Drug Interactions of OTC Analgesics (Part 4):

Drug Interactions of Ketoprofen:

More presentations from Naina Mohamed Pakkir Maideen

vKetoprofen is a Non Steroidal Anti-inflammatory drug (NSAID) and is available as an OTC analgesic drug which is used to reduce fever and treat pain or inflammation caused by many conditions such as headache, toothache, back pain, arthritis, menstrual cramps, or minor injury.

vConcomitant use of Ketorolac and Ketoprofen is contraindicated due to cumulative risks of inducing serious NSAID-related adverse events (peptic ulcers, gastrointestinal bleeding and/or perforation).

vBleeding risk is elevated by the coadministration of Ketoprofen with drugs such as Warfarin, Heparin, Low Molecular Weight Heparins (LMWHs) (Enoxaparin, Dalteparin, Tinzaparin, etc.), Coumarins and other anticoagulants (Acenocoumarol, Dicumarol, Phenprocoumon, Dabigatran, Anisindione, Phenindione), Direct thrombin inhibitors (Dabigatran, Desirudin, Lepirudin, Bivalirudin, Argatroban), Direct factor Xa inhibitors (Apixaban, Rivaroxaban), Antiplatelets (Clopidogrel, Aspirin, Prasugrel, Ticagrelor, Ticlopidine, Dipyridamole, Abciximab, Eptifibatide, Tirofiban), Danaparoid, Fondaparinux, Selective serotonin reuptake inhibitors (SSRIs) (Escitalopram, Fluvoxamine, Paroxetine, Vortioxetine,  Sertraline, Nefazodone, vilazodone), Selective serotonin and norepinephrine reuptake inhibitors (SNRIs) (Venlafaxine, Desvenlafaxine, Duloxetine, Milnacipran, Levomilnacipran, Sibutramine), Cilostazol, Protein C, Pentoxyfilline, Ginkgo, Meadowsweet, Erlotinib and Gossypol.

vUse of Ketoprofen in patients taking ACE Inhibitors (Captopril, Enalapril, Imidapril, Temocapril, Delapril, Ramipril, Perindopril, Cilazapril), Angiotensin II receptor blockers (ARBs) (Losartan, Valsartan, Telmisartan), Beta adrenergic blockers, Calcium Channel Blockers, Thiazide Diuretics and Loop Diuretics may decrease the antihypertensive effects by decreasing renal prostaglandin production.

vKetoprofen can decrease the renal prostaglandin synthesis and increase the toxicity of Cyclosporine, Tacrolimus and Lithium.

vThe toxicity of Methotrexate, Pralatrexate and Premetrexed may be elevated by the concomitant use of Ketoprofen, due to decreased clearance.

vConcomitant use of Ketoprofen and Fluoroquinolones (Ofloxacin, Levofloxacin, Norfloxacin) may elevate the risk of seizures.

vDue to the risk of earlier closure of ductus arteriosus, Ketoprofen should be avoided after 30 weeks of gestation in Pregnant women.

vPatients should thoroughly read the labels of all over-the-counter and prescription medicines.

vPatients should talk to their doctor or pharmacist before taking any new prescription or over the counter medication.

vPhysicians should be aware of potential drug interactions with OTC medicines when prescribing new medications.

vPharmacists can be instrumental in assisting patients with using OTC medications safely and effectively.

vPharmacists should warn consumers of the risks of misusing OTC pain relievers.

Drug Interactions of OTC Analgesics (Part 3):

Drug Interactions of Ibuprofen:

More presentations from Naina Mohamed Pakkir Maideen

©  Ibuprofen is an OTC analgesic and is used to treat pain or inflammation and to reduce fever.

©  Ibuprofen can cause serious adverse effects by interacting with other common medications such as anticoagulants, corticosteroids, or antihypertensive agents.

©  Use of Ibuprofen by Ketorolac patients, is contraindicated due to cumulative risks of inducing serious NSAID-related adverse events such as peptic ulcers, gastrointestinal bleeding and/or perforation.

