Drug Interactions: Their Impact on AMD and Health

BrightFocus Foundation
Drug Interactions: Their Impact on AMD and Health
December 21, 2016
Transcript of Teleconference with Dr. Gayatri S. Reilly
1:00–2:00 p.m. EDT

Please note: This Chat was edited for clarity and brevity.

MICHAEL BUCKLEY: Hello, I am Michael Buckley, and I’ll be your host for today’s BrightFocus Chat. Today’s topic is “Drug Interactions: Their Impact on AMD and Your Health.” We would like to welcome our speaker today. Joining us is a veteran guest of the BrightFocus Chats, Dr. Gayatri S. Reilly from the Retina Group of Washington, a large practice in the Washington, D.C. area that specializes in retinal conditions such as macular degeneration. In addition to treating patients, Dr. Reilly has dedicated her career to research in ophthalmology.

If today is your first time joining for a BrightFocus Chat, we want to welcome you. Let me take a moment to tell you about BrightFocus and what we will do today. The BrightFocus Foundation is a nonprofit, and it funds some of the top researchers in the world. We support scientists who are trying to find cures for macular degeneration, glaucoma, and Alzheimer’s. We share the latest news from these scientists with families impacted by these diseases. We have a number of free publications and plenty of materials on our website, www.BrightFocus.org, that offer tips for living with diseases like macular degeneration. Today’s BrightFocus Chat is another way that we share this information.

While we are on the topic of materials that we share for free, right after the New Year we are going to have a new free publication called Healthy Living and Macular Degeneration: Tips to Protect Your Sight. Again, that is Healthy Living and Macular Degeneration: Tips to Protect Your Sight. It will be available right after the New Year.
Let’s turn to our guest, Dr. Gayatri Reilly. Dr. Reilly, thank you so much for joining us today.

DR. REILLY: I am glad to be back again. I am excited to talk for the next half-hour or 45 minutes and hopefully answer as many questions as I can.

MICHAEL BUCKLEY: Great. Let’s start with a big picture question, setting the table for today’s discussion, the topic of drug interactions. I was wondering if you could tell us how much of a concern this should be for people. And if it is a concern, how do you think people should best address the topic of drug interactions, particularly as it relates to AMD?

DR. REILLY: I think we know that as patients are getting older and older, they are on a variety of medications prescribed by their internist, and then we have subspecialists also prescribing medications. One thing we know is that somewhere between 5 and 10 percent of hospitalizations for patients over the age of 65 are due to adverse effects from drugs, and even if they are appropriately prescribed, as we get older certain side effects become more pronounced. When you have an additive amount of these adverse events it can certainly affect patients as they get older and cause hospitalizations for multiple days—not just an emergency room visit. It is a concern that we all have to make sure that we are not prescribing drugs that have significant adverse events, but importantly, that they don’t interact with other medications that the patients are already taking. That is where, in particular, we ask patients to bring a list of medications so that it doesn’t matter if you are visiting your eye doctor or if you are visiting any physician, because all of the medications that you take are so, so important to be reviewed.

MICHAEL BUCKLEY: That is a great point. A shockingly high number—5 to 10 percent of hospitalizations—and I really think it underscores how important it is to take it seriously. I want to follow up on your point about bringing a list of prescriptions. I think for a lot of people the names of prescriptions are very long and hard to spell and hard to pronounce. Any tips for what people should do when they find the names a little complicated?

DR. REILLY: Sure. That is where we have a couple of options. Number one is your pharmacist. The pharmacist is able to print out the name of the medication, the common adverse effects of these medications, and they can put this all on a single sheet of paper for the patients. If the patient does have some family who can help them out with making a list—the important thing about these medications is that it isn’t just prescribed medications. We all know that there are also over-the-counter (OTC) medications and herbal supplements, and other things that you don’t need a prescription for that can also cause some adverse effects.

