Cardio drug indications, Poly-pharmacy in elderly

Question 1

Diuretics

Answer 1

Thiazides: 1st line for HTN monotherapy

Loop Diuretic: -ides, used for CKD and CHF

Potassium-sparing diuretics: Spironolactone, use for CHF but may increase the ejection fraction

Question 2

Beta Blocker

Answer 2

-olol

1st line with CAD post MI

Only drug proven to prolong life - cardioprotective

Bad with PVD (no vasodilation), asthma (bronchospasm), DM (hypoglycemia)

Question 3

ACEI

Answer 3

-prils

1st line for HTN in DM, CHF, CKD, MI

Can cause potassium imbalance

Less effective in African Americans and elderly

CI with artery stenosis and K+-sparing diuretics

Question 4

Calcium Channel Blockers

Answer 4

-dipine, Verapamil, Diltiazem

Best single agent to just lower BP, best for African Americans

Edema and constipation are major side effects

Only Amlodipine can be used with CHF

Non-dihydropyridines worsen BBB and bradycardia

Question 5

Aging effects on absorption, distribution, metabolism, excretion

Answer 5

Decreased lean body weight to body fat ratio - alters distribution

Decreased serum protein - more free drug, smaller doses for effect

Substance abuse - 10% are problems drinkers, alters drug metabolism

Question 6

Altered renal or hepatic function

Answer 6

Liver function: 40% decreased blood flow with consistent function - get decreased 1st pass metabolism

-Reduced doses Warfarin, benzos, opiates

Renal function: 1/2 decreased blood flow at 80 yo

Question 7

Most common drugs with adverse drug reactions

Answer 7

Antithrombotics - anticoag and antiplatelet

Antidiabetics

Diuretics NSAIDs

Question 8

Inappropriate drugs in elderly

Answer 8

Diphenhydramine (Benadryl) - anticholinergic- urine retetion

Amitriptyline (Elavil)

Alprazolam (Xanax) - tolerance may be developed

Diazepam (Valium)

Chlorpropamide/Glyburide (1st gen sulfonylurea)

Digoxin >0.125 - anorexia, confusion, declining renal excretion

GI antispasmotics (Belladonna, dicyclomina, hyoscyamine)

Meperidine (Demerol)

Methyldopa (Aldomet)

Question 9

Drugs to use with caution

Answer 9

May cause or exacerbate underlying SIADH

SNRI

SSRI

Antipsychotics

Question 10

Adverse drug reactions most common cause of death and commonly causes:

Answer 10

Most common COD: GI bleed, intracranial bleed, renal failure

Falls

Orthostatic HOTN

Heart failure

Delirium

Question 11

Nitrofurantoin (Macrobid) Beer’s Criteria

Answer 11

Pulmonary toxicity

Lack efficacy with CrCl <30

-inadequate drug in urine

Question 12

Digoxin >0.125 Beers Criteria

Answer 12

Increased risk toxicity

Have decreased renal clearance and protein binding

Question 13

Sliding Scale Insulin Beers Criteria

Answer 13

Higher risk hypoglycemia without improvement of hyperglycemia management

Question 14

Sulfonylureas Beers Criteria

Answer 14

Glyburide

• prolonged hypoglycemia

Question 15

Non-Cox selective NSAIDs Beers Criteria

Answer 15

Increased risk GI bleed and PUD

Use of PPI/misoprostol decreases risk

Question 16

Drugs that may worsen constipation

Answer 16

Antimuscarinics - urinary incontinence

Nondihydropyridine CCB

1st generation antihistamines

Question 17

START Criteria

Answer 17

Screening tool to alert prescriber to right treatment

Most common omissions

• Statins with atherosclerotic dx
• Warfarin with chronic a-fib
• Antiplatelet therapy with arterial dx
• Ca/Vit D supplement with symptomatic osteoporosis