Patient Profile for Robert Doe
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General Information
ID: 5555
Prescriber: M.D.
Name: Robert Doe
Address: Street
City: Anycity
State: State
Zip: 55555
Country: USA
Phone: 123.234.5678
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Current Conditions
• arterial thromboembolism prophylaxis
• benign prostatic hyperplasia (BPH)
• cardiac arrhythmias
• cardiopulmonary bypass (multiple (4))
• defibrillation (cardioversion)
• diabetes mellitus Type II
• fatigue
• gastritis
• heart failure
• hypercholesterolemia
• hypertension
• insomnia severe
• muscle cramps
• nutritional supplementation
• renal impairment
• syncope
• vertigo
• weakness severe
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Current Allergies
No allergies noted
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Current Medications
• Medication
• Aspirin Dosage: 81mg Sig: tab 1 daily for heart
• B Complex H.P.™ Sig: tab 1 daily
• Cyanocobalamin, Vitamin B{12} Dosage: 500mcg Sig: spray in mouth every morning
• Flomax® Dosage: 0.4mg Sig: tab 1 daily for prostate
• Glyburide Dosage: 2.5mg Sig: tab 1 at breakfast
• Iron Salts Dosage: liquid Sig: 10cc daily
• Lisinopril Dosage: 10mg Sig: tab 1 daily
• Metoprolol Dosage: 50mg Sig: tab 1 twice a day
• Olay™ Vitamins Beauty Nutrients Ester-C® Alpha Lipoic Collagen Support Dosage: 50mg Sig: tab 1 daily
• Preventive Nutrition® Coenzyme Q-10 Sig: tab 1 twice a day
• Simvastatin Dosage: 40mg Sig: tab 1 in the evening daily
• Trazodone Dosage: 100mg Sig: tab 1 and a half (150mg) at bedtime
• Vitamin E Dosage: 400 U Sig: tab 1 twice a day
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Dosing Parameters
Gender: Male
Birthdate: 2/27/1920
Weight: 68.18 kgs
Height: 172.72 cm
Ideal Body Weight: 68.61 kgs
Body Surface Area: 1.81 m²
Serum Creatinine: 1.2 mg/dL
Creatinine Clearance: 44.19 mL/min
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Notes
Title: Initial Assessment & Interview
Date: 11/15/2004
This 84 year old white male presents with numerous physical problems that seem to be a result of current drug therapy. Although I didn’t get to meet him face to face, I had a very pleasant visit by phone. He was very open and mentally alert and discussed his problems in much detail. The assessment on his “Geriatric Depression Scale” quiz indicates a high degree of anxiety and depression scoring a value of 12. The patient presents with extreme muscle weakness, dizziness, depression, unsteady gait, very concerned about his lack of ability to play golf and serious fatigue with the least amount of exercise. After a lengthy discussion with the patient and with the information supplied to me, it is apparent that many of his problems are drug related and he can be helped into a higher state of quality of life.
Although it has been said, by his physician, that the drugs he is taking keep him alive, there are alternative measures and drug therapies that would better fit into his life style and afford him the pleasures he once enjoyed. Based on labs presented, maintaining an 84 year old patient at a 5.6% HGA1c will cause serious episodes of hypoglycemia during the day and in combination with the sulfonylurea (glyburide) exacerbates this condition mid-morning and after. His lipid panel is well within range for a much less drastic therapy than use of statin (Simvastatin) drug therapy and will surely exacerbate symptoms of weakness, fatigue, gait changes and loss of liver and renal function. A serious condition Rhabdomyolysis, ( a waisting away of muscle tissue) is present in all geriatric patients just by the fact of getting old. This condition is exacerbated by the statin drugs and should not be used in patients over 70 years of age unless seriously high cholesterol and LDL levels occur. With a cholesterol level of 126 and an LDL of 69, the use of Simvastatin is not advised. Many of the neutropharmaceuticals could be stopped, although, as we will discuss, some are important to continue. Use of ACE drug therapy in this patient is unnecessary since an alpha blocker (Flomax) and beta blocker (Metoprolol) are used. These two drugs are also implicated in the diabetes and depression the patient experiences. Based on the fact that the patient’s mind is clear and his will to do better is strong, changes to a more geriatric friendly drug therapy management program will surely improve his quality of life.
Title: Initial Assessment & Interview (follow-up)
Date: 12/13/2004
I did a follow-up call to Mr. Doe to see how the lowered dosing of Glyberide and Lisinopril affected his blood sugars and blood pressure. We had a pleasant talk and in his opinion he could see no difference in the values recorded with the new dosing. I had anticipated this result but I needed to wait for three or four weeks of therapy at this level to make sure that my recommendations would improve the overall health outlook picture.
Title: Drug Therapy Assessment & Recommendations
Date: 12/15/2004
Review of the drug therapy currently prescribed resulted in the following problem areas:
Aspirin - to continue
Vitamin B12 - 500mcg tablets should be stopped and changed to monthly injections of 1000mcg IM each month. Lack of intrinsic factor in the stomach makes absorption of B12 almost impossible.
Iron salts - based on laboratory results are not needed at this time.
Flomax - used to treat the BPH is a very good choice and should be continued.
Glyburide - Use of sulfonylurea in this age patient with type II diabetes is contraindicated. Diet alone could be all that is needed to control the condition. The use of steroid therapy a while back that precipitated the hyperglycemia then led to the use of the antidiabetic agent- this medication should not have been started until 30 to 60 days after the problems with the hyperglycemia and use of steroid therapy. Taking the sulfonylurea after breakfast starting the day with a blood sugar in the 90’s will lead to hypoglycemia and weakness, dizziness, fatigue and depression, all of which are present at this time.
Lisinopril - an ACE inhibitor, is not indicated in this patient. Need for nephroprotection at 84 is unreasonable. Problems with orthostatic hypotension, dizziness, syncope all are experienced by the patient.
Metoprolol - Use of a beta blocker in a diabetic exacerbates lose of glucose control. Common problems with depression are seen in the geriatric patient. Use of cardioprotection at 84 is of little value. Use of calcium channel blocker from the benzothiazepine group, diltiazem, will provide the needed antihypertensive and cardiac support to allow for fewer adverse events and better quality of life.
