Scott Webb (Host): When it comes to taking our medications and understanding possible drug interactions and side effects, it's best to rely on an expert, and I have one of them here with me today. I'm joined today by Joshua Rajkumar. He's a doctor of Pharmacy and pharmacist with Franciscan Health, and he's here today to help us to take our heart medication safely.

 This is the Franciscan Health Doc Pod. I'm Scott Webb. Josh, it's great to have you here today. We're going to go through and talk about, you know, folks taking their medication safely, especially heart medication safely. And, you know, yes, we rely on our doctors and pharmacists, of course, but why is it important for patients to also have an understanding of what they're taking and how those things might interact with other medications?

Dr. Joshua Rajkumar: When you're taking your medications, you know, some medications have minor interactions, some have major interactions. And what we mean by an interaction or a drug-drug interaction is that one medication either increasing the concentration of another medication or decreasing that concentration within your body. So essentially, it's affecting the effectiveness of that medication. Therefore, you may not be getting the best effect out of the medication, or you might be getting too much of an effect from the medication, which can lead to some pretty severe side effects that you may feel with that. So, it's important to know about those interactions as well. Because when you're at home, you know, kind of going through your medication list, you may have a list of five medications, you may have a list of 50 medications. You know, I've definitely seen lists as high as that, but knowing and having the assurance that none of them interact gives a greater confidence for you to take those medications, but also, you know, prevents any future effects as well.

 It's one thing to have a sudden heart attack come on and treat that with medications. It's another one to have a drug-drug interaction put you in the hospital. Those things are preventable. So, talking with your doctor, talking with your pharmacist about not only the medications that you're taking, but also different herbal supplements, different foods that you're eating, what your diet looks like as well, that can all affect medication concentrations. And so, having a good awareness of that is vital.

Host: Yeah,. As you say, it's not just other medications, but it could be herbal supplements, food, and so forth. So, I've got a list of things I want to go through and just have you kind of address each one as we go through. So, let's start with anticoagulants and what folks need to be aware of.

Dr. Joshua Rajkumar: So, in terms of anticoagulants, when I'm referring to these medications, there are different medications that can be classified as anticoagulants. So, for the purposes of this discussion here, I'll talk about minor, moderate, and major anticoagulants.

So, I would say, you know, a minor anticoagulant would be something like aspirin. So, when I say minor, I'm referring to aspirin. It has a very, very mild blood-thinning effect to help prevent against cardiovascular disease. Moderate would be medications like Plavix or clopidogrel, Brilinta or ticagrelor are some of those medications you may have heard of. So, that, I would say, has a moderate blood-thinning effect or anticoagulant effect. And then, you have warfarin, Eliquis or apixaban, Xarelto or rivaroxaban, dabigatran or Pradaxa, those are your major anticoagulant medications. So, we'll kind of start here at the top with the major ones and work our way down.

So for major anticoagulants, we'll start with warfarin. Warfarin is the trickiest one. That one has drug-drug interactions associated with it. So if you're ever starting a new medication while you are on warfarin, it is probably a good idea to contact your anticoagulation office, your cardiology office, and inform them that you are now starting this medication. It could be just an antibiotic that you recently started. Maybe you're only taking it for five days, but that could affect the warfarin concentration, or it could be, you know, maybe an antibiotic for a longer term or a short term pain medication, it's very important to be able to inform your provider about those antibiotics in particular, is one I would say. Antifungals is another big one for warfarin in particular.

The other thing with warfarin is you have to have a good concentration of vitamin K and vitamin K is primarily found in leafy green vegetables. So, the more leafy green vegetables that you have, the higher vitamin K concentrations you may have in your body. And so, that can affect the blood-thinning effects of your warfarin medication. And where the concentrations are, so make sure that you're eating a consistent, not varied, but consistent amount of leafy green vegetables such as spinach, kale, green beans, and letting your team know how much you're getting each week. If you don't have it at all, that's okay. If you do have some, make sure your providers are aware of that to do that. So, warfarin is the trickiest one there.

