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Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy The University of New Mexico
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Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Dec 23, 2015

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Page 1: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Pharmacokinetic Considerations in the Elderly

Melanie A. Dodd, Pharm.D., Ph.C., BCPS

Associate Professor of Pharmacy in Geriatrics

College of Pharmacy

The University of New Mexico

Page 2: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 2

OBJECTIVES

At the conclusion of the lecture the student shall be able to:

Describe the effects of aging on pharmacokinetic parameters (absorption, distribution, metabolism, and elimination)

Describe the effects of aging on pharmacodynamic parameters

Discuss basic principles of prescribing for older patients to avoid adverse drug effects

Identify potentially inappropriate medications in a given elderly patient based on the Beers’ criteria

Page 3: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Which of the following principles should NOT be followed when prescribing new medication(s) for a geriatric patient?

A. Start with a low dose

B. Start all new medications simultaneously

C. Titrate the dosage upward slowly

D. Use one drug to treat two different conditions, if possible

Slide 3

Page 4: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 4

Why are geriatric pharmacokinetics important?

Persons aged 65 and older are prescribed thehighest proportion of medications in relation to theirpercentage of the U.S. population

• Now, 13% of total population buy 33% of all prescription drugs

• By 2040, 25% of total population will buy 50% of all prescription drugs

Page 5: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 5

Why are geriatric pharmacokinetics important?

Increased risk of adverse drug reactions Multiple medications

• >20% of elderly use 5 or more medications• Increased frequency of drug-drug interactions• Decreased medication adherence

Multiple comorbidities Age-related changes in drug pharmacokinetics Age-related changes in drug pharmacodynamics

Page 6: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 6

The Burden of Injuries from Medications

ADEs are responsible for 5% to 28% of acute geriatric hospital admissions

• ADEs occur in 35% of community-dwelling elderly persons

• ADEs incidence: 26/1000 hospital beds

• In nursing homes, $1.33 spent on ADEs for every $1.00 spent on medications

Page 7: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 7

RISK FACTORS FOR ADEs

• 6 or more concurrent chronic conditions

• 12 or more doses of drugs / day

• 9 or more medications

• Prior adverse drug reaction

• Low body weight or body mass index

• Age 85 or older

• Estimated CrCl < 50 mL / min

Page 8: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 8

ADE PRESCRIBING CASCADE

Rochon PA, Gurwitz JH. Optimising drug treatment for elderly people: the prescribing cascade. BMJ. 1997;315(7115):1097.

DRUG 1

DRUG 2

Adverse drug effect- misinterpreted as a new medical condition

-

Adverse drug effect- misinterpreted as a new medical condition

Page 9: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 9

Principles of prescribing for older patients: The Basics

• Start with a low dose

• Titrate upward slowly, as tolerated by the patient

• Avoid starting 2 drugs at the same time

Page 10: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 10

Before Starting a New Medication, Ask:

Is this medication necessary?What are the therapeutic end points?Do the benefits outweigh the risks?Is it used to treat effects of another drug?Could 1 drug be used to treat 2 conditions?Could it interact with diseases, other drugs?Does patient know what it’s for, how to take it,

and what ADEs to look for?

Page 11: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 11

PHARMACOKINETICS

Absorption

Distribution

Metabolism

Elimination

Page 12: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 12

Aging and Absorption

Clinical significance is not well characterized Most drugs absorbed through passive diffusion in

the proximal small bowel

Exception: levodopa Threefold increase in bioavailability due to reduced

activity dopa-decarboxylase in the stomach wall

Page 13: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 13

Absorption

Alterations in GI function Decreased gastric parietal cell function

• Decrease in secretion of hydrochloric acid

Increase in gastric pH• Ex: tetracycline, Fe, ketoconazole

Decreased rate of gastric emptying Ex: anticholinergics, opiates, Fe, anticonvulsants

Drug-drug interactions Divalent cations (calcium, magnesium, iron) and

fluoroquinolones (e.g., ciprofloxacin)

Page 14: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 14

Absorption

Topical absorption (patches, creams, ointments, etc.) Thinning and reduction of absorptive surface

• Skin atrophy and decreased fat content» Reduction in vascular network and risk of contact

dermatitis

Page 15: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 15

Effects of aging on volume of distribution (Vd)

