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Concepts in Geriatric Pharmacology-Charles A. Cefalu MD, MS
8/12/99
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Clinical Pharmacological Issues in the Elderly
Dr.E.Koochaki
Assistant professor of Kashan University of Medical sciences
Evaluation for Possible Polypharmacy
In the study of Lesar et al. (1997),the average of drugs per patient in 85 yr. olds and older; were 5-8 drugs per patient.
Association exists between increased number and severity of illnesses and increased number of adverse drug reactions
Concepts in Geriatric Pharmacology-Charles A. Cefalu MD, MS
8/12/99
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In the other study (Risk Factors for Adverse Drug Events in the Older Outpatients,2004)
Increased risk was for women and those >80 years and increased risk for anticoagulants, antidepressants, antibiotics, cardiovascular, diuretics, hormones and corticosteroids
Factors Related to Adverse Drug Drug Reactions are:
Chronicity and Multiplicity of DiseaseIncreased Disease-Drug InteractionsIncreased Drug-Drug Interactions
Lanoxin and QuinidineTheophylline and Erythromycin
Concepts in Geriatric Pharmacology-Charles A. Cefalu MD, MS
8/12/99
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And particular agents of concern in the elderly-highly bound to protein are
PhenytoinCarbamazepineBarbituratesWarfarin
In the elderly persons malnutrition or hypoproteinemia is associated with increased free fraction of drug and increased toxicityRef: Physicians Desk Reference, Medical Economics-Thomson Healthcare,55th Edition, 2001, p. 2427.
Normal Changes of Aging-Renal
Age-related reduction in renal blood flow and creatinine clearance in the face of a normal BUN and serum creatinine:
Implications-
Adjust dose of renally excreted drugs with age according to the following formula
Concepts in Geriatric Pharmacology-Charles A. Cefalu MD, MS
8/12/99
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Renal function is often overlooked when prescribing renally excreted drugs to older long-term care residents and emphasizes the need for consideration of creatinine clearance when prescribing such drugs in this population.
Ref: Papaioannou A et al. Assessment of Adherence to renal dosing guidelines in long-term care facilities. J Am Ger Soc. 48(11), Nov. 2000, p. 1470-3.
Aminoglycoside Dosing in the Elderly With Impaired Renal Function
Once daily dosing of aminoglycosides associated with reduced risk of morbidity (ototoxicity and renal failure) in patients with reduced creatinine clearance (usually below 50 ml/minute). Also alleviates the need for expensive peak and trough testing.Ref: Cefalu CA & Agcaoli D. Preventing antibiotic
misuse in older patients. Hospital Medicine, December 1998, p. 39-43.
Concepts in Geriatric Pharmacology-Charles A. Cefalu MD, MS
8/12/99
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“conclusion: We must be cautious in prescribing drugs in the elderly persons.
For example we must
Reduce by half the dose of the particular renally excreted agent with a creatinine clearance of 50 ml/minute or less.
Physiological changes of the GI Tract
Stomach- little change in gastric acidity with aging. In presence of dsyphagia and H2 blocker therapy, may increase risk of morbidity and mortality from pneumonia (bacteria more viable after aspiration due to reduced acidity)
Decreased GI motility and blood flow-- increased frequency of constipation
Ref: In: Hall KE, Wiley JW. Age-Associated Change in Gastrointestinal Function. In: Hazzard WR et al. Principles of Geriatric Medicine and Gerontology, 4th Ed., 2000, p. 835-842.
Concepts in Geriatric Pharmacology-Charles A. Cefalu MD, MS
8/12/99
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High Risk Drugs-Beta Blockers
B-Blockers (propranolol)-side effects of:Precipitation of or exacerbation of CHFMasking of hypoglycemiaDevelopment of hypotensionMasking of symptoms of endocrine disease (hypothyroidism)Reduction in exercise capacityExacerbation of chronic lung disease or bronchospasmDepressionMemory lossProduction of arthropathy
Ref: Cahill et al: Beta-adrenergic activation and memory for emotional events, Nature, 371, P. 702-704.
Newbern et al. Cautionary Tales on Using Beta Blockers. Geriatric Nursing. 12(3); 1991, p. 119-122.
.
Beta Blockers-continued
use selective ones: atenolol and metoprolol
Less side-effect profile
Better compliance-once or twice daily
Use associated with reduced cardiovascular morbidity and mortality in high risk patients
Ref: Mangano DT et al. Effect of atenolol on mortality and cardiovascular morbidity after non-cardiac surgery. N Engl J Med, 335, 1996, p. 1713-20.
Australia/New Zealand Heart Failure Research Collaborative Group, 1997
Concepts in Geriatric Pharmacology-Charles A. Cefalu MD, MS
8/12/99
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Diuretics-continued
Use in older caucasian women associated with reduced risk of hip fracture
Adverse reactions
Dehydration; postural hypotension; K loss (especially during the summer and sweating)
Consider discontinuing in elderly when possible, especially advanced, demented, or depressed elderly (reduced thirst and appetite drive)
Diuretics-References
Ref: SHEP (Systolic Hypertension in the Elderly) Cooperative Research Group, 1991
Heidrich et al. Diuretic drug use and the risk of hip fracture Ann Intern Med., 115, 1991, p. 1-6.
Physicians Desk Reference, 2003
Gurwitz MM et al. The impact of thiazide diuretics on the initiation of lipid-reducing agents in older people: a population-based analysis. J Am Geriatr Soc., 45(1), Jan. 1997, p. 71-5.
Concepts in Geriatric Pharmacology-Charles A. Cefalu MD, MS
8/12/99
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NSAIDs*:
Can Worsen HBP- removal of NSAID can affect mean blood pressure control
Fluid retention
Worsen CHF
Cause confusion
GI bleeding
Newer Cox-2 agents, gastric sparring
Less risk of Alzheimer's and cognitive decline
*In big doses or used chronically
Ref: Carson JL & Strom BL. Use of Nonsteroidal Anti-Inflammatory Drugs. In: Hazzard WR et al. Principles of Geriatric Medicine and Gerontology, 4th Ed., 2000, p. 1113-1119; Stewart WF et al. Risk of Alzheimer’s disease and duration of NSAID use. Neurology, 48, 1997, p. 626-632.
“Tips” for Safe Traditional NSAID Use
Substitute acetaminophen when possible around the clock instead of NSAID
Use PRN when possible
Use lowest dose possible
Use for acute flare for 7-10 days then d/c
When necessary for chronic use, insist on routine q 3 month BUN and CBC