©  The risk of bleeding is increased by Ibuprofen in patients taking Warfarin, Danaparoid, Heparin, Low Molecular Weight Heparins (LMWHs) (Enoxaparin, Dalteparin, Tinzaparin, etc.), Coumarins and other anticoagulants (Acenocoumarol, Dicumarol, Phenprocoumon, Dabigatran, Anisindione, Phenindione), Direct thrombin inhibitors (Dabigatran, Desirudin, Lepirudin, Bivalirudin, Argatroban), Direct factor Xa inhibitors (Apixaban, Rivaroxaban), Antiplatelets (Aspirin, Clopidogrel, Prasugrel, Ticagrelor, Ticlopidine, Dipyridamole, Abciximab, Eptifibatide, Tirofiban), Fondaparinux, Selective serotonin reuptake inhibitors (SSRIs) (Escitalopram, Fluvoxamine, Paroxetine, Vortioxetine,  Sertraline, Nefazodone, vilazodone), Selective serotonin and norepinephrine reuptake inhibitors (SNRIs) (Venlafaxine, Desvenlafaxine, Duloxetine, Milnacipran, Levomilnacipran, Sibutramine), Cilostazol, Protein C, Pentoxyfilline, Ginkgo, Meadowsweet, Erlotinib and Gossypol.

©  The antihypertensive effects of ACE Inhibitors (Captopril, Enalapril, Imidapril, Temocapril, Delapril, Ramipril, Perindopril, Cilazapril), Angiotensin II receptor blockers (ARBs) (Losartan, Valsartan, Telmisartan), Beta adrenergic blockers, Calcium Channel Blockers, Thiazide Diuretics, Loop Diuretics and Potassium sparing Diuretics.

©  The plasma levels of ibuprofen is elevated by the co-administration of Amiodarone, Voriconazole and Mifepristone by inhibiting CYP2C9-mediated ibuprofen metabolism.

©  By decreasing renal prostacyclin synthesis, Ibuprofen may increase the risk of Cyclosporine associated nephrotoxicity, Tacrolimus associated acute renal failure and Lithium toxicity (weakness, tremor, excessive thirst, confusion).

©  Ibuprofen may increase the toxicity of Methotrexate, Pralatrexate and Premetrexed by decreasing their renal clearance.

©  Concomitant use of Ibuprofen and Fluoroquinolones (Ofloxacin, Levofloxacin, Norfloxacin) may elevate the risk of seizures.

©  Due to the risk of earlier closure of ductus arteriosus, Ibuprofen should be avoided after 30 weeks gestation in Pregnant women.

©  Patients should thoroughly read the labels of all over-the-counter and prescription medicines.

©  Patients should talk to their doctor or pharmacist before taking any new prescription or over the counter medication.

©  Physicians should be aware of potential drug interactions with OTC medicines when prescribing new medications.

©  Pharmacists can be instrumental in assisting patients with using OTC medications safely and effectively.

©  Pharmacists should warn consumers of the risks of misusing OTC pain relievers.  

Drug Interactions of OTC Analgesics (Part 2):

Drug Interactions of Aspirin:

More presentations from Naina Mohamed Pakkir Maideen

Ø Aspirin or Acetyl salicylic acid (ASA) is an OTC analgesic which can cause potentially serious adverse effects when used in combination with other common medications such as anticoagulants, corticosteroids, or antihypertensive agents.

Ø Coadministration of the Ketorolac and aspirin is contraindicated, because of the cumulative risks of serious NSAID-related adverse events (peptic ulcers, gastrointestinal bleeding, and/or perforation).

Ø It is contraindicated to use live influenza virus vaccine and aspirin in children 2 to 17 years of age due to the potential for Reye's syndrome.

Ø The risk of Reye's syndrome is also enhanced by the use of aspirin within six weeks of Varicella vaccine administration.

Ø The risk of bleeding is increased by aspirin in patients taking Warfarin, Heparin, Low Molecular Weight Heparins (LMWHs) (Enoxaparin, Dalteparin, Tinzaparin, etc.), Coumarins and other anticoagulants (Acenocoumarol, Dicumarol, Phenprocoumon, Anisindione, Phenindione), Antiplatelets (Clopidogrel, Prasugrel, Ticagrelor, Ticlopidine, Dipyridamole, Abciximab, Eptifibatide, Tirofiban), Tissue Plasminogen Activators (Alteplase, Reteplase), Direct thrombin inhibitors (Dabigatran, Desirudin, Lepirudin, Bivalirudin, Argatroban), Direct factor Xa inhibitors (Apixaban, Rivaroxaban), Anagrelide, Cilostazol, Selective serotonin reuptake inhibitors (SSRIs) (Escitalopram, Fluvoxamine, Paroxetine, Vortioxetine,  Sertraline, Nefazodone, vilazodone) and Selective serotonin and norepinephrine reuptake inhibitors (SNRIs) (Venlafaxine, Desvenlafaxine, Duloxetine, Milnacipran, Levomilnacipran, Sibutramine).