Depends mostly on physiochemical properties of individual medications

t½ = (0.693 x Vd)/Cl

Page 16: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 16

Distribution

body water (10-15%) lower Vd for hydrophilic drugs Ex: warfarin, digoxin, lithium, cimetidine, APAP, ETOH

lean body mass lower Vd for drugs that bind to muscle

fat stores higher Vd for lipophilic drugs Ex: diazepam, lidocaine, TCAs, propranolol

Page 17: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 17

Distribution Protein Binding

Decreased serum albumin 10 to 20% in hospitalized or poorly nourished pt. Increase in unbound fraction of highly protein

bound acidic drugs Monitor drug levels—free phenytoin level with low

albumin• Ex: warfarin, phenytoin, naproxen

Increased -1 acid glycoprotein Decrease in unbound fraction of highly protein

bound basic drugs• Ex: lidocaine, propranolol, imipramine

Page 18: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 18

Aging and Metabolism

The liver is the most common site of drug metabolismMetabolic clearance of a drug by the liver may be

reduced because … Decrease in liver blood flow

40 to 45% with aging, related to cardiac function Increase in bioavailability Decreased 1st pass effect = more parent drug

• Reduce initial dose, then titrate Decrease in liver size

20 to 50% decrease in absolute weight up to age 80 Reduction of total amount of metabolizing enzymes Leads to decrease in Cl and increase in t½

Start with lower dosage Caution with toxic metabolites

• Ex: meperidine and propoxyphene

Page 19: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 19

Other Factors that Affect Drug Metabolism

GenderHepatic congestion from heart failureSmoking

Page 20: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Based on the above table, which of the following statements correctly explains the change in volume of distribution for amitriptyline (a lipophilic drug) with increasing age?

A. An increase in the percentage of lean body mass with age

B. A decrease in the unbound fraction of highly protein bound basic drugs

C. An increase in the unbound fraction of highly protein bound basic drugs

D. An increase in the percentage of fat body mass with age

Slide 20

Mean Age in years Volume of

distribution (L/kg)

22 14.1

71 17.1

Page 21: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 21

Elimination

Most drugs exit body via kidney

Reduced elimination drug accumulation and toxicity

Aging and common geriatric disorders can impair kidney function

Page 22: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 22

The Effects of Aging on the Kidney

kidney size renal blood flow

~1%/year after age 50

number of functioning nephrons renal tubular secretionResult: Lower glomerular filtration rate

• ~35% in healthy individuals between ages 20 and 90• Accumulation increased risk of toxicity

» Ex: lithium, aminoglycosides, captopril, NSAIDs

Page 23: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 23

Serum Creatinine does NOT reflect Creatinine Clearance

• lean body mass lower creatinine production

and• glomerular filtration rate (GFR)

Result: In older persons, serum creatininestays in normal range, masking change increatinine clearance (CrCl)

Page 24: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 24

How to Calculate Creatinine Clearance

• Measure:Time-consuming to be accurateRequires 24-h urine collection8-h collection may be accurate but not widely

accepted

• Estimate: Cockroft and Gault equationMDRD

Page 25: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 25

Cockroft and Gault Equation

(Ideal weight in kg) (140 - age) _________________________ x (0.85 if female)

(72) (serum creatinine in mg/dL)

Page 26: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

An elderly person with a serum creatinine in the normal range may actually have a decreased creatinine clearance because they have:A. Increased creatinine production and an increased

glomerular filtration rate (GFR)

B. Increased creatinine production and a decreased GFR

C. Decreased creatinine production and a decreased GFR

D. Decreased creatinine production and an increased GFR

Slide 26

Page 27: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 27

Pharmacodynamics

Definition• Time course and intensity of pharmacologic effect

of a drug

Impairment varies considerably from person to person

All organ systems are affected

Kidneys, liver, GI, CNS, CV, GU

Page 28: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 28

Altered Pharmacodynamic Mechanisms

Change in receptor numbersChange in receptor affinityPostreceptor alterationsAge-related impairment of homeostatic

mechanisms

Page 29: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 29

CNS

Changes are significant, yet idiosyncratic Decrease in weight and volume of brain Alterations in cognition