Simvastatin - A perfect contraindication of this drug with this patient is clear. Rhabdomyolysis symptoms are present and will prevail in deteriorating his physical condition and quality of life. The Coenzyme Q10 on board has surely slowed this process but need for control of lipids can be accomplished in other ways. All studies indicate that risks are too great to use statin therapy unless critical conditions are present. Using the assumption that elevated homocystine and methylmalonic acid levels are high, use of Vitamin B12, B6 and folic acid will bring down cholesterol and LDL levels and improve HDL in most geriatrics. I feel strongly that removal of the simvastatin will allow the patient to regain much strength and allow for him to get back to playing golf.
Trazadone - This drug is not very successful in treating the geriatric patient. It is a very weak SSRI and has many side effects consistent with the age and condition of this patient. Need for an antidepressant-antianxiety drug therapy is apparent based on a score of 3 on the depression scale assessment and indications of general boredom. Use of Effexor XR a SSRI and SNRI given at bedtime improves sleep and provides the necessary support for anxiety and depression. As he regains his strength and is able to participate in his hobbies again, this drug can probably be removed. The patient will know when this change should occur.
Drug Therapy Management
Stop B Complex HP
Stop Vitamin B12 tablets
Stop Glyburide
Stop Iron Salts
Stop Lisinopril
Stop Olay Vitamins
Stop Simvastatin
Stop Trazadone
New Drug Therapy
Aspirin EC 325mg - 1 tablet daily
Vitamin B6 200mg - tablet 1 daily
Folic Acid 1mg - tab 1 daily
Vitamin B12 1000mcg Inj. - 1000mcg IM weekly x 4 weeks then 1000mcg IM monthly
Flomax 0.4mg - cap 1 daily
Diltiazem CD 180mg - cap 1 daily…. Then taper to discontinue Metoprolol 50mg daily for four days, then 50mg every other day for 4 days and discontinue completely…..
Centrum Silver - tab 1 daily
Coenzyme Q 10 - tab 1 two times a day for 4 more months and discontinue
Effexor XR 37.5mg at bedtime for 5 days, then 75mg at bedtime for 5 days, then 112.5mg at bedtime.
Vitamin E 400 units - cap 1 daily
Fish Oil 1000mg – cap 1 daily
ANYTHING NOT LISTED ABOVE DISCONTINUE COMPLETELY
Continue to keep your blood pressure log and record your beginning AM blood pressure and your ending PM blood pressure with pulses. After about 10 days on the diltiazem cd 180mg evaluation of mean blood pressures will indicate a need to titrate the drug up to 240mg daily or down to 120mg daily…
Continue your blood sugar log and don’t worry about a 200 blood sugar. The latest studies show that in the geriatric patient, allowing for higher HGA1c in the range of 7 to 8 % makes for better quality of life. This may show at times blood sugars that are from 175 to 225 and that is alright. Your next HGA1c in 90 days will show just how good the mean glucose control has been. The mean glucose control is the most important, not the snapshot of a finger stick.
Get new labs in 90 days with new lipid panel to evaluate your progress and need for adjustments in your drug therapy management.
Remember that it will take time to see all the changes that the new drug therapy will produce. After completing the titration processes that are required, you should see big improvements relating to the complaints recorded. The additional vitamin supplements should also make you feel better after 30 days or so. Further titration of the diltiazem dosing may be needed until we reach your dose. Continue to keep your blood pressure and pulse log. This is very important. Talk to you friends and see if they want to assist you by allowing you to start back playing a few holes at a time until your stamina returns, which may take 4 or 5 months. Continuing the Coenzyme Q10 will help you regain muscle tone. Walk a little farther each day and push yourself to make this muscle tone reappear. Continue your diet and stay away from white foods. White foods being bread, potatoes, rice, candy or just complicated carbohydrates. The Atkin’s Diet candies with 0 to 2 net carbs can be consumed without affecting your blood sugar. You may want to sample these.
Let me remind you that this drug therapy regimen is thoroughly thought out and should be followed in its entirety. Choosing only bits and pieces of it may keep us from reaching our mutual goal of improvement in your quality of life and health. I am as close as your phone, so if problems occur please call me. I look forward to hearing from you after your visit with your doctor. I am always available to talk to your doctor if necessary. After the changes are made I want you to call me if any drug problem or symptom occurs during your entire rehab process, but would like review this overall progress in 90 to 120 days by phone.
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Drug Interactions
Aspirin, ASA (Aspirin) and Glyburide
Severity: Moderate
Displacement of glyburide from protein binding sites by other drugs may lead to enhanced hypoglycemic action. In vitro, the protein binding exhibited by glyburide is predominantly non-ionic. Drugs such as clofibrate (and possibly fenofibrate), phenylbutazone, salicylates, and sulfonamides displace the ionic-binding sulfonylureas (e.g., chlorpropamide, tolbutamide, tolazamide) from serum proteins to a far greater extent than the non-ionic binding glyburide.[29] However, this difference in protein binding has not been shown to result in fewer drug-drug interactions with glyburide versus other sulfonylureas in clinical use. Aspirin, ASA has been shown to decrease both glyburide protein binding and glyburide AUC.[1309] Additionally, salicylates, by inhibiting prostaglandin synthesis, can indirectly increase insulin secretion. Thus, salicylates can decrease blood sugar. If any of these drugs are administered or discontinued in patients receiving oral antidiabetic agents, patients should be monitored for hypoglycemia.
