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Geriatrics > Pharmacotherapeutics > Flashcards

Pharmacotherapeutics Flashcards

1
Q

difference between pharmacokinetics vs pharmacodynamics

A

Pharmacokinetics- What the body does to the drug
Pharmacodynamics- What the drug does to the body

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2
Q

Pharmacokinetics can be altered by (3)

A
  1. disease
  2. environment
  3. meds
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3
Q

is absorption changed with aging?

A

minimally altered by aging

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4
Q

how does aging affect absorption?

A
  1. decreased size of absorptive surface
  2. increased gastric pH
  3. decreased splanchnic blood flow
  4. decreased Gastric motility
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5
Q

what is absorption altered by

A
  1. Drugs that
    - alter stomach PH
    - inc/dec GI motility
    - cause mucosal damage
    - prevent absorption
    - reduce active transport mechanisms
  2. Disorders that change GI motility: DM, IBS, GERD, dumping syndrome
  3. Bariatric surgeries, gastroparesis, achalasia, biliary dyskinesia, hiatal hernia, spastic esophagus, GI obstruction, diarrhea, constipation, pseudo-obstruction, infections
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6
Q

Drugs that Delay Gastric Emptying

A

Alcohol
Aluminum hydroxide antacids
Anticholinergics
BB
CCB
Cyclosporin
Diphenydramine
GLP1
GLP2
H2 receptor antagonists
Levadopa
Lithium
Ondansetron
Opioids
Phenothiazines
Antipsychotics
PPI
TCA

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7
Q

how are the physiologic changes with aging on distribution?

A
  1. Impacted by lean muscle replaced with adipose tissue
  2. reduction in total-body water content
  3. decreased serum albumin
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8
Q

how does increased adipose tissue affect distribution

A

Inc adipose tissue: lipophilic drugs (BZD) = dec serum level, inc vol of distribution, inc metabolism, inc elimination ½-life

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9
Q

how does low total-body water content affect distribution

A

Low total-body water content = dec vol of distribution for Hydrophilic meds (e.g., digoxin, lithium) = higher serum levels

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10
Q

how does decreased serum albumin affect distribution

A

occurs with poor nutrition

impaired renal function + other medical conditions = inc “free” drug levels = inc risk of SE when high protein-binding drugs are used

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11
Q

how does aging impact metabolism?

A

Reduction in CYP450 metabolism d/t age-related reduced hepatic blood flow and liver size

  • Drugs can inhibit or induce P450 enzymes
  • Px if one drug inhibits P450 and another requires it for metabolism
  • Px if one drug induces P450 and leads to rapid metabolism of another drug
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12
Q

what are the physiologic changes with aging on excretion?

A

Impacted by decrease in Renal tubular function and GFR

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13
Q

why is there physiologic changes with aging

A
  • d/t a loss in muscle mass, a patient’s serum creatinine may be normal despite renal impairment
  • Creatinine is a waste product produced by muscles from the breakdown of a compound called creatine.
  • Creatinine is removed from the body by the kidneys, which filter almost all of it from the blood and release it into the urine.
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14
Q

Pharmacodynamics change as we age, secondary to

A
  1. altered receptor affinity or numbers
  2. post-receptor alterations
  3. impairment of homeostatic mechanisms
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15
Q

Older patients are more sensitive to drugs that suppress the CNS, leading to

A

delirium
confusion
agitation

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16
Q

The simultaneous use of multiple drugs by a single patient, for one or more conditions; >5 drugs
what is this term?

A

Polypharmacy
Most common in older adults

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17
Q

Complications of polypharmacy

A

Increased adverse drug reactions, drug-drug interactions, drug-disease interaction
Cost burden
Increase risk of hospitalization
Decreased quality of life

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18
Q

Polypharmacy – Adverse Reactions

A
  • Not necessarily related to age
  • MC from use of multiple meds and number of chronic illnesses present
  • The primary purpose of a medication may also be the source of an adverse drug reaction

approx. 14 million hospitalizations occur each year in elderly patients

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19
Q

what two medications are responsible for 2/3 of all medication related hospitalizations

A
  1. Anticoagulants (Warfarin)
  2. hyperglycemics (insulin)
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20
Q

narrow TI drugs

A
  1. digoxin
  2. warfarin
  3. lithium
  4. theophylline
  5. cyclosporine
  6. tacrolimus
  7. gentamicin
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21
Q

wide TI drugs

A
  1. ibuprofen
  2. acetaminophen
  3. antihistamines
  4. most abx
  5. BB
  6. multivitamins
  7. proton pump inhibitors
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22
Q

Unwanted effects of drugs at normal dosage and use
what is this adverse reaction term?

