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Clinical pharmacology and therapeutics > Drugs in health and disease 2 > Flashcards

Drugs in health and disease 2 Flashcards

1
Q

What percentage of the population are over 65s?

A

13%

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2
Q

What percentage of prescriptions are for over 65s?

A

30-40%

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3
Q

How many times more common are drug reactions in the elderly?

A

2-3

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4
Q

What does an increased number of drugs cause?

A

Increased reactions
Increased adverse effects
Decreased adherence

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5
Q

Define pharmacodynamics

A

The effect the drug has on the body

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6
Q

Describe pharmacokinetics

A

The way the body affects the drug over time

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7
Q

List some concepts involved in pharmacokinetics

A

Absorption
Distribution
Metabolism
Excretion

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8
Q

Describe drug absorption in the elderly

A 
Reduced saliva
Reduced gastric acid 
Decreased GI motility 
Reduced surface area for absorption 
Reduced splanchnic blood flow

Overall effect:↓ rate of absorption & ↑ time to steady state

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9
Q

When should levodopa be taken and why?

A

Not at mealtimes

Competes with nutrients

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10
Q

Describe how bisphosphonates should be taken

A

On an empty stomach
Sitting up
30 mins before food

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11
Q

What is the volume of distribution?

A

Hypothetical volume obtained if all the drug was in the blood

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12
Q

What is the equation for the volume of distribution?

A

Vd = Amount of drug in body / Concentration in plasma

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13
Q

What does Vd affect?

A

Half life and duration of action

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14
Q

Describe how drug distribution is affected in the elderly

A

Decreased lean body mass (muscle), Decreased volume of distribution for drugs that distribute into muscles, Increased plasma concentration of drugs that distribute into muscles

Increased body fat, increased volume of distribution for fat soluble drugs, increased half life

Decreased body water, decreased volume of distribution of water soluble drugs, increased plasma concentration

Albumin decreased by 15-25% so drug binding capacity is reduced which increases the free drug

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15
Q

Describe the presentation of digoxin toxicity

A

Cardiac - heart block, bradycardia, junctional tachycardia

Psychiatric - delirium, fatigue, malaise, confusion and dizziness

Visual - blurred or yellow green vision, halos, double vision, photophobia

Gastrointestinal - anorexia, vomiting, nausea, diarrhea, abdominal pain

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16
Q

What are normal digoxin values?

A

1-2ng/ml

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17
Q

Which patient has the more serious cardiotoxicity?

a) Normal dioxin levels 6hrs post dose with renal insufficiency and severe hypokalemia
b) high digoxin levels and no renal or electrolyte disturbance?

A

A

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18
Q

How is digoxin toxicity treated?

A

Correction of electrolytes
Withdrawal of drug
If severe - use digoxin specific antibody fragments

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19
Q

List some fat soluble drugs

A

Benzodiazepines

Haloperidol

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20
Q

Give some symptoms of benzodiazepine toxicity

A

Confusion
Drowsiness
Ataxia
Dependence

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21
Q

How is benzodiazepine toxicity treated?

A

IV flumazenil 200mcg
Antagonist
Shorter half life than diazepam so the patient may become resedated

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22
Q

Name a water soluble drug

A

Gentamicin

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23
Q

Name some drugs which bind to albumin

A 
Phenytoin
Warfarin
Propranolol
Diazepam 
Levothyroxine 
Digoxin 
Furosemide
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24
Q

What conditions depress albumin?

A 
Old age
Heart failure
renal disease
RA
hepatic cirrhosis
Malignancy
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25
Q

List the sins of phenytoin toxicity

A 
Nausea, vomiting
Tremor
Ataxia
Nystagmus
Coarse facies
Hepatitis
26
Q

What is warfarin highly bound to?

A

Plasma albumin

27
Q

What properties does warfarin have?

A

Narrow therapeutic index

Small volume of distribution

28
Q

Describe the interaction between aspirin and warfarin

A

Aspirin can displace warfarin from plasma albumin

Displacement of 1-2% bound warfarin doubles or triples the concentration of warfarin and so increases the risk of bleeding.

29
Q

Give the adverse effects of antiplatelet drugs

A

Peptic ulcer disease
Increased bleeding risk
Fluid retention
Renal failure

30
Q

Give the adverse effects of anticoagulants

A

Bleeding tendency

Interaction with other drugs

31
Q

Describe liver metabolism in the elderly

A

Decreased liver size - (30%)
Decreased liver blood flow (12-40%) - decreased first pass metabolism
Decreased enzymatic activity of CP450 - decreased clearance of drugs and increased half life

32
Q

Which drugs are metabolised by the liver?