Ø The risk of gastrointestinal adverse effects (ulceration, bleeding, perforation) is increased by the concomitant use of aspirin and NSAIDs (Ketoprofen, Naproxen, Meloxicam, Piroxicam) and Corticosteroids (Betamethasone, Prednisone, Prednisolone, Methyl prednisolone, Dexamethasone, Paramethasone, Triamcinolone).

Ø Due to additive hypoglycemic effect of aspirin, it may increase the risk of Hypoglycemia in patients taking Antidiabetics (Insulin, Sulfonylureas).

Ø Concomitant use of aspirin and ACE Inhibitors (Captopril, Enalapril, Imidapril, Temocapril, Delapril, Ramipril, Perindopril, Cilazapril) and Angiotensin II receptor blockers (ARBs) (Losartan, Valsartan, Telmisartan) may leads to decreased antihypertensive effects.

Ø Ethanol consumption should be avoided within 12 hours of aspirin ingestion to prevent gastrointestinal blood loss.

Ø Aspirin is not recommended during pregnancy, particularly in the third trimester due to reported teratogenic and other effects.

Ø Aspirin is considered unsafe during breastfeeding, due to its association with Reye's Syndrome in children.

Ø Patients should thoroughly read the labels of all over-the-counter and prescription medicines.

Ø Patients should talk to their doctor or pharmacist before taking any new prescription or over the counter medication.

Ø Physicians should be aware of potential drug interactions with OTC medicines when prescribing new medications.

Ø Pharmacists can be instrumental in assisting patients with using OTC medications safely and effectively.

Ø Pharmacists should warn consumers of the risks of misusing OTC pain relievers.

Drug Interactions of OTC Analgesics (Part 1):

Drug Interactions of Acetaminophen (Paracetamol):

More presentations from Naina Mohamed Pakkir Maideen

ª  Acetaminophen is a most commonly used analgesic drug and can be found in over 200 OTC products.

ª  Concomitant use of Acetaminophen and warfarin may increase the risk of bleeding. Acetaminophen is still the analgesic and antipyretic of choice in warfarin patients, due to lack of a safer alternative.

ª  The risk of hepatotoxicity is elevated by the coadministration of Acetaminophen and CYP enzyme inducers (Carbamazepine, Oxcarbazepine, Phenytoin, Fosphenytoin, Deferasirox, Piperaquine, Barbiturates, Isoniazid, Rifampin, and Rifabutin).

ª  Smokers may need more dose of Acetaminophen due to increased metabolism and the toxicity of Acetaminophen is also increased.

ª  Chronic Alcoholics increase their chances to develop hepatotoxicity by using Acetaminophen.

ª  Presence of food in the GIT may delay the absorption of Acetaminophen and for rapid relief of pain it can be taken on an empty stomach.

ª  Normal therapeutic doses of Acetaminophen for a short period are considered to be safe in Pregnancy and Breast feeding.

ª  Patients should thoroughly read the labels of all over-the-counter and prescription medicines.

ª  Patients should talk to their doctor or pharmacist before taking any new prescription or over the counter medication.

ª  Physicians should be aware of potential drug interactions with OTC medicines when prescribing new medications.

ª  Pharmacists can be instrumental in assisting patients with using OTC medications safely and effectively.

ª  Pharmacists should warn consumers of the risks of misusing OTC pain relievers.

Drug Interactions of Antidiabetics (Part 8):

Drug Interactions of DPP 4 Inhibitors:

§  Dipeptidyl peptidase 4 (DPP 4) inhibitors like Sitagliptin, Vildagliptin, Saxagliptin and  Linagliptin can prevent the degradation of Glucagon Like Peptide 1 (GLP 1) by inhibiting the enzyme Dipeptidyl peptidase 4 (DPP 4).

§  Prevention of degradation of Glucagon Like Peptide 1 (GLP 1) results in to increased GLP 1 levels which inhibit the Glucagon release leading to increased insulin secretion, decreased gastric emptying, and decreased blood glucose levels.

§  Concomitant use of DPP4 inhibitors and P-glycoprotein inhibitors such as Tocofersolan, Nilotinib and Lomitapide may result into increased plasma levels of DPP4 inhibitors due to the inhibition of P-glycoprotein-mediated efflux transport of DPP4 inhibitors.

