Maggie McKay (Host): When you're prescribed a medication or an over the counter one, how much of that fine print do you need to know and understand? Well, today we're going to find out. Welcome to Total Health Talks, your Cook County health podcast, where we empower your journey to better health. I'm your host, Maggie McKay. And today we're going to talk with Dr. Mark Loafman and Dr. Nimmi Rajagopal about managing prescription and OTC medications.

Thank you both for being here. Would you like to please introduce yourselves? We'll start with you, Dr. Loafman.

Mark Loafman, MD, MPH: Yeah, thank you for having us. I'm Mark Lofman. I Chair Family and Community Medicine at Cook County Health and have been practicing primary care for a few decades here in Chicago. So really happy to be here talking about this important topic with you today.

Host: Thank you. And Dr. Rajagopal.

Nimmi Rajagopal, MD: I'm Nimmi Radjagopalan. I'm the Associate Chair of our Department of Family and Community Medicine. Also really grateful to have this opportunity to talk with our patients and hopefully clarify some things.

Host: Great. Looking forward to it. Dr. Loafman, in order for medications to work properly, they must be taken correctly, of course. So many things can affect how medications work. Can you touch on some of these things?

Mark Loafman, MD, MPH: Yeah, it's a great question and one of the most important things we deal with in primary care and in health care. Medications half life, they build up in your system over a few days. So one of the most important things is taking them as directed. So most of them are daily or twice a day, some sort of a routine like that.

It's very clearly spelled out on the prescription label and it does need to be followed that way. You know, studies show less than half of patients take their medications, according to the directions. And it's not necessarily people mean to harm themselves, but it does cause a fair amount of harm when they're not taken properly.

So timing is important. Daily frequency is critical. And then whether it should be taken with food or without food, first thing in the morning or bedtime, a few things like that. So, I'm sure we'll talk more this morning about how to get that done and some tips around that. But those are the key factors.

Host: And what about medications that are outdated? How outdated can you go? Or do you have to really throw them out on that date on the bottle?

Mark Loafman, MD, MPH: Yeah, the rule of thumb is about a year. They have it, so one year, they don't just at midnight that day, suddenly decompose. So, there's a rule of thumb of about a year. There are some case by case exceptions to that, but that's generally true. Dr. Raj, have you heard anything different than that?

Nimmi Rajagopal, MD: No, I agree. I think the rule of thumb is if you've had it for a year, it's time to get something new.

Host: And what are some strategies that can make managing multiple medications easier and safer?

Nimmi Rajagopal, MD: So this is key. We have a lot of patients that are on more than one medication. One of the things is really understanding what your medications are for. It helps us to not get them mixed up and confused. But also as Dr. Loafman mentioned, it's really important to take medications when they're intended to be taken. So once a day doesn't mean just any time once in that day, but at about the same time every day. So if it's multiple medications that can be taken at the same time, using something like a medication or a pill box can be helpful, sometimes helping our staff or someone in your doctor's office or the pharmacy can be key in helping to manage those.

So really understanding which medications can be taken at the same time,or might need to be taken at different times and then creating a schedule that really works with your own schedule. So it's really easy for me to say, take this every morning, but if you work nights, that may not be the best time for you. So really trying to find first what the medications are, when they need to be taken. So if there's more than one medication that can be taken at the same time, that's good to know. And then also looking at your schedule and saying, okay, this medication I can take at 9 a. m. every day. That's a good goal. And this medication can be taken at 9 at night.

 Understanding those things can be really hard. But often our pharmacists and their staff can help with educating and understanding those things and figuring out where it fits in your day, what the optimal timing is for you.

Host: Well, lookalike medicines, unclear communication and distractions during administration; medication errors can occur for a lot of different reasons. So, they all have in common that they're unintended mistakes in the drug treatment process that may or may not lead to patient harm. What are the most common causes for medication errors?

Because I know when I'm prescribed something and they tell you really fast and I say, can you please write it down because I'll never remember. But what are the most common causes?

Mark Loafman, MD, MPH: Yeah, you touched on a few, just getting confused about the administration instructions. So, there's just a general framework around what we call medication reconciliation, and I'm sure will come up again here in this talk, just to keep your medication list well managed. I think we know in most people's medicine cabinets, there's old medication, medication no longer being used, that's being held onto.

Don't hold onto those things. Just plain old dispose, or don't flush them down the sink or toilet, but just in the garbage. So they just go out, get rid of them. A common cause of harm is taking old meds that you're not supposed to be on anymore and getting confused. So one is just keeping a clean, profile list of medications that are what we're supposed to be using, number one.