Increased sensitivity to medications Ex: benzodiazepines, opioids, anticholinergics,

NSAIDs

Page 30: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 30

CNS

Cholinergic blockade results in Sedation, confusion, and reduced ability to recall

• Ex: TCAs, diphenhydramine, antispasmodics, antipsychotics

Benzodiazepines can cause severe CNS depression Leads to falls and hip fractures Use caution and small dosages

Page 31: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 31

Cardiovascular

Decreased baroreceptor responsiveness Results in orthostatic hypotension

• Ex: Antihypertensives—use caution and counseling

Page 32: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 32

GU

Urinary incontinence 15 to 30% of community-dwellers 50% of nursing home residents Enlarged prostate, urine retention

• Ex: anticholinergics

Page 33: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Inappropriate Medication Use in Older Adults (Beers Criteria update)

Fick DM, et al. Arch Intern Med 2003;163:2716-2724.48 medications or classes to avoid in older adults20 diseases/conditions and medications to avoid in

older adults with these diseases“Medications to be used with caution in the elderly: a

statewide clinical recommendation on potentially inappropriate medications”

http://www.nmmra.org/providers/drug_safety_pims_guideline.php

Page 34: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 34

Inappropriate Drug Therapy based on Beers’ Criteria

Authors Setting Prevalence of Inappropriate Prescribing

Goulding MR 2004

Ambulatory care visits

7.8% of visits

Zhan et al. 2001 Community dwelling elderly

21.3% of patients

Simon SR, et al. 2005

Elderly in managed care

28.8% of patients

Golden et al. 1999 Nursing home-eligible

39.7% of patients

NM Medicare Advantage plans 2009

New Mexico Medicare patients

21.5% of patients

Page 35: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 35

Beers’ Criteria: Independent of DiagnosisAnalgesics

Meperidine (long t1/2 metabolite, CNS) Non-steroidal anti-inflammatory drugs

Indomethacin (CNS) Ketorolac-immediate and long-term use (GI bleeds)* Non-COX selective NSAIDs, longer t1/2-long-term use (GI

bleeds, renal failure)* Propoxyphene Pentazocine (CNS)

Page 36: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 36

Beers’ Criteria: Independent of DiagnosisPsychiatric

Antidepressants Amitriptyline/doxepin (anticholinergic) Daily fluoxetine (CNS)*

Anxiolytics Long-acting benzodiazepines-chlordiazepoxide,

flurazepam (sedation/fractures) Doses of short-acting benzodiazepines Meprobamate (addiction/sedation)

Antipsychotics Thioridazine (CNS/EPS)* Mesoridazine (CNS/EPS)*

Page 37: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 37

Beers’ Criteria: Independent of DiagnosisCardiovascular

Ticlopidine (no better than aspirin) Disopyramide (negative inotrope/anticholinergic) Amiodarone (QT interval/torsades de pointes)* Methyldopa (bradycardia/depression) Clonidine (CNS/orthostatic hypotension)* Doxazosin (hypotension/dry mouth)* Short-acting nifedipine (hypotension/constipation)* Ethacrynic acid (HTN, fluid imbalances)*

Page 38: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 38

Beers’ Criteria: Independent of Diagnosis

Antihistamines (anticholinergic) Diphenhydramine (confusion/sedation) Chlorpheniramine Promethazine Hydroxyzine

Stimulant laxatives, long term use: e.g., bisacodyl (bowel dysfunction)

Cimetidine (CNS, confusion)*Chlorpropamide (hypoglycemia/SIADH)

Page 39: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 39

Beers Criteria Considering Diagnosis

Heart failure-disopyramide (negative inotropic effect)

Gastric or duodenal ulcers-NSAIDs and aspirin >325 mg (exacerbate existing ulcers or produce new ulcers)

Epilepsy-clozapine, chlorpromazine (may lower seizure threshold)

Insomnia-decongestants, theophylline, methylphenidate (CNS stimulants)

Page 40: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 40

Beers Criteria Considering Diagnosis

Depression-long-term benzodiazepines (exacerbate depression)*

Syncope or falls-TCAs and short to intermed acting benzodiazepines (may produce syncope/additional falls)*

Chronic constipation-CCBs, anticholinergics, TCAs

Page 41: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Alternatives to Beers criteria

Stefanacci RG, Cavallaro E, Beers MH, Fick DM. Developing explicit positive beers criteria for preferred central nervous system medications in older adults. Consult Pharm. 2009 Aug;24(8):601-10.