And then, with Eliquis, Xarelto, and stuff, you don't have to worry about those vitamin K foods, but you do have to worry about over-the-counter pain medications. So, taking ibuprofen, naproxen, these are what they call non-steroidal anti-inflammatory drugs, or NSAIDs, you might hear them referred to. That's a fancy name. But, you know, ibuprofen, Aleve, naproxen, some of those drugs there, those ones I would definitely not take because they actually can exacerbate bleeding risk with Eliquis, Xarelto, Pradaxa medications. Within their mechanism, they would work on top of the blood-thinning effect for anticoagulants. So, I would pretty much steer clear of those while on it.

But if you do need something for pain, we do recommend Tylenol. Tylenol is very safe from that standpoint and doesn't have any drug-drug interactions with your anticoagulants, which is good, which is why we always recommend it. But some patients may not have a great effect from that. And so, you know, if you need something stronger, I would talk with your primary care doctor because the next level stronger is those ibuprofen and naproxens. And unfortunately, those would exacerbate bleeding and cause interactions. So, I would stay clear of those.

In terms of some any other notable drug-drug interactions for anticoagulants, those medications, since they are in the major category, if you are starting a new drug or a new supplement of some sort, I do think it's always good to check with your Cardiology office or provider's office about drug-drug interactions there, or your pharmacist. Because what the risk with that one is, is a chance of major bleeding. And if you don't tell them, you could potentially have a major bleed. And so, we want to avoid that. So, telling them about that and screening for that is important. Over-the-counter pain medications are the big class, and antibiotics are also something to watch out for as well.

In terms of the Plavix and Brilinta medications, this one will go a little bit quicker. One medication for Plavix to steer clear of Is omeprazole. That is a medication that's used for GERD or, you know, stomach upset. A lot of patients are on it. You may know it as omeprazole or Prilosec. Protonix or pantoprazole is okay, but omeprazole, steer clear of. That one has drug-drug interactions. And then, you also want to watch out for some of those over-the-counter pain medications. It's not as big of a concern there, but it is something to Monitor and screen for. And then, aspirin has, again, a mild blood-thinning effect. Little to none drug-drug interactions you have to worry about with aspirin and being on that.

If you are on all three, let's say you're on aspirin, Plavix, and Eliquis, the risk for bleeding is high then, since those are all of your anticoagulant medications on board. There are patients that are on that, and there is some data to suggest good efficacy there. But I would make sure you're in contact with your office about when one of those would come off, because very rarely do we see patients on all three.

Host: Yeah, makes sense. I want to move to blood pressure medications. I'm on a blood pressure medication. Not that this podcast is about me, of course, but I'm an interested party to be sure. What do we need to know?

Dr. Joshua Rajkumar: So for your blood pressure medications, you know, in terms of big, landmark drug-drug interactions, there's not really a lot that comes to mind. One of the big ones would be lisinopril. That is a medication that most people may be on for blood pressure, and it's a very common one. And that medication has some drug interactions with some chemotherapy agents. Some antibiotics as well. One of those antibiotics being Bactrim. That's a big drug-drug interaction there that we'd want to be aware for. And what the interaction is there is it's increasing your lab. So, it's increasing potassium. It could increase your kidney labs. So, that's specifically there with lisinopril.

Some of your other blood pressure medications like metoprolol, not really a lot of drug-drug interactions. There is some evidence to suggest if you're taking that with an inhaler like albuterol, maybe the inhaler may not have as much efficacy as it does when you're taking it with metoprolol or carvedilol than if you're just taking it alone. But clinically, that hasn't really amounted to much. It is an interaction that pops up on our charts. But clinically, it hasn't really affected any patient as much as we've seen here. But if there is increased shortness of breath, we do kind of take that into account as well.