A

adverse drug reaction

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23
Q

An injury/harm resulting from the use of a pharmacologic agent
what is this adverse reaction term?

A

Adverse Drug Event

24
Q

Bradycardia leading to syncope with B-blocker use
Diarrhea related to abx use
Bleeding associated with anticoagulants

are all examples of what type of adverse reaction?

A

adverse drug reaction

25
Q
  • Adverse drug reaction
  • Unintentional overdose
  • Withdrawal reaction after abrupt discontinuation

are all examples of what type of adverse reaction?

A

adverse drug event

26
Q

how does polypharmacy cause adverse reactions to the metabolism?

A
  1. Inhibition of the P450 system (MC)
    - Inhibition of P450 slows metabolism of atorvastatin leading to toxic levels of statin resulting in liver dysfunction, myalgias, and rhabdomyolysis
  2. Induction of the P450 system
    - Results in rapid clearance and decreased effectiveness of drugs that are metabolized by P450
27
Q

how does polypharmacy contribute to drug-disease interactions?

A

Underlying disease increases susceptibility to unwanted physiologic effects of a drug

28
Q

Pt has multiple health care providers
what is this condition/term?
how much does an additional prescriber increase the risk of an adverse drug reaction?

A

poly-provider syndrome
Each additional prescriber = 29% increase in adverse drug reactions

29
Q

prevention for poly-providers

A
  1. Limit the number of providers prescribing to one patient
  2. Limit the number of pharmacies (should only have 1)
  3. Use electronic prescribing (e-scribe)
    - Helps keep track of prescriptions
    - Some have a drug-drug interaction checker
    - Alerts provider to drug interactions before submitting
30
Q

The practice of pharmacotherapy in older adults is similar to the practice of pharmacotherapy in younger adults
what is this term?

A

Geriatric Pharmacotherapy
Requires an understanding of:
Drug indications
Dosing
Adverse reactions
Drug–drug interactions

31
Q

what equation can be used to guide drug dosage levels in the geriatric population in terms of creatinine clearance?

A

cockcroft-gault equation

32
Q

why Don’t be misled by following serum creatine levels when calculating creatinine clearance?

A

Serum creatinine levels often remain within normal limits despite a decrease in GFR
older people typically have less muscle mass and are physically less active than younger adults and thus produce less creatinine

33
Q

what are the Tools to help providers avoid misuse/overuse/underuse of prescription drugs in older adults
(4)

A
  1. The Brown Bag Medication Review - Patient to bring medications with them if possible
  2. AGS Beers Criteria® - updated in 2019
  3. STOPP - Screening Tool of Older Person’s Prescriptions
  4. START – Screening Tool to Alert providers to Right Treatment
34
Q

An expert reviewed list of medications that should be avoided or used with caution in geriatric patients
which geriatric pharmacotherapy criteria is this?

A

AGS Beers Criteria

35
Q

Five categories of drugs in AGS Beers Criteria

A
  1. Drugs to avoid in most older pts
  2. Drugs to avoid in pts with specific conditions
  3. Drugs to avoid in combo with other tx d/t DDI
  4. Drugs to use with caution bc of SE
  5. Drugs to dose differ
36
Q

what medication is MC implicated in ER visits and hospitalizations for adverse drug reaction
Benefits of stroke prevention in A.Fib and for tx of VTE outweigh risk of hemorrhage for most patients

A

warfarin

37
Q

Older age is associated with increased risk of drug-induced hypoglycemia
2nd most common cause of adverse drug reaction for ER visits
what is this drug?
effects?

A

insulin
Factors that contribute to hypoglycemia
Diminished renal function
Medications that interact with insulin’s effects
Impaired cognitive function

38
Q

which type of insulin has less risk of hypoglycemia? increased risk?