If we can get family involved, that is ideal to help, because these names are hard for physicians as well. It is a matter of being able to transfer from the bottle, but the pharmacist can certainly help as well. They really are looking out for the patients and want to do everything that they can, and we will talk a little bit more about that when we talk about low vision as well.

MICHAEL BUCKLEY: I appreciate that. I want to start off with that point you made about OTC medicines. You hear people who sometimes take baby aspirin for AMD or regular aspirin—maybe not for AMD but they take that parallel. Are there concerns that people should have about aspirin, Advil, Tylenol, that family?

DR. REILLY: Yeah, absolutely. One thing we don’t alert patients to is that in addition to aspirin, when you’re taking ibuprofen, Advil, these OTC medications have a blood-thinning effect. That can be an important thing to mention, if you know you’re taking 600 mg of ibuprofen every day, as it can impact your blood clotting ability. But in general, aspirin and all blood thinners—such as Motrin or newer medications like Xarelto—all these medications do the same thing, which is thin the blood.

When it comes to macular degeneration it’s a little bit tricky, since there are two kinds of macular degeneration—dry and wet. One thing that characterizes wet macular degeneration is bleeding, so intuitively there’s a concern: If you are bleeding in the eye and taking a blood thinner, would that cause more bleeding? We’ve had a lot of research done on this; most of the conclusions have been that when you are taking the aspirin or another blood thinner to decrease risk of overall mortality—trying to reduce cardiovascular disease like heart attack and stroke as much as 25 percent by just taking aspirin—the overall risk of having increased bleeding from macular degeneration is very low. When comparing it to patients who aren’t taking aspirin at all there is probably a slight risk of having more bleeding, but when you’re taking into account the overall risks of heart attacks and strokes and overall survival, most retina specialists feel comfortable with their patients continuing on an aspirin or another blood thinner.

I’ve had patients who have come into the office and taken themselves off of aspirin without discussing it with myself or their primary care physician, and that’s where we can run into some problems, because almost everyone over a certain age is on aspirin, there is research and reasons why they are on that medication. For us, as retina specialists and taking care of the overall patient’s health, most of us are very comfortable allowing patients to continue using aspirin even if there is a slight risk of bleeding.

MICHAEL BUCKLEY: I’m glad you mentioned that. It certainly underscores the importance of not freelancing and not reaching conclusions that should be best discussed with a professional. Staying on that theme of the blood thinners and prescription medications, I would assume a lot of your patients are on statins, such as Lipitor, to reduce cholesterol. Are there concerns that patients and doctors should discuss under those conditions?

DR. REILLY: Most interestingly, there was a recent publication in 2015 that looked at high-dose statins, higher dosage that what is most typically given to patients for their cholesterol, and they have found that in dry macular degeneration there may be a benefit from it. I certainly have had many patients on statins—for me, I try to work with a primary care physician—I think overall, there’s little concern with macular degeneration and using statins. Overall, I don’t recommend changing dosages for dry macular degeneration yet, but there is a potential that certain dosages of statins might be helpful for dry macular degeneration.

MICHAEL BUCKLEY: That’s very interesting. BrightFocus supports a number of researchers that are going in that area. It really is interesting to see possible connections.

Moving on to blood pressure medication, I’m assuming it’s very common among your patients. Are there any impacts from blood pressure medications on AMD?

DR. REILLY: Overall, I recommend continuing all blood pressure medications that the primary care physician has started them on, because—not just in macular degeneration—the overall blood pressure control is so vital for eye health in general. There really haven’t been any concerns with blood pressure medications for any negative affects specifically for macular degeneration, but—similar to the statins—if anything, having well-controlled cardiovascular status is really important for your overall eye health.

MICHAEL BUCKLEY: I certainly agree. How about prednisone or other steroids?

