhea; strenuous physical exercise (especially unconditioned persons); in patients receiving salt substitutes, potassium-sparing diuretics (e.g., amiloride, spironolactone, triamterene), ACE inhibitors, or angiotensin II antagonists; or in patients with renal disease, renal failure, or renal impairment. Potassium supplements should also be used cautiously in patients with severe burns because these patients are prone to hyperkalemia secondary to tissue breakdown and renal insufficiency. Serum potassium levels and renal function should be monitored closely in patients at risk for hyperkalemia. Because elderly patients are more likely to have decreased renal function, potassium salts should be dosed cautiously based on an assessment of renal function and therapeutic goals. NOTE: Potassium acetate injection contains aluminum (<= 200 mcg/L). Thus, aluminum may reach toxic levels with prolonged administration in patients with renal impairment. Premature neonates are at particular risk for aluminum toxicity following administration of aluminum-containing injectables. Since premature neonates have immature kidneys, they may require large amounts of calcium and phosphate solutions, which contain aluminum. Research indicates that patients with renal impairment, including neonates, who receive parenteral aluminum at rates greater than 4—5 mcg/kg/day may accumulate aluminum at levels associated with CNS and bone toxicity. Tissue loading may occur at lower administration rates.
Precaution: Centrum® Silver® in renal impairment
Magnesium salts should be used with caution in patients with renal disease, including patients with renal impairment or renal failure. Magnesium salts are renally eliminated, so patients with renal impairment have an increased risk of developing magnesium toxicity from decreased excretion of magnesium. In patients with severe renal dysfunction, no more than 20 grams (162 mEq) of magnesium should be administered within a 48-hour period. Parenteral magnesium should be avoided in patients with a creatinine clearance of less than 20 mL/minute. Up to 30% of an orally administered dose is absorbed systemically.
Precaution: Centrum® Silver® in females
While steady state plasma concentrations of niacin are generally higher in females than in males, the absorption, metabolism, and excretion of niacin appears to be similar in both genders. Women have been reported to have greater response to the lipid-lowering effects of nicotinic acid (niacin) when compared to males.
Precaution: Centrum® Silver® in renal impairment
Use niacin with caution in patients with renal disease (renal failure or severe renal impairment) since niacin metabolites are excreted through the kidneys. It appears that no special precautions are needed when administering niacin to meet the recommended nutritional daily allowance (RDA). Use caution when administering higher dosages.
Precaution: Centrum® Silver® in renal impairment
Zinc Chloride injection contains aluminum which may reach toxic levels with prolonged administration in patients with renal impairment or renal failure. Neonates of neonatal prematurity are at particular risk for aluminum toxicity following administration of aluminum-containing injectables since they have immature kidneys. Research indicates that patients with renal impairment, including neonates, who receive parenteral aluminum at rates greater than 4—5 mcg/kg/day may accumulate aluminum at levels associated with CNS and bone toxicity. Tissue loading may occur at lower administration rates.
Precaution: Centrum® Silver® in renal impairment
Chromium elimination may be decreased in patients with renal disease or renal impairment. Dosage reductions in supplemental parenteral or oral doses may be needed. Since chromium is primarily excreted via the renal route, supplementation should be approached with caution, particularly in patients maintained on hemodialysis or with renal failure.
Precaution: Centrum® Silver® in renal impairment
Selenium supplements should be used cautiously in patients with GI disease or renal impairment. These conditions may cause high levels of selenium; dosage reductions may be necessary.
Precaution: Effexor® XR in hypertension
Venlafaxine has not been extensively studied in patients with a recent history of significant cardiac disease. Because venlafaxine is associated with dose-related sustained increases in supine diastolic blood pressure, it should be used with caution in patients with preexisting hypertension, as well as patients with hyperthyroidism, recent myocardial infarction, or heart failure, particularly with doses > 200 mg/day. Blood pressure should be routinely monitored during therapy with venlafaxine. For patients who experience increased blood pressure while on venlafaxine, either dose reduction or discontinuation should be considered. Statistically significant and dose-dependent increases in heart rate have been observed on ECGs during venlafaxine therapy. Doses ranging 200 to 375 mg/day resulted in a mean increase of 4 beats per minute, while mean doses > 300 mg/day resulted in a heart rate increase of roughly 8 beats per minute.
Precaution: Effexor® XR in renal impairment
Venlafaxine should be used with caution in patients with renal impairment or renal failure because clearance is reduced. Patients with hepatic impairment have an increase in plasma concentrations of venlafaxine compared to patients without hepatic disease. Thus, this drug should be used with caution in patients with hepatic impairment. Reduced dosages of venlafaxine may be necessary in these patient populations (see Dosage).
Precaution: GNC Glucosamine; Chrondroitin in renal impairment
Chondroitin and glucosamine are both excreted in the urine to some degree. Glucosamine is metabolized in the liver. Studies of chondroitin; glucosamine do not exist for patients with renal disease or hepatic disease; caution is warranted with supplementation in these individuals. Patients with renal impairment or renal failure should avoid chondroitin; glucosamine products that are available in combination with minerals that may accumulate in renal impairment.
Precaution: Mobic® in females
Serious GI tract effects such as bleeding, inflammation, stomach perforation, and ulceration, can occur without warning or symptoms in patients receiving NSAIDs. Therefore, patients receiving meloxicam should be monitored for the signs and symptoms of GI bleeding, even in the absence of symptoms. Serious GI bleeding and GI perforation have been reported in patients receiving meloxicam. NSAIDs should be prescribed with extreme caution in patients with a prior history of GI bleeding, GI perforation or ulcerative GI disease. Most spontaneous reports of fatal GI events with NSAID therapy are in elderly or debilitated patients and therefore special care should be taken in treating this population. As with any NSAID, caution should be exercised in treating the elderly patients. Another caution for meloxicam is that elderly females subjects have an increase in total AUC compared to younger females; however, the differences in pharmacokinetics in females are not likely to be clinically important. Despite the increased total concentrations in t