A

LA basal insulins - less
sliding-scale insulin - increased
AVOID in elderly patients (if possible)

39
Q

risks of LA sulfonylureas

A

All have potential to cause hypoglycemia
Risk is greater in older adults due to decreased drug clearance = Results in accumulation of the drug

40
Q

what is the preferred drug in LA sulonylureas? what do you avoid?

A

Glipizide
glyburide

41
Q

cautions w/ digoxin

A
  1. Very narrow therapeutic window - toxicity common
  2. Impaired renal function and drug-drug interactions lead to elevated serum digoxin levels
  3. sx of toxicity: fatigue, confusion, GI disturbances
  4. Monitor serum levels
42
Q

Potential risks in older adults with NSAIDs

A
  • Peptic ulcer disease
  • Renal impairment
  • Exacerbates HTN
  • Promotes fluid retention
43
Q

NSAIDs are CI in who/what?

A
  1. Heart failure
  2. Renal dysfunction
  3. High risk of peptic ulcer induced GI bleeding
44
Q

what must you do with ASA and NSAIDs if both must be used

A
  1. Maximize the time between taking cardioprotective ASA and NSAID
  2. Take ASA upon awakening, NSAID at least 2 hours later
45
Q

Alternatives with NSAIDs

A
  • acetaminophen (Tylenol)
  • diclofenac gel (Voltaren)
  • Topical NSAID with relatively minimal systemic absorption
  • Follow up in 2-4 weeks after starting NSAID to evaluate for renal dysfunction, fluid retention, BP elevation
46
Q

If NSAIDs are needed for longer than brief episodic use, what are the modifications?

A

Use at the lowest dose, for the shortest duration possible
Co-administer PPI
Take with food

47
Q

cautions with opioids

A

Psychomotor impairment
Increased risk of delirium
impaired gait/falls
sedation
N/V/C
Respiratory depression
Central sleep apnea

48
Q

antipsychotics in dementia is associated with increased likelihood/risk of:

A
  1. MI, stroke, VTE
  2. Falls, fractures
  3. Mortality

When deemed necessary to use:

  • Discuss benefits and risks with family / caregiver
  • Document discussion
  • Use for minimum duration of therapy
49
Q

Complications of nonadherence

A

Inadequate disease control
Increased ER visits and hospitalizations
Increased health care costs
Higher mortality

50
Q

Predictors of nonadherence include

A
  1. Asx disease
  2. Medication side effects
  3. Inadequate follow-up
  4. Lack of patient understanding of the value of tx
    - poor patient education
    - poor provider–patient relationship
    - low literacy
    - poor hearing, cognitive impairments
  5. Missed appointments and transportation difficulties
  6. Complicated dosing regimens
  7. Polypharmacy
  8. Financial hardships
51
Q

Geriatric Pharmacotherapy Improving Adherence

A
  1. Patient education!!!
  2. Review side effect profiles and compliance at EVERY visit
  3. Consider financial implications of treatment regimens
  4. Consider dosing regimens
52
Q

Geriatric Pharmacotherapy Cost Burden

A

(Hypothetical pts with COPD, DMT2, HTN, osteoporosis, osteoarthritis)

  • Guidelines for management could require up to 12 meds with multiple daily dosing regimens
  • avg monthly cost of recommended meds in this patient $406/month
53
Q

how do we use the cockcroft-gault equation (hint: weight)

A
  1. used for CrCl estimation for drug dosing adjustments
  2. equation depends on wt
  3. underweight pt: we use actual body weight
  4. obese pt (>30% of IBW): we use adjusted body weight
54
Q

CrCl ranges for males, females, newborns? how much does it decline as we age?
whats the normal range for a 24h urine creatinine level?

A
  1. adults <40
    - male: 107-139 mL/min
    -female: 87-107
    -babies: 40-65
  2. aging: owing to declines in the GFR, falls 6.5 mL/min/decade of life
  3. 500-2000 mg/day
55
Q

use of multiple anticholinergics has been associated with an increased risk of: (3)

A
  1. falls
  2. functional decline
  3. impaired cognition

Geriatrics (12 decks)

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