Many thanks to those family caregivers who joined me on the Q & A call about medications earlier this week!
In this post, I’ll provide a little more information related to some of the questions that came up on the call.
How to check for risky interactions between different drugs
One caller asked me if I knew of any ways she might be able to check an older person’s medication list for problematic interactions. (I myself use an interaction-checker embedded in UpToDate, but this is a subscription service that costs money and is designed for healthcare professionals.)
After the call, I looked online to see what is available to the general public. Naturally, I turned to Google, searched “drug interaction checker,” and found that several interaction-checkers are available for free.
Having briefly tried the top three search results, here is my current top choice:
I liked this one mainly because it was easy to add medications and there didn’t seem to be too many ads. However, the information at the other sites seemed similar, so you may want to try a few and see which one feels most comfortable for you.
How to know if a drug is in the risky “anticholinergic” class
In my last post, I explained that it can be very helpful for caregivers and older adults to learn to avoid anticholinergic drugs. That’s because these drugs often cause drowsiness and poor balance in seniors. They can also cause confusion, especially in people who have dementia or mild cognitive impairment.
Unfortunately, drugs with anticholinergic effects are often prescribed by doctors, even to the elderly! They are also easily available over-the-counter: a sedating antihistamine such as diphendyramine (Benadryl) has quite strong anticholinergic effects.
Because anticholinergic drugs are often risky for older adults, they are included on the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. However, although I think the Beers Criteria is a great reference for seniors and family caregivers, the “public translation” doesn’t currently have a easy-to-read, comprehensive list of all the anticholinergic drugs that a senior might be prescribed.
For a more comprehensive list of anticholinergic medications, here’s my current top choice:
Drugs with Anticholinergic Activity, from the Prescriber’s Letter
One of the best features of this list is that it tells you whether a drug has “medium/high” anticholinergic activity versus “low” activity. Drugs listed in the “medium/high” category are the ones that we geriatricians tend to avoid or minimize. Whereas drugs in the “low” category are much less risky.
Another nice feature of this list is that the medications are organized by purpose, e.g. “antibiotics,” “antidepressants,” etc.
How to decide between warfarin and Pradaxa
One caregiver on the Q&A call asked me to comment on the safety of Pradaxa (generic name dabigatran), which is a newer blood-thinner that is often being prescribed instead of Coumadin (generic name warfarin). In older adults, a common reason for taking a blood-thinner is a diagnosis of atrial fibrillation.
Pradaxa, which was approved by the FDA in 2010, has become widely prescribed quite quickly, in part because it doesn’t require the burdensome monitoring that warfarin does. It also has fewer interactions with medications and diet. However, since it’s a newer drug, the long-term side-effects and safety risks of Pradaxa aren’t as well understood as those of warfarin.
If you’re trying to learn more about Pradaxa versus warfarin, or if you want to better understand how to evaluate the risks and benefits of blood-thinners for atrial fibrillation, here are some relevant articles that I wrote for Caring.com a few years ago:
- Atrial Fibrillation & Blood Thinners : This article lays out key considerations, such as one’s personal stroke risk and bleeding risk, and also explains the four main blood-thinning options (warfarin, Pradaxa, aspirin, and no blood-thinner).
- What’s My Risk of Bleeding from My Blood-Thinner: This FAQ explains factors that have been linked to a higher risk of bleeding, for people taking warfarin. (We don’t yet have as much research information on risk factors for bleeding while on Pradaxa.)
- What’s My Risk of Stroke from Atrial Fibrillation: This FAQ explains how doctors estimate a person’s risk of stroke due to atrial fibrillation. Assessing stroke risk, and balancing it again the risk of bleeding, is an important part of helping patients figure out whether the risk and hassle of warfarin — or the expense of Pradaxa — is worthwhile.
- Warfarin: 7 Ways to Keep Blood Levels in a Safe Range: This article explains some practical steps that you can take to minimize the risk of bleeding while taking warfarin.
- Atrial Fibrillation Solution Center: If your older relative has a diagnosis of atrial fibrillation, this solution center includes several articles I wrote to address common concerns, such as symptoms, diagnosis, and whether to use medication for “rhythm control.”
I researched and wrote the above articles in early 2012, so this week I checked to see if any major developments had occured regarding the safety of Pradaxa. One study published in 2012 did report a slightly higher risk of heart attacks in people on Pradaxa. However, a recently published study concluded that the new drugs are slightly better than warfarin at reducing strokes.
In general, the expert consensus still seems to be that either warfarin or Pradaxa can be used for blood-thinning in aging adults.
So which drug is better for your older relative? There is probably no exact right answer. The immediate trade-off is cost versus convenience. Taking either warfarin or Pradaxa means accepting the risk of internal bleeding. (To give you a ballpark sense of the risk: in people taking warfarin, the yearly risk of bleeding has ranged from 1% to 8.7%, depending on one’s risk factors. However in most cases the risk of stroke is higher, which is why prescribing warfarin is usually appropriate, despite the dangers.)
Do you have any favorite tips or resources on avoiding medication mishaps in aging adults? If so, please share below in the comments!