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MIXED REACTIONS

In the Booth household, indigestion was terrifying. It seemed that every time Frank had indigestion, his heart would act crazy. Instead of beating, it bounced, sometimes at rates of 190 a minute. Indigestion meant fibrillation - and hospitalization.

The Booth family had theories that gas put distress on his heart, but they didn't know why. At the first sign of gastric distress, he headed for the medicine chest and the Rolaids or Tums, to knock it back before it got started.It never seemed to work.

A year ago, his daughter stumbled on an article outlining the effect of antacids on heart medication.

People on Lanoxin, the medication Booth used to regulate his heartbeat, she read, should never take antacids. It renders the medication ineffective.

It wasn't the indigestion. It was the cure.

Like thousands of Americans, they hadn't paid enough attention to the warning label on the "harmless" over-the-counter drug.

Drug interactions are common; most people know certain medications can't be mixed. And they wouldn't dream of taking alcohol with certain prescriptions because of the complications that can occur.

What isn't well-recognized is the effect over-the-counter medications can have when combined with prescriptions, alcohol or sometimes even with each other.

In the United States, more than 100,000 prescription drugs are available. Three times that many nonprescription remedies exist, according to pharmacist Laura Shane-McWhorter, assistant professor at the University of Utah College of Pharmacy and an active pharmacist.

It's hard for anyone - even well-trained pharmacists - to see all the possible interactions. It's almost impossible for the average consumer, who may believe that because something is not prescription it's completely safe.

We are casual about over-the-counter remedies, she said. People tend to adjust doses to suit themselves. If a little is good, more will be better. And they don't always read or pay attention to the warnings on the label.

The results can be uncomfortable - or even life -threatening.

"There are probably times where (an interaction) is not recognized as a cause of problems," said Dr. Russ Toronto, a Salt Lake sports medicine physician. People who go into the emergency room with heart arrhythmia or people with high blood pressure, for example, may not cite the cause; they may not realize the nonprescription remedy they took could have helped prompt the medical crisis because they didn't realize it was a medication.

Drug interactions can pose a serious threat to senior citizens, the group most likely to take prescription drugs. They consume at least 40 percent of over-the-counter remedies. And during the aging process some body functions change and slow down, which also impact affect the effectiveness of medication. Accepted adult doses may be too strong for older bodies.

A congressional report, released last weekcq by the General Accounting Office, found that one-sixth of America's elderly take drugs that are not suited for older people. That can lead to hospitalization and even death.

The office estimated that 17.5 percent of 30 million Medicare recipients who live at home are taking prescription drugs that either aren't safe or duplicate other prescriptions.

It said 3 percent of all hospitalizations result from adverse drug reactions - and cost $20 million in hospital bills.

That includes falls or accidents caused by medications. An estimated 32,000 elderly suffer hip fractures each year due to those falls. And there are an estimated 16,000 auto accidents involving elderly drivers suffering adverse reactions.

The elderly are also more apt to take incorrect dosages.

Besides that, elderly consumers find it almost impossible to read the tiny warning labeling on products.

So why do warning labels use such tiny lettering to cram information onto a small package?

"They (manufacturers) have to have all that stuff on the box to cover themselves liability -wise," Toronto said.

Adds Chuck VanGorder, a pharmacist at LDS Hospital: "The information that the FDA has required manufacturers to put on OTC preparations is quite extensive, so they've really compressed it to small print. And yes, it may be difficult for a consumer to get all the information they need with that small a labeling."

Do dangerous interactions occur?

"Sure, all the time," said Barbara Crouch, director of the Utah Poison Control Center. "I can tell you that therapeutic errors are common causes of poison" where Mom and Dad each give a child a dose of medication. The results can be minor, like dry mouth, or much more serious.

She said the Poison Control Center frequently gets calls on cough and cold preparations and similar reports of problems abound in medical journals. They take calls where parents misuse the remedies by giving it to children who are too young to be using it or guessing on the dosages."

The list of potential interactions is long and complicated. And a look at the bottles on common nonprescription drugs seems to indicate that almost everything has the potential to be dangerous when combined with something.

"All the antihistamines that you buy over the counter for colds and hay fever and those kinds of things can have some side effects or interactions with other medications," said Toronto.