Salicylates, by inhibiting prostaglandin E2 synthesis, can indirectly increase insulin secretion. Thus, salicylates can decrease blood sugar and may potentiate the effects of other antidiabetic agents. This mechanism may explain how salicylates can potentiate the clinical effects of sulfonylureas, however, displacement of sulfonylureas from protein binding sites has also been reported.[1310] In large doses, salicylates uncouple oxidative phosphorylation, deplete hepatic and muscle glycogen, and cause hyperglycemia and glycosuria. After acute overdose or use of greater than maximum recommended daily dosages, salicylates can cause either hypoglycemia or hyperglycemia. Large doses of aspirin should be used cautiously in patients receiving antidiabetic agents.[5232]
Aspirin, ASA (Aspirin) and Lisinopril
Severity: Low
Aspirin, ASA may reduce the vasodilatory efficacy of ACE inhibitors by inhibiting the synthesis of vasodilatory prostaglandins. This interaction has been documented primarily in heart failure patients.[5718] [6060] However, the established benefits of using aspirin in combination with an ACE inhibitor in patients with ischemic heart disease and left ventricular dysfunction generally outweigh this concern.[5718] [6060] Patients receiving concurrent salicylates and ACE inhibitor therapy should be monitored for antihypertensive or vasodilatory efficacy; the dose of the ACE inhibitor can be adjusted if indicated based on clinical evaluation.
The efficacy of antihypertensive agents needs to be carefully assessed during aspirin usage. During antihypertensive therapy with beta-blockers, high concentrations of vasodilatory prostaglandins are produced in response to reflex-mediated pressor mechanisms (e.g., sympathetic tone). Concurrent use of beta-blockers with aspirin may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow.[5717] Aspirin can increase the risk of renal insufficiency in patients receiving diuretics, secondary to the effects of aspirin on renal blood flow. Aspirin inhibits renal prostaglandin production, which causes salt and water retention and decreased renal blood flow. Thus, the effectiveness of diuretics in patients with underlying renal or cardiovascular disease may be diminished by the concomitant administration of aspirin.[5717] Aspirin may decrease the hyperuricemic effect of hydrochlorothiazide, HCTZ and furosemide. Concomitant use of aspirin and potassium-sparing diuretics, such as triamterene or spironolactone, may cause hyperkalemia.[5717] The hyponatremic and hypotensive effects of angiotensin converting enzyme (ACE) inhibitors may be diminished by concurrent use of aspirin; the inhibition of cyclooxygenase by aspirin prevents the formation of vasodilatory prostaglandins.[5717] Furthermore, reduced renal blood flow is expected from the decreased pressure gradient created in the glomeruli when aspirin is used with an ACE inhibitor.[5718] Low-dose aspirin (e.g., 81 mg/day) may be less likely to attenuate the antihypertensive or cardioprotective effects of ACE inhibitors; however, the dose-related effect is controversial.[6439] The established benefits of using low-dose aspirin in combination with an ACE inhibitor in patients with ischemic heart disease and left ventricular dysfunction generally outweigh concerns, especially with appropriate renal function and serum potassium monitoring.[5718] [6060] [6439] Monitor the patient's blood pressure, renal function, and clinical status for the desired responses and adjust therapy accordingly.
Aspirin, ASA (Aspirin) and Metoprolol
Severity: Low
The efficacy of antihypertensive agents needs to be carefully assessed during aspirin usage. During antihypertensive therapy with beta-blockers, high concentrations of vasodilatory prostaglandins are produced in response to reflex-mediated pressor mechanisms (e.g., sympathetic tone). Concurrent use of beta-blockers with aspirin may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow.[5717] Aspirin can increase the risk of renal insufficiency in patients receiving diuretics, secondary to the effects of aspirin on renal blood flow. Aspirin inhibits renal prostaglandin production, which causes salt and water retention and decreased renal blood flow. Thus, the effectiveness of diuretics in patients with underlying renal or cardiovascular disease may be diminished by the concomitant administration of aspirin.[5717] Aspirin may decrease the hyperuricemic effect of hydrochlorothiazide, HCTZ and furosemide. Concomitant use of aspirin and potassium-sparing diuretics, such as triamterene or spironolactone, may cause hyperkalemia.[5717] The hyponatremic and hypotensive effects of angiotensin converting enzyme (ACE) inhibitors may be diminished by concurrent use of aspirin; the inhibition of cyclooxygenase by aspirin prevents the formation of vasodilatory prostaglandins.[5717] Furthermore, reduced renal blood flow is expected from the decreased pressure gradient created in the glomeruli when aspirin is used with an ACE inhibitor.[5718] Low-dose aspirin (e.g., 81 mg/day) may be less likely to attenuate the antihypertensive or cardioprotective effects of ACE inhibitors; however, the dose-related effect is controversial.[6439] The established benefits of using low-dose aspirin in combination with an ACE inhibitor in patients with ischemic heart disease and left ventricular dysfunction generally outweigh concerns, especially with appropriate renal function and serum potassium monitoring.[5718] [6060] [6439] Monitor the patient's blood pressure, renal function, and clinical status for the desired responses and adjust therapy accordingly.
During antihypertensive therapy with beta-blockers, high concentrations of vasodilatory prostaglandins are produced in response to reflex-mediated pressor mechanisms (e.g., sympathetic tone). Concurrent use of beta-blockers with aspirin and other salicylates may result in loss of antihypertensive activity due to inhibition of renal prostaglandins and thus, salt and water retention and decreased renal blood flow.[5717]
Aspirin, ASA (Aspirin) and Ascorbic Acid, Vitamin C (Olay™ Vitamins Beauty Nutrients Ester-C® Alpha Lipoic Collagen Support)
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.
Acidification of the urine by ascorbic acid will alter the excretion of certain other drugs administered concurrently.[5449] Agents that acidify the urine should be avoided in patients receiving high-dose salicylates. Urine acidifying agents 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.
Niacin, Niacinamide (found in B Complex H.P.™) and Glyburide
Severity: Moderate
Niacin, Niacinamide interferes with glucose metabolism and can result in hyperglycemia; monitor patients on antidiabetic agents for loss of blood glucose control if niacin therapy is added.[6158]
Niacin (nicotinic acid) interferes with glucose metabolism and can result in hyperglycemia; monitor patients on antidiabetic agents for loss of blood glucose control if niacin therapy is added.
Niacin, Niacinamide (found in B Complex H.P.™) and Lisinopril
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 B Complex H.P.™) and Metoprolol
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 B Complex H.P.™) and Simvastatin
Severity: Moderate
Cyclosporine, fibric acid derivatives (e.g., gemfibrozil, fenofibrate, clofibrate), and antilipemic doses of niacin (i.e., vitamin B3 as nicotinic acid) may increase the risk of myopathy, rhabdomyolysis and acute renal failure (see Adverse Reactions);[5336] however, in some cases simvastatin has been used safely in combination with these agents.