And second is keep those labels, follow the instructions. We are very comfortable with taking pills out for a week at a time, and putting them in a little pill box, but longer than that, the pill, what it was and what it's intended for is going to be separated a little bit. So keeping the labels in mind. Reviewing the labels, the package inserts we get from the pharmacy are pages long and they're really intended, of course, to protect their liability and, and we all understand that. So that's just too much information to try to process and manage, but the actual dosing instructions that are on the label are there. And often in our discharge materials, after we leave clinic or leave a hospital, we always have paperwork, either written or electronically that goes over those instructions and, you know, it's good to take time, many, many studies have shown an hour or two or a day after the visit ends.

 Thinking back and exactly what you said, Maggie, I don't remember what they talked about, and we know that's true. So that stuff has been documented. The critical information is there to refresh and go back to view. So those are the tips that are really, really helpful to avoid. Errors are common, and we've kind of learned the hard way what some of these safety moves are, and if you kind of go over the things that we just talked about here, it'll keep you safe when you're using your medications.

Host: When it comes to drug safety, what should patients know about drug induced liver injury?

Nimmi Rajagopal, MD: It's a great question. So one of the things that we always want patients to understand is that any medication we take in has to be broken down in the body, and often by the liver or the kidneys, but that can also put some pressure on those organs. And so there is a long list of medications that can potentially cause some injury to the liver.

And so when prescribing these medications, we want to be more cautious in monitoring for those potential symptoms. Often they're just picked up from repeat blood tests. So if we know that it's a medication that is the potential to cause some liver injury, then we want to do some follow up labs to make sure that that injury isn't occurring.

And often it's something that we can pick up quickly and can be reversible. But also if a patient is having some kind of vague symptoms of, not feeling like eating well or having some abdominal pain or noticing a little bit of jaundice, which is the yellowing of the eyes, kind of. Those are things to bring to your doctor's attention if you notice that happening, particularly after starting a new medication or if a medication has been increased in dose or adjusted.

So things to just look out for, if that happens, but we do want to point out that one of the most common causes of drug induced liver disease or liver injury is actually over the counter acetaminophen, also by the name of Tylenol. So we always want patients to be using caution when they're using over the counter medications, but also to let us know what they're using is really important so that we can gauge if they could be possibly having any sort of reaction to that.

Host: So would that be someone who's allergic to Tylenol or because it just seems like everybody uses Tylenol. That seems scary.

Nimmi Rajagopal, MD: Not necessarily an allergy, but it could also be if they're using it too often or using too much of it.

Host: And who's the most at risk of developing DILI? How's the condition diagnosed and controlled?

Mark Loafman, MD, MPH: Yeah, that's what we both wanted to follow up on a little bit here, I think. And so, people that already have some stress on the liver, so a hepatitis or cirrhosis or other known liver problem, we put that on a patient's list of medical conditions and try to include that. But it's really important that we have that information, so. And then if someone's been out of care for quite some time and has developed a liver problem, then we don't know about that. And so that's where being, keeping your follow up visits and checking, as Dr. Rajagopal mentioned, we do surveillance liver testing on patients who are at risk.

So, keeping those visits and being sure that you're on track with that to keep on top of that. But, as mentioned, acetaminophen, Tylenol products are, you know, can be very effective and we encourage their use for over the counter pain control at home, but we should be on our medication list.

We should know about it. You know, we have this common issue where heh one or two helps me, five will probably be better. I'll take five or six of those. There's a pretty narrow, we call it a therapeutic range between what's safe and effective and what's potentially harmful and toxic.

And it's not very far, with drugs like Tylenol between what's safe and effective and what's harmful. So following the dosing instructions, not overdoing it is really, really critical for this issue.

Host: And I think we know the answer to this, but just in case, should only older adults discuss their medications with their doctor?

Nimmi Rajagopal, MD: No, everyone should discuss their medications with their doctor. Things like using too much Tylenol, like we talked about, or ibuprofen over the counter, those can impact anyone at any age. And I think what most people don't realize is that before medications are released to being over the counter, or even released for us to prescribe; there's many, many, many years of studies that go into it that determine how long it takes for medication to break down, how long before it's safe to take another dose. So those instructions on the package aren't just random, and I think often we overlook that,as again, like Dr. Loafman said, you know, if it worked, two pills helped, maybe taking three will help even more, right?

But that can also cause some damage. So it's really important for anyone to share what they're taking and not just over the counter medications per se, but any supplements, any vitamins is good for us to know what somebody's taking before we can prescribe something else.

