Workshop 4: Drug Interactions
Workshop 4.2: Drug Interactions
|Case Scenario 1 |
|Question |Is it okay to take amoxicillin whilst taking the pill? |
| | |
|What further background |PERSON |MEDICINES |
|information do you need to | | |
|clarify the question and | | |
|minimise the risks when | | |
|advising the caller? | | |
| |Who is asking? |Medicines (name,dose,freq)? |
| |28 year old female - about herself |Amoxicillin 500mg three times a day. |
| | |Cilest. |
| |New or worsening symptoms? |How many pills left? 12 |
| |GP diagnosed a chest infection this morning. |Have you taken the antibiotic? No |
| | | |
| |Any allergies/medical conditions? |Why asking about medicines? |
| |No allergies. |Forgot to check that doctor aware I was taking the pill.|
| | | |
| | | |
|Gather the further background information BEFORE searching for information. |
|What information sources |eBNF: |
|would you use? |Some antibacterials that do not induce liver enzymes (e.g. ampicillin, doxycycline) may reduce the efficacy of |
| |combined oral contraceptives by impairing the bacterial flora responsible for recycling ethinylestradiol from the|
| |large bowel. Additional contraceptive precautions should be taken whilst taking a short course of an |
| |antibacterial drug that is not enzyme-inducing and for 7 days after stopping. If these 7 days run beyond the end |
| |of a packet the next packet should be started immediately without a break (in the case of ED tablets the inactive|
| |ones should be omitted). If the antibacterial course exceeds 3 weeks, the bacterial flora develop antibacterial |
| |resistance and additional precautions become unnecessary unless a new antibacterial is prescribed; additional |
| |precautions are also unnecessary if a woman starting a combined oral contraceptive has been on a course of |
| |antibacterial therapy for 3 weeks or more. |
| | |
| |eMC / Cilest: |
| |Irregular cycles and reduced reliability of oral contraceptives may occur when these preparations are used |
| |concomitantly with drugs such as anticonvulsants, barbiturates, antibiotics, (eg tetracyclines, ampicillin, |
| |rifampicin, etc), griseofulvin, activated charcoal and certain laxatives. |
| | |
| |NetDoctor / Cilest: |
| |Other antibiotics do not affect the breakdown of the pill by the liver. However, if you are prescribed another |
| |antibiotic medicine (eg amoxicillin, doxycycline) while taking this contraceptive, there is a very low risk that |
| |the antibiotic may make your pill less effective at preventing pregnancy. Although the risk of this is very low, |
| |the personal and ethical consequences of an unwanted pregnancy can be very serious. For this reason, it is |
| |recommended that you use an extra method of contraception (eg condoms) while you are taking the antibiotic and |
| |for seven days after finishing the course. If these seven days run beyond the end of a pill packet, a new packet |
| |should be started without a break. For more information talk to your pharmacist. |
| | |
| |If you are prescribed an antibiotic for longer than three weeks, eg for treating acne, then you don't need to use|
| |extra contraception after you have been taking that antibiotic for three weeks or longer. But, if you are then |
| |also prescribed a short course of a different antibiotic, you will need to use extra contraception again, as |
| |above. For more information talk to your pharmacist. |
| | |
| |Medicines Complete - Stockley: |
| |The oral contraceptive / penicillin interaction is inadequately established and controversial. The total number |
| |of failures is extremely small. However, the personal and ethical consequences of an unwanted pregnancy can be |
| |very serious. For this reason the general advice is that a second (barrier) method of contraception be used |
| |whilst taking the penicillin and for 7 days after finishing the course. The FPA recommend that if the 7 days run |
| |beyond the end of the packet then the new packet should be started without a pill-free break. |
| | |
| | |
|What advice would you give? |There is a risk that amoxicillin may stop the pill from working properly. |
| | |
|Or would you refer? |Advise to use a barrier method during the time that she is on the antibiotic and for 7 days following the end of |
| |the course (i.e. 14 days). |