DR. REILLY: Steroids are really interesting for the eye. Steroids have such an overall effect on the immune system that for each person, there is a little bit of a variety of an affect that we see. We don’t see any direct effects of prednisone to both wet and dry macular degeneration, but prednisone can cause a different condition that can affect your macula. This is where discussing which medications have been added or changed with your ophthalmologist is really important, because sometimes you don’t even recognize that you might be on a medication that can do something else. There’s a separate condition in the eye that can sometimes look similar to macular degeneration that can be exacerbated with any oral steroid, such as prednisone. Sometimes you don’t even realize you’re on a steroid, as it can come in a form of an inhaler in your asthma treatment or a hydrocortisone cream, as well. For macular degeneration, there is usually not much of a concern for steroids.

MICHAEL BUCKLEY: It’s interesting—you mentioned that steroids can be found in an inhaler or cream, maybe things that people don’t know to look for it. People maybe too narrowly define what a prescription is, that it’s something from the pharmacy with the label on it. In terms of vitamins or any other supplements, are those things that people should share with their eye doctor?

DR. REILLY: Vitamins always get tricky because they are available over the counter, and you could be taking what you think can be helpful—such as St. John’s wort or Ginkgo biloba extract or medicinal herbs—which also can interact with your other medications. We know for dry macular degeneration, the vitamins that we recommend are vitamin C, vitamin E, zinc, copper, and lutein. You have to keep in mind how much of each vitamin you’re getting. All of those vitamins that we find in the AREDS2 formula have been assessed to be safe when you’re taking a daily multivitamin, but if you’re taking an extra vitamin for vitamin C, then you’re not only getting your multivitamin but you’re also getting your AREDS vitamin C plus you’re taking an extra supplement of vitamin C. So all of these things have to always be discussed and, if possible, written down in terms of dosages to make sure patients aren’t getting too much or have potential interactions with other medications.

MICHAEL BUCKLEY: Sure. I would think that with age-related diseases, you probably encounter patients that have arthritis or related conditions. How does that impact any medicines that they may have for AMD or just the overall course of where their AMD goes?

DR. REILLY: Arthritis is hard. We’ve heard about so many new medications that have been able to better treat conditions like rheumatoid arthritis. And there are medications that, like steroids, can affect your immune system (such as hydroxychloroquine) and medications like plaquenil (which is similar to hydroxychloroquine) that can also affect your macula. The key difference is that, in general, there is no direct correlation between these medications in either dry macular degeneration or wet macular degeneration, but we know that—similar to what I was explaining with the steroids—medications like plaquenil or hydroxychloroquine can cause other macular problems, as well. It is the same idea of discussing how long you’ve been on a medication, what’s the dosage, and so on.

MICHAEL BUCKLEY: Great. We have our first audience question that I want to share with you. Arlene from New York understands that there is both vitamin C and vitamin E in the AREDS formula that you mentioned. She is wondering if there are any negative effects from taking a much larger amount of vitamin C or vitamin E?

DR. REILLY: That is a great concern, and these are questions that almost every day patients have, and I am really glad that you asked that question. The thing is, the studies that looked at these vitamins, these involved more than 4,000 patients taking these medications, and the precise dosages of all of these medications have been very precisely tested to make sure that not only is it beneficial for the eye, but it’s not causing any harmful effects to the overall body.

The most common concern that we get is with both zinc and vitamin E. A few years back, there was a concern about vitamin E—and it’s sort of been now, disproven in the literature—but there was concern that having too much vitamin E could be harmful to your cardiovascular system. And the concern of getting 400 international units (IU) of it in the AREDS plus a multivitamin, like I said, this has really long been disproven: these are still safe and recommended dosages. Zinc was decreased in the AREDS2 formula. Not necessarily because it was harmful, but it does tend to cause a little bit more gastrointestinal (GI) upset—you can get some indigestion and some stomach discomfort from having too much zinc. They were able to find in the AREDS2 study that lowering the dose of zinc still allowed for having its beneficial effects for the macular degeneration without having quite as much toleration issues.

MICHAEL BUCKLEY: That is good to know. Dr. Reilly, we have a few questions about chemotherapy. One person is wondering if chemotherapy can make someone’s AMD worsen, and another person is wondering if chemotherapy can cause the onset of AMD or other vision problems. Would you care to comment on those?

