Rania Habib, MD (Host): Millions of Americans take prescription medications every day, many of them older adults. Joining us today are Prisma Health Clinical Pharmacy Specialists in Ambulatory Care, Shandi Pack and Morgan Rhodes, who is also a Clinical Associate Professor at the University of South Carolina School of Medicine. They are here to talk to us today about how to safely take medications and avoid common mistakes.

This is Flourish, a podcast brought to you by Prisma Health. I'm your host, Dr. Rania Habib. Welcome and thank you both for joining me today about this panel discussion all about prescriptions. What an important topic for us to cover.

Morgan Rhodes, PharmD: Thank you so much for having us today.

Shandi Pack, PharmD: Yeah, thank you. Looking forward to the discussion.

Host: So Shandi, I would like to begin with you. What should you do when starting a new medication?

Shandi Pack, PharmD: I think this is a great question because I think a lot of times, patients will just kind of get in the flow of, "Okay, new medicine," and they just kind of take it at face value. But it's super important to have that conversation with your doctor. You know, "What to expect about the medication? How should I take it? Are there any, you know, important side effects that I should think about or watch out for?"

And also, I think sometimes when we're in the doctor's office, we might forget some of those questions and maybe think about them after the fact. I always encourage patients to be an advocate for themselves. Don't be afraid to call or send a message to your doctor and ask them, but also definitely utilize your pharmacist wherever you get your prescriptions filled. They are definitely the experts on medications and they should be able to answer a lot of your questions that you would have.

Host: I definitely love the fact that, at most pharmacies, you know, they have that option to speak to the pharmacist directly when you're starting a new medication to specifically ask those questions. So, I really appreciate you bringing that up. Morgan, how can you best manage multiple medications? I'd love for you to discuss when to take them, how do we plan around mealtimes, et cetera.

Morgan Rhodes, PharmD: Sure. So if you're taking multiple medications, there are some tools that are out there available to help you, such things as pill boxes and pill packing. For pill packing, certain pharmacies may offer this service and there are also reasonably priced pill boxes that are available for purchase at most pharmacies as well.

The biggest thing is just making and coordinating your medications as a part of your routine. So if you take something in the morning or at bedtime, it might just be helpful to put it next to your toothbrush or an alarm clock to help you remember to take it every day. There are also medicines that maybe have to be taken on an empty stomach or with food or before eating. So if you're not sure about these instructions, there may be some guidelines on the side of the bottle. But that's also a really great time to talk to your pharmacist wherever you get your prescriptions about best times to take the medicine as well.

Host: Okay. Fantastic. I love that tip about keeping the medication handy with those reminders about the time of day. That's a great advice. Shandi, why do some foods interact with certain medicine, and what are some common medicine food interactions that we should avoid?

Shandi Pack, PharmD: So, the most common reason that medications and foods interact with each other is because of the way these things are broken down by our bodies. So, you have foods that can interact with the metabolism or the breaking down process of medications. And ultimately, what ends up happening is you can get an increased concentration or amount of that medication in your body or a decrease. So, that can make the medication either more effective or less effective.

A couple of common interactions we see are grapefruit juice. It actually can interact with quite a few different medications. Two of the most common ones that we see are cholesterol medications and some heart medications. And then, if you're on a blood thinner like Warfarin or Coumadin is the other name of that medication, it has a direct interaction with foods that are rich in vitamin K, which we mostly refer to as those green leafy vegetables.

Host: Okay. Can you elaborate a little bit about the grapefruit juice? Because I think we commonly hear it, but to be honest, I think very few patients really understand why.

Shandi Pack, PharmD: Sure. So, it is an effect of the metabolism of the medication. So, the most common medication that I see this with are the cholesterol medications like your statin drugs, so like your simvastatin, that's, you know, a common one. So basically, what happens is the grapefruit juice interferes with the metabolism of that medication causing higher levels of the medication to be in your system or your body longer than it should be. And the ultimate result is that you can get increased risk of side effects related to the medication. If you avoid the grapefruit juice, then you would have a less risk of those side effects because your body would be able to break down that medication the way it's intended.