| | |
| |As there are only 12 tablets left in the pack, start the next pack of pills straight away without the 7-day pill |
| |free period. Explain that this is safe and that she will not get the usual withdrawal bleed. |
| | |
| | |
|Further learning points |
|For questions about the contraceptive pill |
|Ask how many pills are left in the pack |
|Ask if the second medicine has already been taken. May need to assess the risk of contraceptive failure. |
Workshop 4.2: Drug Interactions
|Case Scenario 2 |
|Question |I have just been to see my doctor. He has given me some ciprofloxacin. I am taking warfarin. Is it ok to take |
| |them together? |
|What further background |PERSON |MEDICINES |
|information do you need to | | |
|clarify the question and | | |
|minimise the risks when | | |
|advising the caller? | | |
| |Who is asking? |Medicines (name,dose,freq)? |
| |61-year old female - about herself. |Warfarin 3mg once a day. |
| | |Ciprofloxacin 500mg twice a day for 1 week. |
| |New or worsening symptoms? | |
| |Doctor has diagnosed a urinary tract infection. |Why asking about medicines? |
| | |Yellow dosing book warns about taking other medicines |
| |Any allergies or medical conditions? |with warfarin. |
| |No allergies. DVT 3 months ago. | |
|Gather the further background information BEFORE searching for information. |
|What information sources |eBNF: |
|would you use? |ciprofloxacin + coumarins - potentially hazardous |
| |ciprofloxacin enhances anticoagulant effect of coumarins |
| |Change in patient's clinical condition, particularly associated with liver disease, intercurrent illness, or drug|
| |administration, necessitates more frequent testing. Major changes in diet (especially involving salads and |
| |vegetables) and in alcohol consumption may also affect anticoagulant control |
| | |
| |eMC- SPC / Ciproxin®: |
| |Prolongation of bleeding time has been reported during concomitant administration of ciprofloxacin and oral |
| |anti-coagulants. |
| |eMC- PIL / Ciproxin®: |
| |Remind your doctor if you are taking drugs that thin the blood (anticoagulants) such as warfarin |
| | |
| |NetDoctor |
| |Ciprofloxacin may enhance the anti-blood-clotting effect of anticoagulant medicines such as warfarin. As this may|
| |increase the risk of bleeding, your blood clotting time (INR) should be monitored more frequently if you are |
| |taking ciprofloxacin with an anticoagulant. |
|What advice would you give? |Ciprofloxacin can in some people enhance the effects of warfarin. This means it can make your blood too thin and |
| |increase the risk of bleeding. |
|Or would you refer? | |
| |Suggest you phone your GP. He may want to change your antibiotic or monitor your blood more closely. |
| | |
| |Signs that your blood is too thin include nosebleeds, easily bruising and blood in the urine. If these occur, |
| |speak to your GP immediately. |
|Further learning points |
|Warfarin is a narrow therapeutic range drug |
|small increases in blood level can lead to haemorrhage including stroke |
|small decreases in blood level can result in blood clots (stroke, DVT, PE) |
|Ciprofloxacin inhibits the metabolism of many medicines. |
Workshop 4.2: Drug Interactions
|Case Scenario 3 |
|Question |Is it OK to take Nurofen® with my yellow tablets? |
|What further background |PERSON |MEDICINES |
|information do you need to | | |
|clarify the question and | | |
|minimise the risks when | | |
|advising the caller? | | |
| | | |
| |Who is asking? |Medicines (name, dose, freq)? |
| |50 yr old man about himself. |Methotrexate 7.5mg weekly as 3 x 2.5mg tablets |
| | |Nurofen® Liquid Capsules |
| |New or worsening symptoms? | |
| |Have a really bad sore throat. |Why taking? |
| | |Have had Rheumatoid Arthritis for past 5 years. |
| |Any allergies or medical conditions? | |
| |No allergies. | |
|Gather the further background information BEFORE searching for information. |
|What information sources |MedicinesChest: |
|would you use? |Nurofen® Liquid Capsules soft capsule containing: |
| |Ibuprofen 200 mg |
| | |
| |eBNF: |
| |methotrexate + ibuprofen - |
| |potentially hazardous |
| |Excretion of methotrexate reduced by ibuprofen (increased risk of toxicity)—but for concomitant use in rheumatic |
| |disease see Methotrexate, section 10.1.3 |