Sudafed, a common decongestant, "can cause a stimulant type effect that can increase blood pressure. And so people with high blood pressure who are taking other medications have to be careful about that effect."

Other decongestants with antihistamines in them - there are "tons" of them, said Shane-McWhorter - can cause interactions with prescription drugs that have similar side effects if people aren't aware of it. It "It can cause sleepiness, drowsiness, disorientation, confusion; it can affect blood pressure; it can cause urinary retention, constipation."

If a man has a prostate problem - and enlarged prostates are common in men over 50 - antihistamines exacerbate it, she said. "They can do two things. First they dry up body secretions so you can't urinate. Then you get a urinary tract infection.

"In the elderly, they have another effect. Anything in that group has an effect on the receptors in the brain. They can cause a lot of confusion. But again, no one considers it could be that. Patients themselves say they're not taking anything."

When someone who is elderly seems confused, there may be a tendency to blame it on the aging process. At least some of the time, said Shane-McWhorter, drug interactions are to blame. And the solution would be simple if people would learn to talk to each other.

People who are taking heart medications need to be careful with over-the-counter cold remedies. Heart medications have side effects that may be complicated by the stimulant effect of the Suda-fed-type remedies, Toronto said.

Asprin and ibuprofen

Aspirin and ibuprofen, two of the most common remedies, are fraught with danger if they aren't used carefully. Both thin the blood, so when used with blood-thinners or other medicines that have that effect, they can cause serious bleeding. (Studies have recommended that some people take an aspirin a day for its blood-thinning properties; ironically, it can also cause serious damage.)

"A lot of products contain aspirin - just not well-labeled on the bottle itself. We instruct our patients to read labels carefully and give specific instructions about what to avoid when taking Cou-madin and other things," Van-Gorder said.

All pharmacists mention Coumadin - a potent and commonly used blood thinner - when discussing interactions. Combined with aspirin, ibuprofen, even Pepto Bismol (which contains an aspirin form called bismol salicylate), bleeding and bruising can become uncontrollable.

Even common foods can interact with some medications. Charlene Hayes takes Coumadin since she had heart surgery. Now she has to restrict her salad intake. The vitamin K found in the leafy vegetables like lettuce increases the effectiveness of the blood thinner, which she needs to prevent blood clots.

As for both prescription and nonprescription medications, one can inhibit the metabolism of the other - or of vitamins and minerals. When substances rich in potassium, for instance, are thrown in, problems may result.

FDA

Dimetapp used to be a prescription drug; so did Pepcid AC, which was prescribed to treat ulcers and has been reformulated as an antacid.

"As a pharmacist, what I'm concerned about are the prescription medications going to over-the-counter status. Most of these medications have proven their efficacy in prescription strengths and under a doctor's care. But when they go to OTC status, they have to have a different indication," said Van-Gorder.

He uses Pepcid AC as an example. "The concern is that people will attempt to self-medicate a potentially serious condition with an OTC medication and not seek appropriate medical advice."

At least 25 prescription drugs are slated for OTC status and are being reviewed by the FDA.

Seldane was "that close" to becoming over-the-counter. But its serious interactions with erythromycin, which is a commonly prescribed antibiotic, caused the FDA to reconsider.

It's hard to predict how a medication - prescription or not - will affect everyone. The FDA has to weigh risks.

"As I see the results, I become more convinced what works for one won't work for another. Take Darvon," said Mardy Jolley, part owner of Jolley's Corner pharmacy. "It makes some people hyper; some people sleep. How do you regulate it? That's the dilemma the FDA faces."

Natural drugs

If prescription and nonprescription medications both pose some dangers, what about vitamins and food supplements?

"There's a lot of natural products being distributed in Utah, an incredible amount," said Van-Gorder. "And since the labeling on these medications is pretty vague," it's important for people to know what they're taking and its possible effect.

Take natural herb products. "There are several references available that actually indicate what effects these individual drugs and natural products have. The problem is, we don't know how much they're getting from batch to batch, and the rules for distribution of these drugs are not as stringent certainly as medication that would be dispensed by prescription."