DR. REILLY: Sure. With all of the chemotherapy medications that have been out so far, nothing has been found to cause macular degeneration—whether it is the dry form or the wet form. Patients can certainly be reassured of that. There are a lot of side effects to the chemotherapy medications, and a lot of them do involve blurred vision and some decreased vision and can affect the optic nerve of the eye. These are really important medications to discuss. Fortunately, when it comes to macular degeneration, none of the chemotherapy agents are considered to be concerning or harmful for macular degeneration.

MICHAEL BUCKLEY: That is good to know. I am sure that people have many concerns during that time, so that is very helpful. We have a question from Anita from Maryland who wants to go back to the point you made about zinc a moment ago, and she is wondering if she could take a lesser amount of zinc if she gets the zinc through other supplements. This is relating to the point you made a minute or two ago about the AREDS2.

DR. REILLY: So the question is, if you take additional zinc supplements?

MICHAEL BUCKLEY: Yes.

DR. REILLY: Well, you know it’s one of those things where you already have a lesser amount of zinc, it’s down to 25 mg of zinc in the AREDS2 formula. There are some formulations of AREDS2 vitamins that come without zinc, but the original formulation had 80 mg. So you have quite an amount of room for being able to tolerate it, assuming that you don’t have too much GI discomfort. The difference in the AREDS vitamins with the zinc is that you also have copper inside of it. The copper actually isn’t meant for any protective or any benefits for the macular degeneration, but it’s to help prevent any anemia that you can get by taking zinc supplementation. The one thing I would recommend being careful of is that if you are taking zinc in a different formulation that you are getting copper to prevent anemia.

MICHAEL BUCKLEY: Yes, that’s a good recommendation. We’ve got a couple of questions about day-to-day food and drinks, such as grapefruit juice or other types of juices. Any concerns people should have related to their AMD?

DR. REILLY: No. I think that most of the time when it comes to supplements and drinks and things, everything is within moderation; as long as you aren’t having excessive quantities of any of these drinks, there really isn’t much to be concerned about.

MICHAEL BUCKLEY: And would that carry over for something like an athletic drink, like a Gatorade or a PowerAde, that people who exercise frequently would want to have?

DR. REILLY: Yeah, and when it comes to drinks like PowerAde and Gatorade, there is an implication that you are devoid of electrolytes and are trying to replenish those electrolytes. It is the same caution—you want to make sure you aren’t using that just as your replacement for water, because you really are trying to replace electrolytes lost on sweat during that exercise. If you aren’t exercising and are just drinking a whole lot of Gatorade or PowerAde, besides having a lot of sugar, you are also having extra electrolytes that you have not lost along the way. Once again, same idea of having everything in moderation is reasonable.

MICHAEL BUCKLEY: Yes, and in terms of moderation it gets to a very timely question at the holidays, and that is alcohol. How should people manage alcohol in relation to their AMD and medicines they may be on for AMD?

DR. REILLY: For AMD, in moderation, there are no harmful effects of alcohol. There are other prescribed medications that may have interactions with alcohol, so while from a macular degeneration and AREDS vitamins point of view there is not any concern for a moderate amount of alcohol or liquor, they certainly should be mentioning it to their primary care physicians to make sure that it does not cause problems with any of the other medications they are taking.

MICHAEL BUCKLEY: Yes, I appreciate that. It underscores the importance of being honest when a physician asks about alcohol or tobacco use.

DR. REILLY: Absolutely. These questions are not designed to be too personal or anything. It is literally designed for the patient’s safety.
MICHAEL BUCKLEY: That is good to know. I’m sure for some that can be a slightly uncomfortable moment in a conversation.

We have a question about some of the complications of AMD, more in terms of things like falling. Are there medications that might increase the complications such as falls?