§  The plasma levels of DPP4 inhibitors also increased by CYP3A4 inhibitors such as Piperaquine and Amiodarone.

§  CYP3A4 inducers like Dabrafenib, Eslicarbazepine and Primidone may decrease the plasma levels of DPP4 inhibitors.

§  The risk of hyperglycemia may be increased by Danazol and Trandolapril.

§  The plasma concentrations of saxagliptin may be increased by CYP3A4 inhibitors like Cobicistat, Azole antifungals (Posaconazole, Itraconazole & Ketoconazole), Antivirals (Indinavir, Nelfinavir, Saquinavir & Ritonavir) and Macrolide antibiotics (Telithromycin and Clarithromycin).

§  The plasma levels of Linagliptin may be decreased by CYP3A4 inducers like Rifampin, Phenytoin, Phenobarbital, Carbamazepine and St John's wort.

§  The blood sugar level should be monitored and dosage of antidiabetics may be adjusted if necessary, to avoid complications from above said interactions.

§  The diabetics should bring a list of all of the drugs they are taking, including prescription drugs, over-the-counter drugs, and any supplements, herbal products, etc. during their visit to the doctor or pharmacist, to minimize the possibility of potentially dangerous combinations.

Drug Interactions of Antidiabetics (Part 7):

Drug Interactions of Alpha-glucosidase inhibitors:

}  Acarbose, Miglitol and Voglibose are the antidiabetic drugs which prevent the digestion of carbohydrates by inhibiting Alpha-glucosidase enzymes found in the brush border of the small intestines.

}  Acarbose may decrease the therapeutic efficacy of Digoxin by reducing its absorption.

}  Acarbose may increase the risk of bleeding by increasing the absorption of Warfarin.

}  The risk of hypoglycemia may be elevated by the concomitant use of Acarbose and Sulfonylureas, Neomycin and Guar gum.

}  The drugs like Pancreatin, Amylase and Activated charcoal may reduce the effectiveness of acarbose.

}  The diabetics should bring a list of all of the drugs they are taking, including prescription drugs, over-the-counter drugs, and any supplements, herbal products, etc. during their visit to the doctor or pharmacist, to minimize the possibility of potentially dangerous combinations.

Drug Interactions of antidiabetics (Part 2):

Drug Interactions of Exenatide and Pramlintide:

¢ More frequent monitoring of INR is recommended when initiating or changing the dose of exenatide during Warfarin therapy due to increased risk of bleeding.

¢ To avoid Digoxin toxicity, the plasma levels and clinical efficacy of digoxin should be monitored when Exenatide is used concurrently.

¢ Antibacterials should be taken at least one hour before Exenatide, to prevent delayed absorption and reduced efficacy of antibacterials.

¢ Increased dose of Exenatide or Pramlintide may be required due to its interaction with Thyroid hormones which decrease its effectiveness.

¢  Danazol is associated with insulin resistance and it interacts with Exenatide or Pramlintide to increase blood sugar level.

¢ The risk of hypoglycemia is increased by the concomitant use of Exenatide or Pramlintide and Trandolapril.

¢ The diabetics should bring a list of all of the drugs they are taking, including prescription drugs, over-the-counter drugs, and any supplements, herbal products, etc. during their visit to the doctor or pharmacist, to minimize the possibility of potentially dangerous combinations.

Drug Interactions of Antidiabetics (Part 1):

Interactions of Insulin:

¢ The therapeutic efficacy of Insulin either increased or decreased by interacting with other drugs.

¢ Further reductions of blood glucose or exacerbation of hypoglycemia may be resulted due to the concomitant use of Insulin and drugs such as Fluoroquinolones, Anabolic steroids (nandrolone, methandienone, testosterone propionate or stanozolol), Antimalarials (Hydroxychloroquine, chloroquine), Orlistat, Bitter melon, Ginkgo, Ginseng, Gymnema extracts, Fenugreek and Alcohol.

¢ The blood sugar level may be elevated by the coadministration of Insulin and Antipsychotics.

¢ The therapeutic efficacy of Insulin is reduced in smokers due to decreased absorption.

¢ Betablockers may delay the recovery from hypoglycemia induced by Insulin.

¢ Thiazolidinediones (Pioglitazone or rosiglitazone) may potentiate the renal effects of insulin on sodium and water retention which may increase the incidence of heart failure.

¢ The diabetics are encouraged to ask their doctor or pharmacist to look over their medication list for any potentially dangerous combinations.