Host: And we touched on this a little earlier, but what are some of the most common things you see in patients mismanaging their medication?

Mark Loafman, MD, MPH: Yeah, I can grab that one. It's, something we work on every day in, in healthcare, and that's, taking the medications as directed, as we talked about before, you're right. But the particular of interest is, you know, over half of the conditions that Americans have that can be managed by medication, so I'll say it again, over half, are not managed to goal.

And that means people with high blood pressure and diabetes and cholesterol problems and other conditions like that. They're not managed to goal and we have the medications and the lifestyle modification needed to do that. And when they're not managed to goal, that's where heart disease and kidney disease and stroke, heart attack, limb loss, vision problems, all those things follow.

So an awful lot of what we suffer from in the United States in terms of ill health are conditions that can be managed to goal, and they're not. And so it's that problem. And the classic issue we have is we see a patient's blood pressure's not controlled or the diabetes not at goal. And patients, you know, honestly think that they are taking their medications.

They just don't have a good system to be sure that they are. And they're missing doses, at times, and again, it's over half the time people are missing those doses. Our response is if you're taking your medication, you're not controlled, you need more medication and we'll increase and increase.

And then the real risk is either that they never get to goal, they never do take them, or suddenly, they become, get a little religion and suddenly become very adherent to the medication, but it's too much now because it really wasn't a matter of a low dose. It was a matter of not taking the dose. So that communication is important.

So tracking and being honest with us. It's not about catching you, not taking your meds. It's understanding why your condition isn't controlled. So there's things like pill counts. If you get 90 days supply of medication, 90 days that medication should be gone. If you get to day 90 and there's still 20 pills left, then that means you missed 20 days in the last three months.

So there's things like that we can do to help and we can track some of that. But it's really managing to goal. Again, mostly it's about underdosing, but occasionally, it's overdosing when we didn't understand that someone wasn't taking their meds and they, they do start taking them. So we can cause harm either way.

And those are the biggest conditions. There's other issues around, you know, not disclosing, people have two or three different pharmacies, that they're using and that one pharmacy doesn't know what the other one has and maybe we're not necessarily always able to see it either. So it may be that physician or provider prescribed a cholesterol medication, another provider prescribed a different cholesterol medication, the patient's actually taking two different medicines, two different names, but that's a common cause of liver harm or another injury right there.

So, we say one pharmacy home. One common set of medication reconciliation and take them as directed. And those are the big lessons.

Host: And be consistent. I was just at the doctor yesterday and I was asking the receptionist if she used something I was thinking of trying and she goes, I did. And I said, did it work? And she said, I don't know. I was not consistent with it. Okay. There you go. You have to stay on it.

Mark Loafman, MD, MPH: It's more common than not.

Host: Right. Okay. So when we're starting a new medication, what are some of the things we should keep in mind?

Nimmi Rajagopal, MD: Whenever starting a new medication, it's good to one, understand why you're taking it, right? So is it for your blood pressure? Is it for your blood sugar? What are we taking it for? And then two, understand what are some of the common side effects that can happen and are those transient? So often we'll have a patient start a medication and come back and say, I took it for a day. It didn't work or I took it for a day and I felt this, so I didn't take it. Sometimes we need to adjust to the medication. And so there can be some things like maybe a little bit of nausea in the first couple days when you take it and then your body adjusts to it. So it's really important to have those conversations with your doctor and let them know if you have any hesitation about taking the medication.

The other is if you're going to start the medication when you see the doctor, right? So we make a plan saying, okay, we're going to start this medication and then maybe we'll see you back in a month thinking that you're taking it. But say, you know, that it's just not going to fit into your life to start this medication now. We want to have these open discussions with people. And I think that's really hard for patients sometimes to say things like, yeah, I really haven't been taking my medication every day. I forget. And that's what leads to what Dr. Loafman was saying about then overmedicating the patient when they start taking it every day.

 Starting new medications, it's key to know what you've already been taking, and if you haven't been taking something that your doctor thinks you were taking, it's time to speak up so that we don't take that risk of over medicating. And then again, knowing what the potential side effects are, what are the things to kind of watch out for, and then what the timeframe where we think something is going to have an impact.

Some medications can take three or four weeks before you get a full impact from those medications. So that you're not expecting to feel different tomorrow because you started the medication.

Host: One of my friends takes a lot of medications and I said, how do you keep it all straight? And she said, on my phone. I do the timer and label it what it's for. And I thought that was brilliant. I mean, it seems so obvious, but how easy would that be? You say which one it's for and what time and your alarm goes off. And even if you can't remember which one, you've already labeled it. Do you think that's effective?