Diuretic medications, in terms of drug-drug interactions. So, these ones would be like hydrochlorothiazide, Lasix or furosemide, or torsemide. Again, not a lot of drug-drug interactions, like big landmark ones that come up here. Those medications affect the kidneys, primarily because they're utilizing your kidneys to help excrete fluid and get rid of fluid from your body. And so, as a result of that, any other medications that would affect the kidneys is something we would need to monitor. So if you're on lisinopril and hydrochlorothiazide, we'd be monitoring your labs a little bit more closely because it's affecting the kidneys and potassium versus if you're just on hydrochlorothiazide, we'll keep an eye on you, but maybe not as much. So, not a lot of drug-drug interactions there. And then, amlodipine, not many drug-drug interactions. Most of your blood pressure medications, if they have a drug-drug interaction, it's very, very unique. It's not a very common one, I would say, that is among most patients.

Host: Yeah. One of the things I'm learning from you today is that sometimes we think about the interaction, sometimes it's just a matter of sort of lowering the efficacy of the thing, of one of the things, right? And sometimes it could lead to, you know, more severe complications, interactions, whatever it might be. So, I've heard this before, Josh, about statins to avoid grapefruit. And I'm not sure why. I want to have you go through statins. And is it an efficacy thing or could it be some really bad side effects?

Dr. Joshua Rajkumar: Particularly statins and grapefruit juice. So, grapefruit juice is something, not only just statins, but other medications as well can decrease the efficacy of. So, that would be what we would call an inducer of the metabolism of those drugs. Therefore, when that happens, your body is metabolizing the drug faster. Therefore, it's going through it faster. Therefore, you have decreased concentration of it. So, grapefruit juice decreases the concentrations, particularly of medications like atorvastatin and rosuvastatin. I've also seen it with orange juice, apple juice. So other fruit juices as well can do it. But grapefruit is like the big hallmark, the big one we learned in pharmacy school, and that's reinforced in our practice. That one definitely reduces concentrations, particularly of your statin medications.

Host: And I'm assuming you just sit right by where you work there. You just have a big picture of a grapefruit with a line through it, right?

Dr. Joshua Rajkumar: Yeah. I should get one for sure, for the amount of times we talk about it.

Host: I'm sure. I want to talk about just the general use of alcohol and sort of, again, generally speaking, on medications. What do we need to know?

Dr. Joshua Rajkumar: Yeah. So, administering medications with alcohol is strongly discouraged against. When you take alcohol with any medications, particularly heart medications, alcohol is, in a sense, a drug itself. It's a chemical compound, and it has its own unique chemical structure that can interact with some of your medications as well. In general, I would never advise taking alcohol with a medication. So, you know, most patients would drink a glass of water there. That's something I strongly prohibit from that standpoint. But, you know, it's not discouraged, like if you're having a few beers on the weekend for the big Colts game, where do we kind of stand on that? That is generally, you know, okay. I would say alcohol in moderation and not in excess is encouraged while being on some of these heart medications. You know, statins are affected by it. Your anticoagulant medications are affected by it. Some blood pressure medications, not all, but some can affect it by raising or lowering blood pressures.

The thing with alcohol is that it is a CNS depressant and it's acting on different receptors that increase your blood pressure, increase your heart rate, and all of that. So, that's why the medications then kind of go a little bit heywire with some excess alcohol there within the system. In terms of a consistent amount, definitely, we would have to consider that with blood thinner medications like Eliquis in particular. We definitely have to consider that with some of our heart rate medications like diltiazem, which is used to treat atrial fibrillation or abnormal heart rhythms. So, those would be some of the big ones where I'd be like, "Hey, like if patients consuming a considerable amount of alcohol consistently, we would need to know about that to modify their therapy.

Host: Right. And that's where, you know, speaking with our providers, our pharmacists, and so forth. As you say, moderate use, probably okay for most folks. But, you know, when in doubt, speak with the experts, right?

Dr. Joshua Rajkumar: Exactly. Yeah.

Host: Yeah. Let's talk about when we think about heart health and supplements, you know, you'd mentioned earlier about herbal supplements. So, let's just kind of go through a little list I put together here. With respect to heart health, how about fish oil supplements? What do we need to know?