| |Aspirin and other NSAIDs If aspirin or other NSAIDs are given concurrently the dose of methotrexate should be |
| |carefully monitored. Patients should be advised to avoid self-medication with over-the-counter aspirin or |
| |ibuprofen. |
| |Important |
| |The dose for methotrexate is a weekly dose. To avoid error with low-dose methotrexate, it is recommended that: |
| |the patient is carefully advised of the dose and frequency and the reason for taking methotrexate and any other |
| |prescribed medicine (e.g. folic acid); |
| |only one strength of methotrexate tablet (usually 2.5 mg) is prescribed and dispensed. |
| |the prescription and the dispensing label clearly show the dose and frequency of methotrexate administration; |
| |the patient is warned to report immediately the onset of any feature of blood disorders (e.g. sore throat, |
| |bruising, and mouth ulcers), liver toxicity (e.g. nausea, vomiting, abdominal discomfort, and dark urine), and |
| |respiratory effects (e.g. shortness of breath). |
| | |
| | |
| |eMC - SPC: Maxtrex® |
| |Interaction with other medicinal products and other forms of interaction |
| |Methotrexate dosage should be monitored if concomitant treatment with NSAIDs is commenced, as concomitant use of |
| |NSAIDs has been associated with fatal methotrexate toxicity. |
| | |
| |Patients should report all symptoms and signs suggestive of infection, especially sore throat. |
| |eMC – PIL: Maxtrex® |
| |Check with your doctor before taking any other medications including any you have bought without a prescription in|
| |particular: NSAIDs (non-steroidal anti-inflammatory drugs) e.g. ibuprofen, indometacin or aspirin (for pain relief|
| |or inflammation), antibiotics (chloramphenicol, penicillin, sulphonamides, co-trimoxazole, trimethoprim and |
| |tetracyclines), thiazides (a group of diuretics for fluid retention), hypoglycaemics (for lowering blood sugar |
| |levels), p-aminobenzoic acid, acritretin (treatment for psoriasis or skin disorders), diphenylhydantoins (for |
| |epilepsy), probenicid, sulphinapyrazone (used to treat gout), phenytoin (an antiepileptic), including vitamin |
| |preparations containing folic acid or its derivatives, and non-prescription remedies, or receiving the anaesthetic|
| |gas nitrous oxide. |
| | |
| |Methotrexate can make you more likely to catch infections. If you think you have an infection, a sore throat, |
| |fever, chills, or achiness during treatment you should tell your doctor immediately. |
| | |
| |NetDoctor: |
| |Salicylate medicines such as aspirin, and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, |
| |ketoprofen and diclofenac can reduce the removal of methotrexate from the body. This can cause levels of |
| |methotrexate can build up in the blood, increasing the risk of side effects. For this reason, people taking |
| |methotrexate should avoid buying aspirin or NSAIDs such as ibuprofen to take as painkillers or |
| |anti-inflammatories. These medicines should only be used on the advice of the doctor who is monitoring your |
| |methotrexate treatment, so that changes can be made to your methotrexate dose if necessary. |
| | |
| |This medicine may rarely cause a decrease in the normal amounts of blood cells in the blood. For this reason you |
| |should consult your doctor immediately if you experience any of the following symptoms: unexplained bruising or |
| |bleeding, purple spots, sore throat, mouth ulcers, high temperature (fever), feeling tired or general illness. |
| |Your doctor may want to take a blood test to check your blood cells. |
|What advice would you give? |Patients taking Methotrexate should only be taken ibuprofen under the supervision of their doctor. |
|Or would you refer? | |
| |Sore throat symptoms may be a sign of a serious blood disorder. The patient should see the doctor as soon as |
| |possible for tests. |
|Further learning points |
|Methotrexate is a type of medicine called a cytotoxic antimetabolite. Methotrexate is used to treat three different conditions: rheumatoid |
|arthritis, psoriasis and cancer of various types. |
| |
|Treatment with methotrexate is usually only initiated by hospital specialists, and regular blood tests are needed to monitor for potential side|
|effects. |
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