A

Benzodiazepines, phenytoin, antidepressants, antipsychotics, beta blockers, calcium channel blockers, warfarin, theophylline, NSAIDS, erythromycin

33
Q

Describe renal excretion in the elderly

A

Decreased renal size (20%), decreased renal blood flow, decreased renal function

34
Q

What happens to eGFR with age?

A

Decreases by 1% each year from the age of 40

35
Q

The excretion of which drugs is affected by renal function

A

Any drug which is greater than 60% excreted by the kidneys

Digoxin
Atenolol
Sotalol 
Lithium
Allopurinol
Antibiotics
36
Q

How does impaired excretion affect the elderly?

A

Increased half life and serum plasma

37
Q

What are the implications for problems in excretion of drugs in the elderly?

A

Reduce the dose in once daily preparations

Increase the dosage interval between more frequently administered drugs

38
Q

What is the normal 12 hour post dose lithium level?

A

0.4-0.8 mmol/L

39
Q

Give some signs of early lithium toxicity?

A

Tremor, twitching and agitation

40
Q

Give some intermediate sin of lithium toxicity

A

Lethargy

41
Q

Give some signs of late lithium toxicity

A

Coma, fits, arrhythmia, renal failure

42
Q

What level of lithium does late lithium toxicity occur at?

A

> 2 mmol/L

43
Q

What level does early lithium toxicity occur at?

A

> 1.5mmol/L

44
Q

What is a treatment of late lithium toxicity?

A

Haemodialysis

45
Q

How many times more potent is SC morphine than PO?

A

2 times

46
Q

Describe the metabolism of morphine in elderly

A

Phase 2 conjugation reaction

Morphine 6 glucuronide 40X more potent

Approximately 80% analgesic action derived from morphine 6 glucuronide

Renal impairment results in accumulation of metabolite

Prolonged effect increases the toxicity

47
Q

Give the signs of morphine toxicity

A 
Nausea
Vomiting
Constipation
Drowsiness
Respiratory depression
Hypotension
48
Q

How do you treat morphine toxicity?

A

IV naloxone 400 micrograms

49
Q

How does ageing affect pharmacodynamics do we think?

A

Decreased number and affinity of receptors
Alterations in 2nd messenger function
Alterations in cellular and nuclear responses

50
Q

Which drug effects are increased in the elderly?

A 
Alcohol - sedation and lateral sway
Hypotensives - postural hypotension
Anticholinergics - central effects increased
Warfarin - increased bleeding 
Increased GI effects of NSAIDs
Benzodiazepines - increased sedation
51
Q

Which drug effects are decreased in the elderly?

A

B1 modulators in cardiac tissue
Reduced and delayed bronchodilatory response to beta agonists
Calcium channel blocker effect on PR interval decreased

52
Q

How should elderly patients take their medications?

A

Upright position with plenty of fluid

53
Q

Describe how frailty affects ability to take oral medications?

A

Unable to swallow

Tablets may cause ulceration in the mouth

54
Q

List the side effects of ACE inhibitors

A

Dry cough
Hypotension
Renal failure
Potassium sparing

55
Q

List the side effects of beta blockers

A 
Hypotension
Confusion
Bradycardia
Impotence
Lethargy
56
Q

List the side effects of calcium channel blockers

A

Hypotension
Negatively inotropic
Fluid retention

57
Q

List the side effects of diuretics

A 
Hypotension
Hypokalaemia
Hyponatraemia 
Confusion
Dehydration
58
Q

List the side effects of traditional antipsychotics

A 
Confusion
Sedation 
Parkinsonism
Tardive dyskinesia 
Neuroleptic malignant syndrome
59
Q

Name a traditional antipsychotic

A

Haloperidol

60
Q

What can you do to increase compliance of the elderly

A

Consider cognitive problems – carer to prompt patient with medications

Simplify regimes as much as possible to once or twice daily

Dossit boxes

Consider manual dexterity and vision of the patient

Check inhaler techniques

Syrups if dysphagia for large tablets

61
Q

What percentage of hospital admissions are due to adverse drug reactions

A

15.3%

Clinical pharmacology and therapeutics (27 decks)

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