Host: Thank you for that detailed explanation. So for those patients, stick to orange juice or something else. Morgan, what will happen if you accidentally eat something that interacts with a medication? What should the patient do?

Morgan Rhodes, PharmD: As Shandi was saying, it just depends on the medication and depends on the interaction with the food that they've eaten. She used the example of statins for cholesterol. They're at increased risk of having some of the side effects like the muscle pain, muscle weakness. And that would just be something to watch out for and to monitor over the next couple of days, to touch base with your doctor if you're noticing severe symptoms.

The other medicine she mentioned, Warfarin, those foods that have a high vitamin K content actually make that medicine less effective, which is a blood thinner, which helps to prevent clots that patients might get. So for that one, what I would recommend doing is just checking in with your doctor. They may want to monitor your levels more carefully, you know, in the upcoming weeks as it is kind of clearing out of the body. So, definitely something to kind of check with your pharmacist, check with your doctor about.

And one thing that's I think confusing sometimes for patients is we talked about the grapefruit juice. It's actually not grapefruit itself. So, checking with your pharmacist too before you get too concerned, you know, if you eat a grapefruit, that is certainly different than drinking grapefruit juice.

Host: Okay. That makes total sense. Shandi, what should you do if somebody has concerns about a drug they're actually taking? So, specifically the side effects or if they don't feel like it's working. Should they start with the pharmacist or would you recommend going back to the primary care?

Shandi Pack, PharmD: Certainly, we always encourage patients to talk with their doctor. You know, we want patients to have that open communication with their physician. They are an advocate for themselves and part of their healthcare team. So, it's not the pharmacist and the doctor and the nurses only, the patient is part of that team. So, we certainly want that patient to talk to their provider and discuss their concerns and their questions.

I think sometimes patients, or just people in general, we can get very nervous if we're concerned about things and the wait times to receive a response back, it might make us more nervous. So, I think sometimes talking to the pharmacist if they're a little bit easier to reach, which a lot of times they are, is a great resource as well. They're still going to encourage you to talk with your doctor, but maybe they can answer some general questions you have about concerns about the medications.

I think, too, something that is super important is just remembering that not everything on the internet is accurate and not everything on the internet is going to be specific to your situation. There may be information on there that sounds scary or, you know, you're very concerned about. And while that information may be true, it could be very specific to a certain situation or in a specific context, that sometimes without some medical background or some medical knowledge, you may not have that full picture to fully understand that information. And so, before taking everything as a warning or everything as that's going to happen to you or to me, then when you have that conversation with a trusted healthcare provider, that probably has a little bit more knowledge or a broader knowledge base to kind of explain what that information might mean and then how it might specifically apply to you.

Host: Absolutely. And I think that's such a great reminder.

Shandi Pack, PharmD: I think too just one other thing I would say is sometimes as healthcare providers when we get the calls from patients about concerns or questions, they're not very specific in what they're asking or what they're concerned about, or maybe where they're coming from, what information they may have been exposed to or read or heard. And sometimes it makes it a little bit harder to answer their questions fully. So, I think that's another piece, is just when you are communicating with your trusted provider or pharmacist, make sure you're being specific in what you're asking so they can really understand where you're coming from and provide you with the best answer.

Host: I love that. And I think a great reminder to patients is write it down, because a lot of times you get in touch with the healthcare provider and you forget what you wanted to ask. So, I think that's a really great reminder.

Shandi Pack, PharmD: Absolutely.

Host: Morgan, how can we safely store medications?