This risk may be increased at higher doses of simvastatin. In patients taking gemfibrozil or cyclosporine, the simvastatin dose should not exceed 10 mg/day PO to reduce the risk of myopathy (see Dosage section).[5336] The risk of myopathy is increased by gemfibrozil, and to a lesser extent by other fibrates or niacin >= 1 g/day.[5336] Fibrates or doses of niacin >= 1 g/day are independently associated with myopathy.[5336 The serious risk of myopathy or rhabdomyolysis should be weighed carefully versus the benefits of combined 'statin' and fibrate therapy; there is no assurance that periodic monitoring of CK will prevent the occurrence of severe myopathy and renal damage.[5336]
Rare cases of rhabdomyolysis have been reported in patients taking niacin (nicotinic acid) in lipid-altering doses (i.e., >=1 g/day) and HMG-CoA reductase inhibitors (i.e., 'statins') concurrently.[5506] Patients undergoing combined therapy should be carefully monitored for myopathy or rhabdomyolysis, particularly in the early months of treatment or during periods of upward dose titration of either drug. Since compounds in went yeast, Monascus purpureus are pharmacologically similar to the HMG-CoA reductase inhibitors,[5911] clinicians and patients should use this dietary supplement cautiously in combination with niacin, particularly in non-prescription use.
Niacin, Niacinamide (found in B Complex H.P.™) and Aspirin, ASA (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.
Tamsulosin (Flomax®) and Lisinopril
Severity: Low
No pharmacokinetic interaction occurred when tamsulosin was co-administered with either digoxin, furosemide, or theophylline. In addition, tamsulosin did not potentiate the hypotensive effects of atenolol, enalapril, furosemide, or nifedipine.[6419] However, since the symptoms of orthostasis (e.g., postural hypotension, dizziness and vertigo) are reported more frequently in tamsulosin-treated vs. placebo patients, there is a potential risk of enhanced hypotensive effects when co-administered with antihypertensive agents.[6419] Tamsulosin should not be used with other alpha-blockers.[6419]
Tamsulosin (Flomax®) and Metoprolol
Severity: Low
No pharmacokinetic interaction occurred when tamsulosin was co-administered with either digoxin, furosemide, or theophylline. In addition, tamsulosin did not potentiate the hypotensive effects of atenolol, enalapril, furosemide, or nifedipine.[6419] However, since the symptoms of orthostasis (e.g., postural hypotension, dizziness and vertigo) are reported more frequently in tamsulosin-treated vs. placebo patients, there is a potential risk of enhanced hypotensive effects when co-administered with antihypertensive agents.[6419] Tamsulosin should not be used with other alpha-blockers.[6419]
Glyburide and Metoprolol
Severity: Moderate
Beta-blockers exert complex actions on the body's ability to regulate blood glucose. Beta-blockers can prolong hypoglycemia by interfering with glycogenolysis (secondary to blocking the compensatory actions of epinephrine) or can promote hyperglycemia (by inhibiting insulin secretion and decreasing tissue sensitivity to insulin). Since insulin secretion is mediated via beta2-receptors, beta-blockers, particularly nonselective agents, can directly antagonize the major beneficial effect of sulfonylureas. Also, beta-blockers can blunt the tachycardic response and exaggerate the hypertensive response to hypoglycemia.
Thus, beta-blockers may interact pharmacodynamically with antidiabetic agents. No pharmacokinetic interaction has been observed between beta-blockers and antidiabetic agents. Selective beta-blockers, such as acebutolol, atenolol, metoprolol, or penbutolol, antagonize beta2-receptors less than nonselective agents and, as a result, may cause fewer problems with blood glucose regulation, although all beta-blockers can still mask the tachycardic response to hypoglycemia.[6141]
Beta-blockers exert complex actions on the body's ability to regulate blood glucose.[6141] Beta-blockers can prolong hypoglycemia by interfering with glycogenolysis (secondary to blocking the compensatory actions of epinephrine) or can promote hyperglycemia (by inhibiting insulin secretion and decreasing tissue sensitivity to insulin). Since insulin secretion is mediated via beta2-receptors, beta-blockers, particularly nonselective agents, can directly antagonize the major beneficial effect of sulfonylureas. The ability to decrease tissue sensitivity to insulin interferes with one of the therapeutic effects of metformin. Also, beta-blockers can blunt the tachycardic response and exaggerate the hypertensive response to hypoglycemia. Thus, while no pharmacokinetic interaction has been observed between beta-blockers and antidiabetic agents, beta-blockers may interact pharmacodynamically. Selective beta-blockers, such as acebutolol, atenolol, metoprolol, or penbutolol, antagonize beta2-receptors less than nonselective agents and, as a result, may cause fewer problems with blood glucose regulation, although all beta-blockers can still mask the tachycardic response to hypoglycemia.
Iron Salts and Ascorbic Acid, Vitamin C (Olay™ Vitamins Beauty Nutrients Ester-C® Alpha Lipoic Collagen Support)
Severity: Low
The absorption of non-heme iron (primarily from plant sources) from the intestinal tract depends on iron being in its reduced form (ferrous). Ascorbic acid, by maintaining iron in the ferrous state, can enhance the absorption of oral iron; however, the magnitude of the increase is in the range of 10% and only occurs with doses of ascorbic acid, vitamin C of 500 mg or greater. Healthy individuals usually absorb iron supplements (e.g., iron salts or polysaccharide iron complex) adequately from the GI tract, but some patients may benefit from receiving supplemental ascorbic acid with each oral iron dose.[6740]
Ascorbic acid is necessary for many physiologic functions, including the metabolism of iron.[5449] The absorption of nonheme iron (primarily from plant sources) from the intestinal tract depends on iron being in its reduced form. (Heme iron, found in meat, fish, and poultry, appears to be absorbed intact.) Ascorbic acid, by maintaining iron in the ferrous state, can enhance the absorption of oral iron, however, the magnitude of this increase is in the range of 10% and only occurs with doses of ascorbic acid, vitamin C of 500 mg or greater. Healthy individuals usually absorb iron supplements (e.g., iron salts or polysaccharide-iron complex) adequately from the GI tract, but some patients may benefit from receiving supplemental ascorbic acid with each oral iron dose.