VanGorder doesn't counsel people not to take natural remedies. "I'm just saying it's not very wise to take them not knowing what you're taking." People should be careful with natural supplements, especially if they're taking prescription or OTC medications.

Some herbs and other naturopathic remedies are similar to drugs that cause increased blood pressure and decrease nasal congestion. This can aggravate blood pressure medication.

"With a lot of health-food store products, we can't identify a lot of the ingredients," said Shane-McWhorter.

"People forget that medication came from herbs in the very beginning," said Toronto. "A lot of herbs have potent medicines in them, and in those vitamin and `energy capsule' kind of thing there are stimulants that if taken in too great a dose can be dangerous. Or they can react dangerously with medication."

He urged extra caution with supplements that promise to boost energy.

"Those are the ones that have potentially dangerous chemicals in them, if they're mixed with other stimulant-type medication."

When Shane-McWhorter worked in a renal clinic with children several years ago, she saw firsthand that natural products could be dangerous. Many of the children were critical renal patients who were on antirejection drugs following kidney transplants.

The medical staff found that some of them had high blood pressure they couldn't account for. "It turned out that when we couldn't explain why the blood pressure wasn't controlled, we'd find out the mom had put the child on products (made by a now-defunct company) that were touted as natural and lauded for cleaning out the body."

There is no regulation of the food supplement industry, although it's an issue that periodically comes up in Congress.

Natural treatments pose another danger: They may fool the patient into thinking he's getting treatment when he's not getting anything effective. "This could threaten life, in cases where there's a serious medical condition," Toronto said.

Multiple vitamins even pose a danger. "If a patient has a normal diet, there's not much reason to take supplements unless a doctor has a specific reason to," said VanGorder. "An exception to this may be calcium supplements for pregnant women or after menopause; or iron supplements in the case of pregnancy or under the advice of a physician - or patients with wasting diseases such as lymphomas, cancers or those undergoing dialysis. These patient groups would often require additional supplementation other than what they can get in their food."

Taking a single one-a-day multiple vitamin daily won't hurt, he said. But it's possible to take too much. "Certainly vitamins, especially the fat-soluble vitamins, could be toxic in a higher dose because the body retains it." Vitamins D, E and K are fat soluble.

Water-soluble vitamins, such as vitamin C, aren't retained effectively, so larger doses generally don't hurt, he said, "unless the patient is taking medications that can react with vitamin C."

Right can be wrong

"Sometimes we have what we call a synergistic reaction," said Joel Jolley, founder and retired pharmacist at Jolley's Corner Pharmacy, 902 E. 900 South. One medication might be good and another one good, but taken together the properties are disproportionately increased, resulting in grogginess or other undesirable effects.

Two doctors might be prescribing for the same patient. If they don't communicate with each other, they won't be aware of possible drug interactions. "That's one of our biggest problems," he said.

Human nature

Try loitering in the remedy section of a store and you can learn a lot about human nature. For example, people don't ask questions about OTCs.

An informal two-hour survey showed that people may check the active ingredients to make sure they're getting the same contents when they buy the cheaper, generic formula. But they almost never read the warning label.

Why not?

"If it wasn't safe, it wouldn't be over-the-counter," a 20-something male shrugged as he threw his cold remedy into a shopping cart.

Mardy Jolley finds peril in that casual approach. "It's dangerous. You should ask the pharmacist, `What can I take if I have high blood pressure?' "

"Everyone out there should be talking to a pharmacist," said Shane-McWhorter. "The consumer should make a push for having someone there to talk to. The role of a pharmacist is such that it has gotten out of hand in terms of retail. What consumers want is McDonald's: Get me my prescription as fast as you can. They don't really understand. We have sort of let that happen to us; we've let management do it.

"We should be pushing for someone to ask questions and guide them."

Computers have made life easier for pharmacists - and safer for their customers.

Some insurance companies and pharmacies are linked into data bases that flash a warning on the screen if a patient is taking medications that have a bad interaction.

Many pharmacies routinely run off a printout of instructions and warnings when filling a prescription. It's more complete than a warning label and a lot easier to read.

But it doesn't help much with over-the-counter medications if the customer doesn't ask any questions.

In fact, many customers not only don't ask questions - they get mad if the pharmacist offers advice on nonprescription remedies.