Slide 41

Page 42: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

STOPP and START Criteria

Screening Tool of Older Persons’ Prescriptions (STOPP)

Screening Tool to Alert doctors to Right Treatment (START)

Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D. STOPP and START. Consensus validation. Int J Clin Pharmacol Ther 2008;46:72-83.

Slide 42

Page 43: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 43

Conclusions

Age alters pharmacokinetics (drug absorption, distribution, metabolism, and elimination)

Age alters pharmacodynamicsADEs are common among older patientsSuccessful drug therapy means:

Choosing the correct dosage of the correct drug for the condition and individual patient

Monitoring the therapy

Page 44: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 44

References/Additional Reading

Cusack BJ. Pharmacokinetics in older persons. Am J Geriatr Pharmacother. 2004;2:274-302.

Fick DM, et al. Arch Intern Med 2003;163:2716-2724. (Beers’ criteria)

Gallagher P, et al. STOPP and START. Consensus validation. Int J Clin Pharmacol Ther 2008;46:72-83.

Golden AG, et al. J Am Geriatr Soc 1999;47(8):948-53. Goulding MR. Arch Intern Med 2004 164(3):305-12. Levy HB, et al. Ann Pharmacother 2010;44:xxxx. Simon SR, et al. J Am Geriatr Soc 2005;53(2):227-32. Stefanacci RG, et al. Consult Pharm. 2009;24(8):601-10. Zhan C, et al. JAMA 2001;286(22):2823-9.

Page 45: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 45

Case: AB 81 year-old femaleProblem List

1. CVA X 6

2. Carotid stenosis

3. Right endarterectomy in 6/05

4. Osteoarthritis

5. Chronic constipation

6. Diabetes

7. Peripheral neuropathy

8. Coronary artery disease

9. Hypertension

10. Hypothyroidism

11. Hypercholesterolemia

12. Osteopenia

13. Urinary incontinence

14. Recurrent pyelonephritis

15. Atrophic vaginitis

16. Reactive airway disease

Page 46: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 46

Medications

1. levothyroxine 75 mcg daily2. lovastatin 10 mg, 2 tablets at

bedtime3. clopidogrel 75 mg daily4. nitroglycerin SL tabs 0.4mg prn5. amlodipine 10 mg daily6. furosemide 20 mg daily7. potassium 10 mEq, 2 tablets twice

daily8. clonidine 0.2 mg, 2 tablets twice

daily9. metoprolol 50 mg twice daily10. Novolin 70/30, 25 units qam, 15

units qpm

11. glipizide extended release 10 mg twice daily

12. conjugated estrogen vaginal cream twice weekly

13. gabapentin 300 mg tid for neuropathy in feet

14. amitriptyline 10 mg at bedtime15. hydrocodone/ acetaminophen 5/325

mg, 1 tab every 4-6 hours prn pain (uses 3-4 tabs/day)

16. alendronate 70 mg po weekly17. tolterodine (Detrol LA) 4 mg qhs18. albuterol MDI with chamber once

weekly

Page 47: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 47

Medications(continued)

19. docusate 100 mg bid20. mineral oil prn constipation 21. glycerin suppositories prn constipation (uses about 2x/week) 22. aspirin 81 mg daily23. diphenhydramine 25 mg at bedtime for sleep (uses 3-4 x/week)24. calcium 500 mg with vitamin D bid25. glucosamine 2 caps qd

Page 48: Pharmacokinetic Considerations in the Elderly Melanie A. Dodd, Pharm.D., Ph.C., BCPS Associate Professor of Pharmacy in Geriatrics College of Pharmacy.

Slide 48

Objective

Vital Signs:BP 168/63 HR 79 RR 24 Temp. 97.8˚F Weight 177.9 lbs. Pain 1/10Lab Values: Na 140 K 4.8 Cl 104 BUN 25 Scr 1.3

HbA1c 6.8% Mean blood glucose 164.8 TSH 5.680Lipids

TC 144 TG 258 HDL 39 LDL 53