Dr. Joshua Rajkumar: Yeah. No, great question. I think in general with supplements, before I get specifically into the fish oil, you know, supplements are something I see a lot of patients, they take them because on their labels, they have a lot of saying like, "Oh, this helps with coronary artery disease. This helps with your heart health. This helps reduce heart attacks and stuff." And the thing about supplements is they have a different regulation process than medications do. Medications are very strictly put under the microscope with regulation testing from the the Federal Drug Administration, the FDA, and different testing sets to make sure they're up to par before they go on the market.

Dietary supplements has sort of an abridged process, but they can't say that their supplements can treat, cure or help with any specific condition. So, the labeling is very specific on those medications. It's not actually saying it's going to help, it is giving something that it'll help there, giving a little inkling there. They can say it, but not specific verbiage. And that's because when you look at the dietary supplement studies that looked at these medications, there's not a lot out there, truly. There's not a lot of published literature there, and the published literature that is out there doesn't really show anything super promising for the medication.

And so, we'll get into each of these here with the options that we talk about. But you mentioned fish oil. You know, fish oil is one of those medications that doesn't really have a lot of benefit. It does have some. Now, I'm not going to say it doesn't have any, it has some. But this medication in particular is used for patients that are on, you know, maximum dose of their statin medication, maximum dose of a medication like ezetimibe or Zetia, a maximum dose of a medication like fenofibrate, and then they're putting on this medication that could reduce their bad cholesterol or the risk of cardiovascular disease by maybe 2-3% at most. You know, you're not seeing like very big numbers there like with statins, I mean, you're reducing that cholesterol by 50%. With Zetia, maybe like 15%, right? You know, when you come to fish oil, it's about 1-2%; at most, 3% in some cases. So, not a lot of efficacy there. Now in terms of risk then, you know, let's balance that against the risk of taking that supplement.

The big thing with that is this one does have a blood-thinning effect with the medication. And this is actually something we're working on here and our cardiologists is there's a lot of patients that might be on fish oil with Eliquis or with Plavix, and there's actually an increased risk for bleeding while on fish oil while taking Eliquis or Xarelto medication. So, on its own, you know, it's not going to cause any major or minor bleeds. But you know, with other anticoagulant medications, it does. And so, when you're weighing the risks and benefits of that medication in terms of when you take it. And the thing I tell my patients as well, particularly with fish oil, is like, "Hey, if you're on an anticoagulant, you know, the fish oil is coming off. There's very minimal benefit for you and a very high cost," versus, you know, if somebody is just taking it, help reduce their cholesterol, not any other blood thinners, generally, you know, I'm like, "It's okay. But it's not really helping as much as you may think." So then, that might come to like a medication financial cost at that point.

Host: It sure is a lot to take in and a good thing about podcast, Josh, is folks can listen, they can rewind, they can play it over. And as we said, you know, when in doubt, speak with your own provider, of course. How about niacin? What do we need to know about niacin?

Dr. Joshua Rajkumar: So with niacin medication, that one, in terms of its use, so that was originally used for, again, like cholesterol medications, it's actually not really recommended for patients with abnormal cholesterol or dyslipidemia. The guidelines no longer advocate it and that's because, you know, in the studies that looked at that medication as an add-on to statin therapy or as its own, a lot of the evidence shows it did not reduce the chance of passing away due to any cardiac conditions or non-cardiac conditions. It didn't prevent any future heart attacks or strokes for patients, but it was associated with a lot of side effects. The main one being flushing. Patients will get very, very like red in the face, feel very flushed. You'll see like these rosy, rosy cheeks on them. Nausea and vomiting are also associated with the medication. So in general, I don't really advocate for niacin, unless like we've tried everything, patient is statin intolerant, can't be on any other of our lipid-lowering agents, maybe then we'll go to niacin. But again, not a lot of benefit in the long-term for patients, particularly with, you know, those big outcomes, which we're trying to keep in mind being keeping them from passing away or keeping them out of the hospital, these medications aren't really doing anything to help against those major outcomes that we're trying to prevent for patients.

Host: And then, let's finish up in this list here, Josh, with CoQ10 right?