Iron Salts and Vitamin E
Severity: Low
Natural vitamin E appears to exhibit complex functions and interactions with iron in vivo. In plasma and red blood cells, vitamin E protects cell membrane lipids from peroxidation and scavenges free radicals, including those produced by oxidation of liposomal membranes by ferrous ion. The use of large doses of iron may catalyze vitamin E oxidation and increase daily vitamin E requirements. When body stores of vitamin E are depleted, as in premature infants who are not receiving adequate dietary vitamin E dietary intake, iron supplements may act as a pro-oxidants, and may induce lipid peroxidation or hemolysis. There is limited evidence that the supplementation of vitamin E may protect against oxidative stress-related degenerative changes induced by iron supplementation and other pro-oxidant compounds. Thus it appears that the interaction between vitamin E and iron would be beneficial in most circumstances. There is no evidence, except in vitamin E deficiency states, to routinely supplement vitamin E during iron therapy (e.g., iron dextran, iron salts, polysaccharide iron-complex, sodium ferric gluconate).
Natural vitamin E appears to exhibit complex functions and interactions with iron in vivo. In plasma and red blood cells, vitamin E protects cell membrane lipids from peroxidation and scavenges free radicals, including those produced by oxidation of liposomal membranes by ferrous ion. The use of large doses of iron may catalyze vitamin E oxidation and increase daily vitamin E requirements. When body stores of vitamin E are depleted, as in premature infants who are not receiving adequate dietary vitamin E dietary intake, iron supplements may act as a pro-oxidants, and may induce lipid peroxidation or hemolysis. There is limited evidence that the supplementation of vitamin E may protect against oxidative stress-related degenerative changes induced by iron supplementation and other pro-oxidant compounds. Thus it appears that the interaction between vitamin E and iron would be beneficial in most circumstances. There is no evidence, except in vitamin E deficiency states, to routinely supplement vitamin E during iron therapy (e.g., iron sucrose; iron dextran, iron salts, polysaccharide-iron complex, sodium ferric gluconate complex).
Lisinopril and Metoprolol
Severity: Moderate
Lisinopril can enhance the hypotensive actions of other antihypertensive agents and diuretics when given concomitantly.[5365] This additive effect may be desirable, but dosages must be adjusted accordingly. Patients with hyponatremia or hypovolemia are more susceptible to developing reversible renal insufficiency when given lisinopril and diuretic therapy concomitantly.
Metoprolol is an antihypertensive agent,[5269] so its effects are additive with other antihypertensive agents. This interaction is often used advantageously in treating hypertension; however, lower doses of each agent may be necessary. Hypotension can be potentiated when beta-blockers are co-administered with dihydropyridine-type calcium-channel blockers, most notably rapid-release nifedipine. Nicardipine been reported to increase plasma concentrations and oral bioavailability of certain beta-blockers (e.g., metoprolol, propranolol). It is prudent to avoid using beta-blockers with guanethidine, reserpine, or other rauwolfia alkaloids that have a high incidence of orthostatic hypotension due to catecholamine depletion, since beta-blockers will interfere with reflex tachycardia, worsening the orthostasis.[5269]
Trazodone and Lisinopril
Severity: Low
Due to additive hypotensive effects, patients receiving antihypertensive agents concurrently with trazodone may have excessive hypotension. Decreased dosage of the antihypertensive agent may be required when given with trazodone.
Trazodone and Metoprolol
Severity: Low
Due to additive hypotensive effects, patients receiving antihypertensive agents concurrently with trazodone may have excessive hypotension. Decreased dosage of the antihypertensive agent may be required when given with trazodone.
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Adverse Reactions
• abdominal pain (Aspirin | Glyburide | Iron Salts | Metoprolol | Simvastatin)
• agranulocytosis (Aspirin | Glyburide | Metoprolol)
• alopecia (Metoprolol | Simvastatin)
• amblyopia (Flomax®)
• amnesia (Metoprolol)
• anaphylactic shock (Cyanocobalamin, Vitamin B{12})
• anaphylactoid reactions (Aspirin | Lisinopril)
• anemia (Glyburide)
• angioedema (Aspirin | Glyburide | Lisinopril | Flomax®)
• anorexia (Iron Salts)
• anxiety (Cyanocobalamin, Vitamin B{12})
• aplastic anemia (Aspirin | Glyburide)
• arthralgia (Glyburide | Metoprolol)
• asthenia (Simvastatin | Flomax®)
• ataxia (Cyanocobalamin, Vitamin B{12})
• AV block (Metoprolol)
• azotemia (Aspirin | Lisinopril)
• back pain (Flomax®)
• bleeding (Aspirin | Vitamin E)
• blurred vision (Glyburide | Trazodone | Vitamin E)
• bronchospasm (Aspirin | Metoprolol)
• chest pain (unspecified) (Metoprolol | Flomax®)
• cholestasis (Glyburide | Lisinopril | Simvastatin)
• cirrhosis (Simvastatin)
• confusion (Aspirin | Metoprolol | Trazodone)
• constipation (Aspirin | Iron Salts | Metoprolol | Simvastatin | Trazodone)
• contact dermatitis (Vitamin E)
• confusion (Aspirin | Metoprolol | Trazodone)
• constipation (Aspirin | Iron Salts | Metoprolol | Simvastatin | Trazodone)
• contact dermatitis (Vitamin E)
• confusion (Aspirin | Metoprolol | Trazodone)
• constipation (Aspirin | Iron Salts | Metoprolol | Simvastatin | Trazodone)
• contact dermatitis (Vitamin E)
• cough (Lisinopril)
• dehydration (Aspirin)
• depression (Metoprolol)
• diabetes mellitus (Metoprolol)
• diaphoresis (Aspirin)
• diarrhea (Aspirin | Cyanocobalamin, Vitamin B{12} | Glyburide | Iron Salts | Metoprolol | Simvastatin | Vitamin E | Flomax®)