Mark Loafman, MD, MPH: That can be very powerful. Yes. And, again, the issue becomes if you're, not at your medication when the alarm goes off and you snooze it, you know, it's the same issue as anything else. It's how do you stay on top of it when you can't carry your medications around with you all the time.

So we think there are a few things like that that are important, but keeping the pill box is important because if you have it set for the week and you're getting ready to go to bed and you realize your evening dose is still there, whoops, I had the alarm, I, I snoozed it and I didn't ever take it, it's not too late to catch it then.

But if it's three days later and you realize you haven't been taking your meds, it's too late now. You've really gotten behind. So it's not just one plan, it's a plan with a backup. I think that's really important.

Host: Well, let's talk about younger people and hangovers and Tylenol. It's common for them to use Tylenol or other over the counter medications to treat a hangover. Can you touch on the impact this has on their body? Does timing play a role in how effective it can be? Like when should they take Tylenol versus other medications?

Mark Loafman, MD, MPH: It's really an important safety issue. So both Tylenol and ibuprofen, Aleve, you know, naprosyn, those kinds of medications can be very helpful for aches and pains and, hangover type symptoms. So they are on the list of things to do. But a couple of points in particular about alcohol use is, first of all, if you had enough alcohol to have a hangover, you've had some liver injury.

 It's just inevitable. It's toxic and will cause an injury. And most times you recover from that injury without a problem. But if you also now overdose on Tylenol, you've added injury on top of injury. And that combination of the two injuries can be, cause some permanent damage. So, again, the key is to be thoughtful about dosing and timing of frequency, just take the maximum dose allowed.

There isn't any evidence that additional is helpful anyway, so you're not going to cause any benefit, but you can cause harm. So just follow the directions. And then, medications like Aleve, ibuprofen, Advil, the so called non steroidal anti inflammatory medications also are very effective. But they tend to have focus more on the, on the kidneys for harm.

One of the things, again, about having a, an alcohol use, overuse episode is alcohol is a diuretic and tends to dry us out a little bit. And if you slept in 8 or 10 hours and haven't had any hydration, so you may already have a little bit of kidney injury. Again, that will recover with starting to drink fluids and avoid any further injury.

But, overdosing on non steroidal anti inflammatories on top of the kidney injury that you already had, can again add insult to injury and be double. So, the simple rule is follow the directions when you're taking them and hydrate. Push fluids, they're not, all the other hangover remedies are sort of myth based, but, dehydration is a big part of why people feel bad. So hydrating, electrolyte solution or not, whatever you prefer, but those are the things to do, to try to be sure, following the directions, again. Not thinking more is better is really important.

Host: Good to know. Well, one thing some of us have probably heard our parents say is, I didn't take my high blood pressure medicine today and I feel just fine. So what is the reason for that and why is it important to never ever skip medication use?

Nimmi Rajagopal, MD: So one of the things that people may not realize is that our bodies are really good at accommodating. So our bodies can get used to running at that high blood pressure, but that doesn't mean that it's healthy or safe for us. And that's why we know that high blood pressure is kind of the silent killer, right?

So people can walk around with a really high blood pressure and feel fine. But that doesn't mean that it's not doing some damage internally. And so that's why it's really important to take these medications. When we're taking a medication that's meant to be taken daily, it has to build up to a certain level that it's working effectively for us.

And when we miss doses or skip doses, it's not able to maintain that level and have the impact that we want it to. So although we may feel fine, if you check the blood pressure, it may be high, and that's still having an internal inpact. So, even though we feel fine, we essentially feel fine until we don't.

Until our body can't accommodate and can't make up for it, and that's when something more is going to happen. And so it's really important that we manage the medications and take them as prescribed. And like we said, if it's once a day, it doesn't mean any time during that day, but about the same time every day.

So, really getting into that routine, so that we're taking it and we can maximize the effect that the medication is meant to have, and then mitigate those effects and try and keep those effects that are happening in the background from happening, right? So even though we feel fine, what's going on inside isn't necessarily fine.

Host: Can you share some tips for those who maybe care for someone who needs help managing their medications, maybe parents, neighbors, what are some steps that can help prevent overmedication and related problems?

Mark Loafman, MD, MPH: Thank you for that question. It's really important. There's an awful lot of caregivers, either for a senior, a parent, or someone who's disabled, or a child, adolescent who has health conditions. And, overmedication is a concern, also undermedication. We often see, quite a bit of harm coming from lack of organization of medication.