Morgan Rhodes, PharmD: If you have children in your home, the best place to keep those is in a place they can't reach, even with a, you know, a step stool or ladder. I have a three-year-old at home who tends to find those very easily. You also want to make sure that when the pharmacist fills the prescriptions that they have a childproof lid on them. If you're really concerned about someone getting into your medicines, there are also lockbox available that you can use. it is also really best to just get rid of things you don't need or that are expired just to avoid having any of that in the house. And then finally, if you have a medicine that requires refrigeration, it's important to make sure it stays adequately cold, but that doesn't freeze.

Host: Okay. Now, Morgan mentioned expired medications, and Shandi, I'd like you to elaborate a little bit about that. Is it okay to take expired medications, or can they become harmful?

Shandi Pack, PharmD: We really don't recommend taking expired medications for a variety of reasons. For a lot of medicines, is there information that says it's truly harmful or toxic or poisoned, you know, if it's a couple of months older than when you got it, not really. But what you do have to worry about is if you're taking something, you know, especially for a very important condition like an arrhythmia or abnormal heart rhythm, which could be deadly if you are not treating the right way and you're taking the medicine for that and expired, that medicine may not be as potent or effective. And so, that could increase your risk of that condition being uncontrolled. And so, that can certainly pose a health risk by not having an effective or potent medication to treat your condition that could lead to other issues. So, that's kind of the big thing, is the loss of potency and effectiveness.

The one kind of caveat to that are going to be your liquid medications and then your eye drops, ear drops, those sorts of things. So when you mix the powder to make it into like a suspension or a liquid, you see that a lot with kids' medications, but when you're mixing that, after a while, that's not really like a sterile product anymore. And so, mixing those products, and same with eye drops and ear drops, after a while, those things lose their ability to be protected from growth of bacteria. So if you're using a liquid medication, eyedrop, eardrop after its expiration or longer than you should, you're actually going to increase your risk that you're introducing bacteria into your eyes or ears or into your body. And so, that certainly could be very dangerous.

Host: So, I think the bottom line is let's not take any expired medications. A hot topic is the effects of discarded medications on wildlife and in the environment. Is it okay to flush or throw away medications that aren't being used? Morgan, what is the best way to get rid of these medications?

Morgan Rhodes, PharmD: Yeah, you brought up about the concerns for the environment. And actually, the primary way that medications get into the environment is through like human excretion, so things that, you know, are kind of put out by humans themselves after they've been metabolized. But truly, the best way to dispose of medicines is to find a drug take-back location.

RT is one of the companies that allows you to mail in medications for safe disposal. About a couple of times a year, there's a drug take back day that, you know, is normally at your kind of local hospital and local pharmacies. Well, they'll take back anything. In South Carolina, a lot of the sheriff's offices also have that. There's some websites online that you can find the nearest drug take-back location.

Generally, for flushing medications, it's not recommended as they can enter the water supply in small amounts. But medications that have a high risk for abuse or can cause harm or death from taking, like opioids, they can be flushed if there's no drug take-back location that's available to you.

The FDA has a really nice list of medicines that are safe to be flushed, in the instance that you don't have a drug take-back location available. If your medicine isn't on that list that's safe to be flushed and you still don't have a drug take-back option, you can throw that medicine in the regular garbage. But before you do that, it's recommended to mix it with something undesirable like coffee grounds or food scraps for safety of pets and children and to make sure that anyone kind of going through the trash would not be able to get into that medicine. You then should kind of put that into like another plastic bag and then put it into the regular trash. The other consideration is just making sure you're removing all your personal information before you throw that away.

Host: That's a really good tip, because I think we often forget to remove that label from our prescription bottle. And I love that point that you brought up about the FDA list, because I even didn't know that that existed. So, I appreciate you bringing that up. Shandi, what should you keep in mind if you're traveling with medications?

Shandi Pack, PharmD: I think there are a few different things to remember or to think about when you're planning for your trips. And it is going to depend on what type of travel you're doing as well. So, more simply thinking about within your state or within your country that you're just driving to, kind of that more basic type travel. You want to think about are any of your medicines required to be refrigerated. If so, make sure you have a cooler with ice packs or whatever it is that you want to use to keep them at their correct temperature.