• disseminated intravascular coagulation (DIC) (Aspirin)
• dizziness (Aspirin | Lisinopril | Metoprolol | Trazodone | Flomax®)
• drowsiness (Aspirin | Metoprolol | Simvastatin | Trazodone | Flomax®)
• dysgeusia (Lisinopril | Flomax®)
• dyspepsia (Aspirin | Glyburide | Iron Salts | Simvastatin | Flomax®)
• dysphagia (Aspirin | Iron Salts)
• dyspnea (Metoprolol)
• edema (Lisinopril)
• ejaculation dysfunction (Trazodone | Flomax®)
• elevated hepatic enzymes (Aspirin | Metoprolol | Simvastatin)
• encephalopathy (Aspirin)
• enterocolitis (Vitamin E)
• erythema (Glyburide)
• erythema nodosum (Aspirin)
• esophageal stricture (Aspirin | Iron Salts)
• esophageal ulceration (Aspirin | Iron Salts)
• esophagitis (Aspirin | Iron Salts)
• exfoliative dermatitis (Metoprolol)
• fatigue (Lisinopril | Metoprolol | Simvastatin | Trazodone | Vitamin E)
• fever (Aspirin)
• flatulence (Metoprolol | Simvastatin)
• gastritis (Aspirin)
• GI bleeding (Aspirin)
• GI perforation (Aspirin)
• hallucinations (Aspirin | Metoprolol)
• headache (Aspirin | Cyanocobalamin, Vitamin B{12} | Lisinopril | Metoprolol | Simvastatin | Trazodone | Vitamin E | Flomax®)
• hearing loss (Aspirin)
• heart failure (Metoprolol)
• hemolysis (Glyburide)
• hemolytic anemia (Aspirin)
• hemorrhoids (Aspirin)
• hemosiderosis (Iron Salts)
• hepatic failure (Lisinopril | Simvastatin)
• hepatic necrosis (Aspirin | Lisinopril | Simvastatin)
• hepatitis (Aspirin | Lisinopril | Metoprolol | Simvastatin)
• hyperbilirubinemia (Aspirin)
• hyperglycemia (Aspirin | Metoprolol)
• hyperkalemia (Lisinopril)
• hypernatremia (Aspirin)
• hypertriglyceridemia (Metoprolol)
• hyperuricemia (Aspirin)
• hyperventilation (Aspirin)
• hypoglycemia (Aspirin | Glyburide | Metoprolol)
• hypokalemia (Aspirin)
• hyponatremia (Glyburide)
• hypoprothrombinemia (Aspirin)
• hypotension (Lisinopril | Metoprolol | Trazodone | Flomax®)
• impotence (Metoprolol | Flomax®)
• infection (Cyanocobalamin, Vitamin B{12} | Simvastatin | Flomax®)
• insomnia (Metoprolol | Simvastatin | Flomax®)
• interstitial nephritis (Aspirin)
• intracranial bleeding (Aspirin)
• jaundice (Aspirin | Glyburide | Lisinopril | Metoprolol)
• laryngeal edema (Aspirin | Lisinopril)
• leukocytosis (Aspirin)
• leukopenia (Aspirin | Glyburide)
• libido decrease (Metoprolol | Flomax®)
• libido increase (Trazodone)
• maculopapular rash (Aspirin | Glyburide)
• melena (Aspirin)
• metabolic acidosis (Aspirin)
• muscle cramps (Simvastatin)
• musculoskeletal pain (Metoprolol | Simvastatin | Trazodone)
• myalgia (Simvastatin)
• myasthenia (Simvastatin)
• myoglobinuria (Simvastatin)
• myopathy (Simvastatin)
• nausea/vomiting (Aspirin | Cyanocobalamin, Vitamin B{12} | Glyburide | Iron Salts | Metoprolol | Simvastatin | Trazodone | Vitamin E | Flomax®)
• odynophagia (Aspirin | Iron Salts)
• oral ulceration (Iron Salts)
• orthostatic hypotension (Lisinopril | Trazodone | Flomax®)
• palpitations (Metoprolol | Trazodone)
• pancreatitis (Simvastatin)
• pancytopenia (Aspirin | Glyburide)
• paresthesias (Cyanocobalamin, Vitamin B{12})
• peptic ulcer (Aspirin)
• peripheral edema (Metoprolol)
• peripheral vasoconstriction (Metoprolol)
• pharyngitis (Flomax®)
• photosensitivity (Glyburide | Trazodone)
• platelet dysfunction (Aspirin)
• pneumonitis (Lisinopril)
• premature ventricular contractions (PVCs) (Trazodone)
• priapism (Trazodone | Flomax®)
• prolonged bleeding time (Aspirin)
• pruritus (Cyanocobalamin, Vitamin B{12} | Glyburide | Metoprolol | Trazodone | Flomax®)
• psoriasis (Metoprolol)
• psychosis (Metoprolol)
• pulmonary edema (Aspirin | Cyanocobalamin, Vitamin B{12})
• purpura (Aspirin)
• pyrosis (heartburn) (Glyburide | Metoprolol)
• rash (unspecified) (Metoprolol | Simvastatin | Trazodone | Flomax®)
• renal failure (unspecified) (Aspirin)
• renal papillary necrosis (Aspirin)
• renal tubular necrosis (Aspirin)
• renal tubular obstruction (Simvastatin)
• respiratory arrest (Trazodone)
• respiratory depression (Aspirin)
• Reye's syndrome (Aspirin)
• rhabdomyolysis (Simvastatin)
• rhinitis (Aspirin | Cyanocobalamin, Vitamin B{12} | Flomax®)
• secondary failure (Glyburide)
• seizures (Aspirin | Trazodone)
• serotonin syndrome (Trazodone)
• SIADH (Glyburide)
• sinus bradycardia (Metoprolol)
• sinus tachycardia (Lisinopril)
• sinusitis (Flomax®)
• skin hyperpigmentation (Metoprolol)
• skin irritation (Vitamin E)
• Stevens-Johnson syndrome (Aspirin)
• stool discoloration (Iron Salts)
• syncope (Lisinopril | Metoprolol | Trazodone | Flomax®)
• teratogenesis (Lisinopril)
• thrombocytopenia (Aspirin | Glyburide | Metoprolol)
• tinnitus (Aspirin)
• tooth discoloration (Iron Salts)
• toxic epidermal necrolysis (Aspirin)
• tremor (Trazodone)
• urticaria (Aspirin | Glyburide | Flomax®)
• vasculitis (Glyburide)
• ventricular tachycardia (Trazodone)
• vertigo (Flomax®)
• visual impairment (Aspirin)
• weakness (Simvastatin | Vitamin E)
• wheezing (Aspirin | Metoprolol)
• xerosis (Metoprolol)
• xerostomia (Trazodone)
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Indication Alerts
Drugs that can be used to treat current conditions:
• Aspirin can be used to treat arterial thromboembolism prophylaxis
• B Complex H.P.™ can be used to treat nutritional supplementation
• Cyanocobalamin, Vitamin B{12} can be used to treat nutritional supplementation
• Flomax® can be used to treat benign prostatic hyperplasia (BPH)
• Glyburide can be used to treat diabetes mellitus
• Iron Salts can be used to treat nutritional supplementation
• Lisinopril can be used to treat heart failure, and hypertension
• Metoprolol can be used to treat heart failure, and hypertension
• Olay™ Vitamins Beauty Nutrients Ester-C® Alpha Lipoic Collagen Support can be used to treat nutritional supplementation
• Preventive Nutrition® Coenzyme Q-10 can be used to treat heart failure, and nutritional supplementation