So some of the tips we talked about here before, for the individual apply in this setting as well. So having a single pharmacy home, having that person get all their medications at one pharmacy, is very helpful because they're all reconciled and organized so you can help avoid drug-drug interactions that way.

So that's critical. Secondly is using the medication management, you know, daily dosing devices. They even have one set up for a month, that have up to two or three different, one, two, three time a day medications. So, you can just load the whole thing for a month for that senior, or the parent or grandparent that you may not visit every day, but at least a week at a time is there.

And then I think the appointment follow ups too, to make sure they're there, to be able to go back and keep on top of the refills. Refill management is pretty straightforward. But it's not uncommon that people notice they don't have any refills when they're already out of medication and there's going to be some turnaround time there.

Kind of keeping an eye on that. We always say if your bottle says I have refills left, then when you need a refill, you call the pharmacy. If your bottle says I have zero refills left, you make sure you call your provider, well in advance of taking that last pill. ' We always give enough refills until we need to see and check on you again for these medications.

That's the usual rule. So we try to avoid kind of these last minute refill issues that can get in the way, and help kind of mess up the whole care plan at that point. So those are the most important things to keep track of. And don't hesitate to butt in and say, hey, I love you. I care about you. Let me check that pill box.

Host: Absolutely, right. Because sometimes, sometimes when people get older, they get a little defensive. You know, you, you call them

Mark Loafman, MD, MPH: Exactly and very independent. And the child becomes the parent.

Maggie McKay (Host): That's a good approach to say, I love you. I care about you. So this also probably goes without saying, but I think it's worth bringing up.

Never, ever, ever share your medications, right? I can't tell you how many times I've heard someone say like, oh, I have some Valium or leftover painkiller, you know, if someone's in pain from an injury, say a sports injury, you can just use mine. I'm like, what? No way. Right?

Mark Loafman, MD, MPH: You're absolutely right. Yeah. You haven't had all of the provider and the pharmacy. The pharmacists do a tremendous job of profiling and risk screening and we count on them as well. You know, we do our part, but at the end of the day, we know that if the pharmacist hands you a medication, they've looked at your allergies, they looked at what else you're on. So all of that happens. When your friend gives you the medicine, you've cut out about five steps of safety screening. So, yeah, don't take other people's meds.

Host: Okay. Is there anything else either of you would like to add that we didn't cover in closing?

Mark Loafman, MD, MPH: One big thing is just people commonly think, I have to take this medicine the rest of my life. If I take this medicine, I'll be dependent on it. And, it's rarely a problem. I mean, I think, I often say you can take these medicines for the rest of your long life. Or you can not take them for the rest of a shorter life, and that's often the truth. So, I think don't look at medications as a sign of weakness or harm. It's a wonderful thing that we have the ability to stop the progression of these conditions and improve quality of life. So, make medication management a positive thing and just do it safely.

Host: Dr. Rajagopal, anything else?

Nimmi Rajagopal, MD: Yeah, so you mentioned using your phone as reminders. Our phones can actually come in very handy in other ways, too. So when we talk about taking care of others or helping our parents or grandparents taking care of themselves, keeping a list of their medications. So I keep a list of medications for my mom so that I know if she goes to a doctor's office or goes to an appointment that I'm not at, I still know what the medications are.

And also for patients that we want tracking their blood pressure, their blood sugar, keeping those lists in their phone, so that they have them when they come into the doctor and then as Dr. Loafman mentioned, reconciling meds. So I like for my patients to bring all their medicine when they can, because it helps us to clarify things in the office, in the visit together, get rid of old medications.

We're looking at, Hey, this is actually something we stopped last year. Let's just take it out of here. So really using this technology to our advantage to help us and help us to stay organized and on top of it so that we can all keep on the same page is a big point that can help here.

Host: Great idea, the list. I love that for, you know, whoever you're taking care of, even yourself, having it on your phone. That's brilliant. Thank you so much for that idea and for sharing your expertise today. We appreciate all this invaluable information. I'm taking mental notes now, I have to write them down.

So again, it was a pleasure to have you both here.

Mark Loafman, MD, MPH: Thank you Maggie.

Nimmi Rajagopal, MD: Thank you.

Host: Thank you so much. Again, that's Dr. Mark Loafman and Dr. Nimmi Rajagopal. As we wrap up another insightful episode of Total Health Talks, make sure to visit cookcountyhealth.org/podcast and subscribe to our podcast, share and connect with us on social media. Stay tuned for more engaging discussions.

This is Maggie McKay signing off from Total Health Talks. Stay well.