If you're using pill bottles versus a pill organizer, you want to think about that too. Some people like to take their pill organizer because they set that out a week or two at a time and it's just easier for them. They can keep track on if they took their medication or not. And also, just thinking about too if you are taking your bottles or your pill organizer, you probably don't want to travel with your entire quantity of pills. You probably just want to take what you need for your trip. That way, if something happens, they get lost or something of that nature, then you still have some medication that you can get to at home if needed.

The other thing is thinking about traveling with medications that are not in their prescribed bottle or in their bottle with the label on them. So if you're traveling with your pill organizer or you're using some other form that maybe the label's not on there identifying what each medication is, then I recommend that you have a printed list of all your medications that are in this pill organizer and their doses and how you take them. This would be super helpful in case you get involved in an accident or something, you end up in another healthcare system and that's available. Or for some reason, there's a question about what's in your pill organizer, then you can provide the list and say, "These are all the medicines I'm taking." And it just helps you be more prepared and potentially avoid any scrutiny or concern over what might be in your pill organizer.

When you're thinking about traveling like internationally or flying, the best thing that I can say, because I certainly don't have this memorized, is check with your airline. More than likely, the airlines have some specific requirements or recommendations about how to travel. You want to think about traveling with your medications on your person, so like on your carry on or on your personal item versus in your luggage that you're checking in case something happens to that luggage. Then if you're carrying your medications with you on your person, then you're not worrying about losing that. If your flight gets delayed and your luggage goes on, then you haven't lost your medications because you have them with you.

Also, just thinking about internationally too, if there are any specific requirements for those international airports or flights about having medications labeled or requiring any specific notes from doctors about what you're taking, and that kind of goes along too with if we're using a medication that requires an injection, so like the pen needles or syringes, those are important to you. There could be some concern for those going through TSA or security. So, just making sure that you have all the documentation of what you might need to show why you're using those medications.

Host: Absolutely. And I love the idea of that list because it keeps everything super organized and everyone knows what medications you're taking and why you're taking them. I want to thank both Shandi and Morgan for joining me today on this very helpful panel discussion on prescriptions. Are there any other tips on prescriptions that either of you would like to share with the audience?

Morgan Rhodes, PharmD: The final thing I'd like to share is just making sure you're asking questions, asking questions of your doctor, asking questions of the pharmacist. A common thing I see is that patients may be taking medicine and they might even not even realize why they're taking the medicine. So, making sure you're asking questions about why you're being prescribed that medicine.

Also, making sure you're asking about cost. That's something that's really important that patients I think sometimes are afraid to ask their pharmacist or their doctor. Because medicines really only work if you're able to afford them and able to get them. So, just don't be afraid to ask about cost and ask for assistance and switching to alternative medications if it does end up being too expensive.

Shandi Pack, PharmD: Yeah. I want to definitely echo what Morgan said about the cost along with just really encouraging people not to be afraid to speak up and ask questions, display your concerns if you're concerned about certain medications. Even if your concern is based off of something that you have heard someone say or heard on TV, there's never a problem with asking or questioning if the medicine is right for you.

You know, your healthcare providers, we are people too. So, we can certainly overlook things or think we've told you something and maybe we haven't told you something. So, we want the patients to be advocates for themselves, be a part of their healthcare team and ask questions when they have them. We want them to get the information that they need to make educated decisions about their health.

Host: And I want to remind, you know, our patients out there, utilize not only your primary care health provider or your doctors, but don't forget to use your pharmacists. They are experts about medications as we saw today with both Shandi and Morgan. Thank you, ladies.

Morgan Rhodes, PharmD: Thank you so much for having us today.

Shandi Pack, PharmD: Thank you.

Host: For more information and to listen to additional episodes of Flourish, please visit prismahealth.org/flourish. This has been Flourish, a podcast brought to you by Prisma Health. I'm your host, Dr. Rania Habib, wishing you well.