• Simvastatin can be used to treat hypercholesterolemia
• Trazodone can be used to treat insomnia
• Vitamin E can be used to treat nutritional supplementation
Conditions not currently being treated:
• Bartonella bacilliformis
• cardiopulmonary bypass
• fatigue
• gastritis
• heterotopic ossification
• renal impairment
• vertigo
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Precautions
Precaution: Aspirin in gastritis
Aspirin can induce gastric or intestinal ulceration that can occasionally be accompanied by iron-deficiency anemia or other anemia from the resultant blood loss. Aspirin should be used cautiously, if at all, in patients with a history of or active GI disease including erosive gastritis, esophagitis, GI bleeding, peptic ulcer disease, or previous NSAID-induced bleeding. Such patients should be monitored closely, with special caution in tobacco smoking patients or in patients with alcoholism. All patients receiving chronic treatment should be routinely monitored for potential GI ulceration and bleeding. In patients who develop gastric or duodenal ulcers during aspirin treatment, the drug should be discontinued due to an increased risk of bleeding and/or perforation. In addition, patients should not self-medicate with aspirin if they consume 3 or more alcoholic beverages per day because of the potential increased risk for GI bleeding. In patients with anemia, this condition may be exacerbated during aspirin therapy due to GI blood loss. Hematocrit should be monitored periodically in patients receiving prolonged or high-dose aspirin therapy since iron deficiency anemia may occur. Traditionally, aspirin has been recommended to be discontinued for a time interval (e.g., 1 week) prior to surgery to minimize postoperative bleeding. However, data presented at the 2003 meeting of the American College of Chest Physicians indicates a risk of increased coronary events with abrupt discontinuation of aspirin in patients with pre-existing coronary artery disease.[4425] Patients with stable coronary disease developed acute coronary events within one week of stopping aspirin therapy; these events included unstable angina and myocardial infarction. Until the results of this trial are published and/or consensus recommendations are available, the decision whether to discontinue aspirin therapy abruptly should include a careful evaluation of the overall risks and benefits given the patient's coexisting conditions and the type of surgery or procedure. The use of aspirin is generally not recommended in patients expected to require CNS surgery due to the increased risk of perioperative bleeding.
Precaution: Aspirin in heart failure
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: 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: 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: B Complex H.P.™ in diabetes mellitus
Niacin, especially in high doses, may cause hyperglycemia. Niacin should be prescribed cautiously to patients with diabetes mellitus. These individuals should be advised not to purchase OTC forms of niacin without the guidance of a physician. In addition, niacin has been reported to cause false-positive results in urine glucose tests that contain cupric sulfate solution (e.g., Benedict's reagent, Clinitest(R)).
Precaution: B Complex H.P.™ 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: Flomax® in renal impairment
Tamsulosin should be used cautiously in patients with orthostatic hypotension, vertigo, or syncope. The signs and symptoms of orthostasis (postural hypotension, dizziness, and vertigo) were more frequently reported in tamsulosin-treated patients than those receiving placebo. As with other alpha-adrenergic blocking agents, there is a potential risk of syncope and patients should be cautioned to avoid situations where injury could result should syncope occur. Patients with renal impairment, renal failure or other renal disease and the elderly should also be monitored carefully for exaggerated hypotensive effects (e.g., first dose effect).
Precaution: Glyburide in renal impairment
Glyburide is not recommended in renal disease associated with moderate to severe renal impairment (CrCl < 50 ml/min) or renal failure, due to the risk of drug accumulation and prolonged hypoglycemia. Glyburide should be administered with caution in patients with hepatic disease. According to the manufacturer, patients with hepatic insufficiency should receive conservative initial and maintenance doses of glyburide. Both renal impairment or hepatic disease can cause elevations in glyburide blood concentrations and hepatic disease can reduce gluconeogenic capacity; both problems increase the risk of hypoglycemia.
Precaution: Lisinopril in heart failure
Lisinopril is relatively contraindicated in patients who exhibit hypotension. Similarly, lisinopril should be used cautiously in patients who exhibit hyponatremia or hypovolemia, in part because inhibition of aldosterone production would be expected to exacerbate both conditions. Excessive hypotension may occur in patients undergoing dialysis or in patients treated vigorously with diuretics (e.g., patients with congestive heart failure). Lisinopril should be used cautiously in patients with congestive heart failure (initial doses should be lower than in the treatment of hypertension) because of a greater risk of developing hypotension. Hypotension may aggravate ischemia in patients with coronary artery disease or cerebrovascular disease precipitating a myocardial infarction or cerebrovascular accident. Lisinopril should be used with caution in patients with aortic stenosis or hypertrophic cardiomyopathy. As with all vasodilators, ACE inhibitors should be given with caution to patients with obstruction in the outflow tract of the left ventricle.