DR. REILLY: There are definitely medications, especially with the elderly, that increase your risk of falling. It can be as simple as hypoglycemic medications or medications that you are taking because you are diabetic and are trying to lower your blood glucose, and if that gets too low it can certainly be a concern for falls. Other medications, such as blood pressure medications—if you are too hypotensive and your blood pressure it too low, there can be a concern for falls. Some medications that are prescribed for nausea are very commonly used but can also affect your overall send of balance and things. In general for macular degeneration, any falls or trauma can certainly be a risk for bleeding, but you want to make sure that you don’t limit the ability to function by going through every single medication. But a lot of these medications do interact with one another to cause dizziness and may cause you to become off-balance.

MICHAEL BUCKLEY: I’m sure that has got to be a real challenge when there already is vision loss. We’ve got a question from Janet in California. She has Grave’s disease and also takes medicines for asthma. Are there any interaction issues she should be concerned about?

DR. REILLY: No. As I mentioned, sometimes in asthma medications there can be a little bit of a steroid medication, but for macular degeneration, neither one of those medications for either your thyroid or in general for asthma should be any concern. Macular degeneration is—fortunately, now we’ve had such a large amount of patients with it and on a variety of different medications that as long as nothing is changing, I wouldn’t be overly concerned.

MICHAEL BUCKLEY: I appreciate that. We have a question from Ohio. Someone is wondering about artificial sweeteners. They are wondering if that can affect your eye health.

DR. REILLY: Artificial sweeteners are difficult because there is so much that we are still learning about the effects that they can cause systemically. In general, for eye health and macular degeneration there is no concern that I am aware of or that I’ve come across. But in general, the artificial sweeteners we know have a very—somewhat confusing effect on insulin in the body. For diabetics it certainly is a concern, because it alters how your body is perceiving sugar. For macular degeneration, it should not be any concern, but for patients who have diabetes it is something to certainly follow with your primary care physician.

MICHAEL BUCKLEY: We have time for a few more questions. We have a caller wondering about dry eye. Any type of lubricants for dry eye? How does that impact AMD, if at all?

DR. REILLY: Well, it doesn’t directly impact AMD at all, which is good. But we know that when you are suffering from dry eye it makes your vision even worse, and when you are seeing worse that is when it can certainly predispose you to having other problems, like falls and other low vision issues. There is no direct impact. In general, especially as we enter the winter season, the air is very dry, and very commonly dry eyes are at their worst right now and over the next couple of months. Lubricating the eye with artificial tears is certainly the way to go, but there is no direct impact on macular degeneration regarding dry eye.

MICHAEL BUCKLEY: That is good to know. Another question we have is, you discussed the importance of sharing the names and dosages of your prescriptions. What about for people who may find the print on the prescription labels a little small or it smudges or fades over time? Any suggestions for how people can best manage that?

DR. REILLY: Yes, definitely. That is where your pharmacist can be a huge help. As I mentioned earlier, the pharmacist doesn’t have to print out the medication with that tiny, tiny print that you can barely see even if you can see very well. They can make these labels into large print. They can make it much more legible and can print out a completely separate sheet that has the name of the medication and the dosage on it. There are a lot of things that the pharmacist can help you with.

Also, you can try to identify each medication by color coding, and family can certainly help with doing this sort of thing. Having a good list of all of your medications—and I’ve had patients who bring literally exactly what the pharmacist prints out. Granted, it has every adverse event possible, but it has the name of the medication, the dosage of the medication, and the most common adverse events, all just on one piece of paper. It also will say if they are using it twice a day, etc.—and they have a page for every single medication. That is just terrific to be able to know just how often someone is taking something. For both patients and physicians, it is very helpful.

MICHAEL BUCKLEY: I’m glad you said that. To me it reinforces the importance of what you said earlier about really good communication with your pharmacist. I know a lot of us—when you are at the pharmacy counter it can be hot or crowded, and you feel bad about backing up the line, or whatever, but I think it really shows the importance of taking the steps that you need to get the information that you need. I really appreciate you sharing and the color coding is a wonderful suggestion. We will be sure to share that with people here.

