Expert: Dr. Ravindra Bhaskar Ghooi - 8/24/2007

Question
QUESTION: Hi!  My mother, age 54, is on the following meds for various conditions.  Would you review the following list & tell me of any interactions to watch out for?  (I'm particularly concerned about warfarin interactions.)

Warfarin (Coumadin)          2.5 mg / qd 4 days
         5 mg / qd 3 days
Metoprolol Succinate (Toprol XL)  100 mg / bid
Lansoprazole (Prevacid)          30 mg / qd
Bumetanide  (Bumex)          2 mg / bid
Potassium Chloride (K-dur)         20 mg / bid
Allopurinol          100 mg / bid
Prednisone          10 mg / qd
Paroxetine HCL (Paxil)          10 mg / qd
Levothyroxine sodium (Levoxyl)   .175 mg / qd
Amlodipine (Norvasc)          5 mg / qd
Simvastatin (Zocor)          80 mg / qd
Aspirin          81 mg / qd
Fentanyl patch (Duragesic)        100 mcg/ hr

She also takes the following meds on an as needed basis:

Acetaminophen/oxycodone 5/325  (Percocet)
Methocarbamol (Robaxin)   750
Metolazone (Zaroxolyn)      5 mg
Simethicone
Ibuprofen
Charcoal caps

Thank you for your time & attention.

Sincerely,
Shanon, concerned daughter

ANSWER: Hi Shanon,
When I see such a long list, the first thng that come to my mind is that she is being over medicated. Let me segregate her medication. She appears to have hypertension hence metoprolol, bumetanide, amlodipine. She also has high cholesterol hence simvastatin, aspirin to prevent risk of embolism. She seems to have depression hence paroxetine, thyroid problem hence Levothyroxine, She may have had some cloting disorder hence warfarin. I mean she is being treated for different symptoms without deep thught on her main problems.
I would need more details on her health status before I can comment anything.
Ravi Ghooi

---------- FOLLOW-UP ----------

QUESTION: She has a laundry list of conditions that I will try to list for you....hopefully, it will help.

Hypertension
High Cholesterol
Hypothyroidism
Mechanical heart valve (hence, the warfarin)
Lupus (SLE)
Rhuematoid arthritis
Gout
Fibromyalgia
Renal insufficiency
Depression

I think that's it.

Shanon

Answer
Hi Shanon,
You have given an equally long list of problems. Now even if she does have an interaction we have little options than to continue the medication. As I see it, none of the medicines can be stoped. Most interactions that take place with warfarin are due to protein binding, and these are class interactions, substituting one drug with another will not help. The first quest that one must ask, is does she have any symptom that cannot be correlated to any one of her drugs. If so then we may think of interactions. If she does not have any serious adverse effects, I see little reason in worrying. In any case my worry is that if we try to make small changes here and there she may have different set of interactions which we may not be bale to handle.
There are interactions between two drugs which are affected by the third and the fourth, and so on. So we are in an area where there would be harldy any case reports of all these drugs used together. I would suggest you try to keep her comfortable and not try to make changes in her medication if she is comfortable.
I am sorry but at some stage we have to accept that the patients comfort is more important than trying to cure her.
Ravi Ghooi