Dr. Joshua Rajkumar: So, this is also a medication that is not recommended by the American College of Cardiology. So, this medication, its use was for cardiovascular disease, for cardiac surgeries, congestive heart failure, hypertension, stroke. This is when it first came out. Now, coenzyme Q10 does have other like anti-inflammatory and antioxidant effects in diseases such as, you know, diabetes or cancer or fertility. But I'll keep it kind of focused here on Cardiology since that's my area of expertise. So for CoQ10, it is not recommended as a therapy according to the heart guidelines. And again, that's just due to a lack of efficacy data. It doesn't have a lot of data to show that it is effective at reducing your risk for cardiovascular disease. I think there are still patients that develop cardiovascular disease with being on coenzyme Q10. And so, it's not really shown to be a really good dietary supplements as well. In fact, when taken with statins, in particular statin medications, it can cause myalgias or muscle symptoms, or that muscle twinging that's very particularly known with statin medications, it would exacerbate that. So, not only is there really no benefit and it's not recommended by the American College of Cardiology, it also can cause significant side effects for a medication that is doing a lot for the heart in reducing cardiovascular disease.

Host: Like I said before, you know, a lot to take in here today and folks can rewind and play again, talk with their own providers, speak with you, of course. Let's just finish up and just sort of give folks a sense of like when they should speak with their doctors, when should they speak with their providers, you know, through the lens of what we're talking about today, which is making sure that they're taking their heart medication safely.

Dr. Joshua Rajkumar: Talk to your doctors and the following scenarios, one, if you're starting a new medication and you're on a blood thinner, you know, definitely let your doctors know about that. We want to screen for drug-drug interactions. We want to make sure you're getting the best care there and it's the best therapeutic option. There are some other medications that may not interact that could still be beneficial. So, particularly for those on blood thinners, you let your doctors know about any new medications that you're starting.

Additionally, I would also keep a list of your medications with you at all times. Write down your list of medications, you know, at the end of most provider visits, at least here at Franciscan, I know we print off a medication list and it's always there at the back. And, you know, I know sometimes patients go through a lot of medication changes, especially on discharges, but keep a list, keep an active list, work through it, be on top of your medications is something I would strongly advise. You wouldn't believe how many patients may not be familiar with that. So yeah, go ahead, you know, ask your doctor. "Hey, can I get a medication list? Hey, can you show me what I'm taking? Why am I taking them and stuff?" Don't be afraid to ask those questions there.

You know, if you're on a medication and it runs out of refills, this is something I just see a lot in my practice that I want to say, and the doctor forgot to refill it, it's not because, you know, they didn't want you taking the medication anymore. It's because you need to get seen and see if you still need that medication. There's so many patients that are like, "Oh, I ran out of refills, so I don't know if I still need that medication." And it's like, well, in those scenarios, ask your doctor, "Hey, I didn't see any refills reordered. Do you still want me taking it? Because sometimes if it's like an aspirin medication, you know, in my opinion, it's like, "All right, maybe plus or minus on that." But if it's something like Eliquis, if you go a few days without that, we could be potentiating a potential stroke from happening.

So, definitely keep in mind, you know, if you're out of medications, contact your doctor's office and get refills ordered. If you're not familiar with your medications, get an appointment with a provider or talk to your pharmacist that's in the clinic there. They'd be happy to help you as well.

Host: Yeah. Well, lots of great advice from an expert today. I appreciate your time, giving me a lot to think about. I'm thinking about all my medications and making sure, you know, doing things you recommend here. Just keep that list of medications with you. Take a picture of it, keep it in your phone, keep it in your wallet. Lots of good stuff today. Lots of good information. Thank you so much.

Dr. Joshua Rajkumar: Yeah. Thank you.

Host: And if you have questions about medications, please talk to your pharmacist, primary care physician, or specialist. And when you receive a new prescription, don't hesitate to check with your pharmacist about possible side effects or interactions with other medications. And for more information about heart disease and other topics, visit our blogs at franciscanhealth.org/blogs.

And if you found this podcast helpful, please share it on your social channels, and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.