I would like to do a couple of housekeeping items and then turn to Dr. Reilly for some concluding thoughts. First, as I mentioned earlier, right after the holidays we will have a brand new free publication called Healthy Living and Macular Degeneration: Tips to Protect Your Sight. It is a great resource that gets into a lot of these day-to-day life questions as far as protecting your sight.

Dr. Reilly, I would like to just conclude today’s call. I think it has been really helpful, and you’ve provided very good, hands-on tips for people as they interact with their physicians and their pharmacists. I just want to conclude with the question, in your years of practice is there a big picture bit of advice that you would like to pass on to patients about protecting their sight or how to make their interactions with their physicians most effective? Any big picture advice from your career perspective?

DR. REILLY: I have noticed that there has been a shift for the positive. It is really encouraging, the direction that things have gone, in terms of improving communications between physicians, amongst physicians, and between physicians and patients.

I think the most important thing is that patients are their best advocates, and having information like we’ve been talking about over the past half an hour is super important, so that you can ask your physician and your eye doctor, “Am I on any medications that might, potentially be a problem?” Or, “I have concerns about being on an aspirin, and I have macular degeneration. Is this concern valid?”

No matter how rushed it might seem the physician may be, these are the things that you should ask, because you are your best advocate. I feel like that has improved so much over the past few years. We’ve seen that with electronic medical records and things; the communication is getting there. We still have a lot more ways to go with making sure everybody understands which medications everybody is on and what concerns they have, but it is all headed in the right direction.

I really think that, more than anything, all of this information is empowering and allows you to ask the right questions so that you have a conversation for at least the 5 minutes of your doctor’s time to be guided and well educated, trying to get the most out of that visit. Otherwise, it’s hard from our side of things as physicians to know what your concerns may be. It has been a really positive shift where patients bring in a list of questions. It’s hard when you are on the spot to think about everything that you have concerns about. When you have a list of two or three questions with you, then you know that you have them and they get answered and then you can move on from it. Having that organization and recognizing that you need to know these things and understand why you are concerned about being on a statin and macular degeneration, and the like. It’s been fortunate for me that I’ve gotten to see things improve over the past few years, and hopefully they will continue that way.

MICHAEL BUCKLEY: That is great advice, and I think it shows the importance of taking responsibility for your health. And, for better or worse, there is no shortage of information out there nowadays, but to do your homework and to prepare is really helpful. I definitely appreciate your point about the partnership with the pharmacist and going to the pharmacy counter prepared and comfortable speaking up for what you need. This has been fantastic, and I want to thank you very much Dr. Reilly for answering our questions today.

This concludes the Chat. I want to thank everyone for being with us today and throughout the year. If there is anything we can do to help you feel free to call us any time at (800) 437-2423, and you can find us on the internet at www.BrightFocus.org, and a lot of our materials are there. Dr. Reilly, thank you for joining us today, and on behalf of all of us at BrightFocus, thanks so much for being helpful. We wish you the best of the holiday season.

DR. REILLY: Thanks for having me. I enjoyed it, and hopefully I will be back again. Thank you.

MICHAEL BUCKLEY: Look forward to that. Thank you. This concludes today’s BrightFocus Chat. Thanks!

BrightFocus Foundation: 1-800-437-2423 or visit us at www.BrightFocus.org. Available resources include:

• Information on research funded by BrightFocus
• Amsler grid
• Macular Degeneration: Essential Facts
• Safety and the Older Driver
• The Top Five Questions to Ask Your Eye Doctor
• Clinical Trials: Your Questions Answered
• Healthy Living and Macular Degeneration: Tips to Protect Your Sight

The information provided in this transcription is a public service of BrightFocus Foundation and is not intended to constitute medical advice. Please consult your physician for personalized medical, dietary, and/or exercise advice. Any medications or supplements should be taken only under medical supervision. BrightFocus Foundation does not endorse any medical products or therapies.