Elderly 1 Flashcards
What happens to lipophilic drugs? Give examples for drugs
Inc. Vd & elimination t1/2 due to inc. fat= longer time to leave the body
E.g: diazepam - amitriptyline - valporic acid - amiodarone - verapamil
What happens to hydrophilic drugs/ give examples
Lower body water> high levels of drugs in body > need to dec. dose
E.g: aspirin - digoxin - morphine - lithium
What happens to highly protein bound drugs ? Examples
The serum albumin may or not change,
The drugs free fraction in plasma increases
E.g ; warfarin, phenytoin, diazepam
How dose the change in hepatic metabolism changes?
Give examples.
Inc. bioavailability dec. clearance inc. elimination t1/2
CVS: CCB, nitrates, statins, labetalol, propranolol, metoprolol
CNS: Levodopa, morphine, TCA
What happens to the 1st pass activation of prodrugs?
Might be slowed or decreased
E.g: ACEI (enalapril & perindopril) - clopidogrel
What happens to drug dependent on phase II rxn?
Relatively unaffected
E.g: lorazepam, oxazepam, temazepam, glipizide
What drugs to avoid if CrCL < 30mL/min?
Dabigatran - fondaparinux - spironolactone - duloxetine - tramadol ER - metformin
What drugs to reduce dose if CrCL < 30mL/min?
Ciprofloxacin- trimethoprim/sulfamethoxazole (avoid if < 15mL/min)
Enoxaparin, colchicine
What drugs to avoid if CrCL < 25 mL/min?
Apixaban
Digoxin criteria
Avoid if:
- 1st line AFib/HFrEF
- > 125mcg/day w/ impaied RF ( eGFR <50ml/min)
- eGFR < 30 ml/min
Loop diuretic: furosemide criteria
Avoid in :
- Ankle edema w/o evidence of HF, liver failure, nephrotic syndrome or CKD
- 1st line monotherapy for HTN
Thiazide diurets : hydrochlorothiazide - Chlorthalidone - metolazone
Avoid if: sK < 3,0mmol/L sNa < 130 mmmol/L Corrected sCa > 2.65 mmol/L History of gout Dose > 25mg (HCTZ, CT) eCrCl <30ml/L (except metolazone)
Aldosterone antagonist
Spironolactone- eplerenone criteria
Avoid :
sK > 5mmol/L a&/or eCrCL < 30 mL/min
spiro dose > 25mg
Concurrent with : ACEI/ARB + k-sparing
Inc. risk of hyperkalemia
BB criteria
Avoid in: Combo w/NDHP CCB - risk of heart block Bradycardia- heart block/asystole Diabetic- masking hypoglycemia symptoms Non-selective BB in asthma- bronchospasm
NHDP-CCB criteria :
Avoid:
with HFrEF - worsen HF
Constipation - Exacerbate
In combo with BB
CCB criteria:
Avoid immediate release CCB as they increase the risk of hypocrisy and precipitating MI
Alpha-blocker criteria
Avoid as routine treatment for HTN - risk of OH
Central a2 agonist: clonidine - methyldopa
Avoid as routine treatment for HTN as they inc. the risk of OH - adverse CNS effects - bradycardia
Amiodarone criteria
Avoid as 1st line treatment for rate control in AFib UNLESS
Patient has HFeEF or rhythm control is preferred over rate control
HF patient should avoid:
- NDHP CCB (HFrEF)
- Dronedarone
- NSAIDs
- Cilostazol
- pioglitazone & rosiglitazone
- saxagliptin
Aspirin criteria
Avoid: - PMH of PUD w/o PPI - > 160 mg/day (inc. risk of bleeding) - combo w/OAC in ptnt w/ chronic AFib Use w/caution in >70y/o CV protection
OAC
Vit. K antagonist (warfarin)
Direct thrombin inhibitor (dabigatran)
Factor X inhibitor ( rivaroxaban - apixaban)
- Dabi & riva : caution in >75 = inc. risk of bleeding
- If the patient had 1st DVT or PE w/o continuing provoking RF
Avoid OAC use for > 6 months (dvt) or >12 months (PE)
What deugs to avoid in combo w/ Warfrain and why?
Avoid with
- trimethoprim-sulfamethoxazole/ ciprofloxacin / macrolides but azithro / MSAIDs
Reason :
Increase risk of bleeding - if used together monitor INR
Antidepressants criteria
Avoid TCA (amitriptyline - imipramine) SSRI (paroxetine - amoxapine) As they’re sedating - inc. risk of OH, falls/fracture- cognitive impairment - constipation - dry mouth - urinary retention
What is START criteria in prescribing antidepressant/
Prescribed in presence of moderate to severe depressive symptoms lasting at least 3 months.
What are the optimal choice of SSRI and when to avoid
Drugs: sertraline - citalopram - escitalopram - fluoxetine
Can cause hyponatremia avoid in current/recent sig. hyponatremia ( <130mmol/L in past 2 months)
citalopram - escitalopram risk of QT prolongation
BDZ/barbiturates criteria
- avoid for insomnia, agitation, delirium
- MAY give for emergency seizure disorder- severe GAD - pre-procedural anesthesia- ethanol withdrawal
Note: if prescribed give short acting for no longer than 4 weeks
Antipsychotics - typical and atypical
Typical:
Phenothiazines ( CPZ - thioridazine)
Butyrophenones (haloperidol- thioxanthenes (flupenthixol))
Atypical:
Risperidone - clozapine - olanzapine - quetiiapine - pimavaserin - aripiprazole