Precaution: Lisinopril in renal impairment
Lisinopril is contraindicated in patients with renal artery stenosis because the affected kidney(s) depend on the renin-angiotensin axis to maintain GFR; renal failure can ensue from lisinopril administration. Lisinopril should be used cautiously in patients with other types of renal disease. Other types of renal disease can actually improve during lisinopril therapy. The dose of lisinopril should be adjusted in patients with renal impairment. Neutropenia and/or agranulocytosis have been reported during therapy with ACE inhibitors, especially in patients with renal disease, patients receiving concomitant immunosuppression, and those with collagen-vascular disease or autoimmune disease. Data from clinical trials of lisinopril are insufficient to show that the drug does not cause agranulocytosis. Therefore, complete blood counts should be established prior to and during lisinopril therapy whenever the drug is administered to these patient populations. Lisinopril should be used with caution in patients with pre-existing bone marrow suppression. The dose of lisinopril should be adjusted in patients with renal impairment. Greater sensitivity to the hypotensive effects of lisinopril is possible in elderly patients, who may have reduced renal function.
Precaution: Metoprolol in diabetes mellitus
Beta-blockers have been shown to increase the risk of developing diabetes mellitus in hypertensive patients; however this risk should be evaluated relative to the proven benefits of beta-blockers in reducing cardiovascular events.[3498] Metoprolol should be used with caution in patients with poorly controlled diabetes mellitus, particularly brittle diabetes. Beta-blockers can prolong or enhance hypoglycemia by interfering with glycogenolysis; this effect may be less pronounced with beta1-selective beta-blockers than with nonselective agents. Beta-blockers can also mask signs of hypoglycemia, especially tachycardia, palpitations, and tremors; in contrast, diaphoresis and the hypertensive response to hypoglycemia are not suppressed with beta-blockade. Beta-blockers can occasionally cause hyperglycemia. This is thought to be due to blockade of beta2-receptors on pancreatic islet cells, which would inhibit insulin secretion. Thus, blood glucose levels should be monitored closely if a beta-blocker is used in a patient with diabetes mellitus.
Precaution: Metoprolol in heart failure
Because these drugs depress conduction through the AV node, beta-blockers are contraindicated in patients with severe bradycardia or advanced AV block. In general, beta-blockers should not be used in patients with cardiogenic shock, acute pulmonary edema, or decompensated systolic congestive heart failure, particularly in those with severely compromised left ventricular dysfunction, because the negative inotropic effect of these drugs can further depress cardiac output. In stable patients with heart failure, however, beta-blockers (e.g., metoprolol, bisoprolol, carvedilol) given in low doses have been documented to be beneficial. Beta-blockers have also been used for the treatment of hypertrophic cardiomyopathy. In the treatment of myocardial infarction, beta-blockers are contraindicated in patients with hypotension (SBP < 100 mmHg).
Precaution: Olay™ Vitamins Beauty Nutrients Ester-C® Alpha Lipoic Collagen Support in diabetes mellitus
High doses of ascorbic acid may interfere with urinary glucose determinations using the glucose oxidase method. Patients with diabetes mellitus should be made aware of the possibility of falsely decreased glucose concentrations with these tests.
Precaution: Simvastatin in renal impairment
Simvastatin should be discontinued immediately in any patient who develops myopathy, elevations in CPK, or signs of rhabdomyolysis. Simvastatin should be used with caution in organ transplant patients receiving immunosuppressant therapy such as cyclosporine because of an increased risk of rhabdomyolysis and renal failure (see Drug Interactions). The risk of developing myopathy is increased when HMG-CoA reductase inhibitors are used in combination with CYP3A4 inhibitors or drugs which have an independent risk of myopathy (see Drug Interactions). The manufacturer suggests a lower maximum dosage of simvastatin when used with some drugs (e.g., amiodarone, cyclosporine, gemfibrozil, verapamil) known to increase the risk of myopathy (see Dosage). Simvastatin may be contraindicated in conditions that can cause decreased renal perfusion since renal failure is possible if simvastatin-induced rhabdomyolysis occurs. Predisposing conditions include renal disease or renal insufficiency, hypotension, acute infection, endocrine disease, electrolyte imbalance, uncontrolled seizure disorder, major surgery, and trauma. Although pharmacokinetic data are lacking for simvastatin in patients with renal failure or renal impairment, data for a related HMG-CoA reductase inhibitor (lovastatin) suggest the need for cautious dosage escalation in such patients (see Dosage). In patients with severe renal impairment (CrCl 10-30 ml/min), the plasma concentrations of total inhibitors after a single dose of lovastatin are approximately two-fold higher than those in healthy volunteers.
Precaution: Trazodone in cardiac arrhythmias
Trazodone should be used with caution in patients with cardiac disease and cardiac arrhythmias because arrhythmias could occur in these patients, even though trazodone has limited arrhythmogenic potential. Trazodone should not be used during the acute recovery period following acute myocardial infarction.
Precaution: Trazodone in renal impairment
Trazodone and its metabolites are excreted primarily in the urine and should be used with caution in patients with renal impairment because of possible reduced excretion and increased effects of the drug.
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Allergy Alerts
No warnings noted
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Therapeutic Duplications
• Cyanocobalamin, Vitamin B{12} and Iron Salts are Hematinics.
• Cyanocobalamin, Vitamin B{12}, Olay™ Vitamins Beauty Nutrients Ester-C® Alpha Lipoic Collagen Support, and Vitamin E are Vitamins.
• Cyanocobalamin, Vitamin B{12} and Olay™ Vitamins Beauty Nutrients Ester-C® Alpha Lipoic Collagen Support are Water-soluble vitamins.
• Flomax® and Metoprolol are Sympatholytics.
• Lisinopril and Metoprolol are Antihypertensive Agents. |