Pharmacotherapeutics - Exam 1 Flashcards
_______ is altered by individual’s diseases, environment, and other medications
Pharmacokinetics
What are the 4 keys to pharmacokinetics?
Metabolism
Elimination
Absorption
Distribution
Name some factors that influence medication absorption. Are they affected by age or diseases/medication?
Absorptive surface
gastric pH
splanchnic blood flow
GI tract motility
mostly NOT affected by age and GREATLY affected by certain diseases and medications
Reduction in normal ______ leads to decreased absorption of some meds. Name 3 in particular
active transport mechanisms
B12, calcium and iron
What are 3 age related changes that effect medication distribution.
reduced lean muscle mass
decreased total-body water content
decreased serum albumin
How does having a reduced lean muscle mass change how medication is distributed?
Results in increased adipose tissue
Increased volume of distribution for lipophilic drugs (ex. BZDs).
Results in lower serum levels and prolonged clearance rates
How does having decreased total- body water content change how medication is distributed?
Decreased volume of distribution for hydrophilic medications (Digoxin, lithium)
Results in higher serum levels
How does having decreased serum albumin content change how medication is distributed?
Results in increased “free” drug levels which leads to increase risk of SE’s when high protein binding drugs are used
Decreased serum albumin can be seen the elderly, name 2 other conditions in which you may also see decreased serum albumin
Can be seen in patients with poor nutritional states, impaired renal function, and many other chronic conditions
How does ages effect the CYP450 metabolism? Why?
reduces CYP450 metabolism
Due to age related decrease in hepatic blood flow and overall liver size
What happens when CYP450 enzyme is inhibited? Induced?
toxic accumulation of other drugs that require P450 for metabolism
rapid metabolism of P450 drugs leading to decreased efficacy
_____ is most common cause of altered pharmacokinetics in elderly patients
_____ and ____ decrease with age. Serum creatinine may be _____ in geriatric patients despite renal impairment due to loss in ______
Renal impairment
Tubular function
GFR
normal
muscle mass
When prescribe certain medications to the elderly, need to check ________.
T/F: You can have normal creatinine and abnormal CrCl.
creatinine clearance
True!!
**What is the Cockcroft-Gault formula for estimating creatinine clearance?
Define pharmacodynamics. How does it change with aging?
Defined as how a drug affects the body
Altered receptor affinity or numbers, postreceptor alterations, and/or impairment of homeostatic mechanisms
**Specifically, geriatric patients are more sensitive to _______. What can it result in?
CNS depressants
delirium, confusion, agitiation
(example in class was Benadryl)
Define polypharmacy
Defined as simultaneous use of multiple medications by a single patient (more than 5 meds)
What re the risks/complications of polypharmacy
Increased adverse drug reactions, drug-drug interactions, drug-disease interaction
Increase cost burden
Increase risk of hospitalizations
Decreased quality of life
Adherence
**What is an adverse drug reaction? Adverse drug event?
Unwanted effects of drugs at NORMAL DOSAGE AND USE!!
An injury/harm resulting from the use of a pharmacologic agent (adverse drug reactions fall into adverse drug events)
- unintentional overdose, withdrawal reaction
Hospitalization rates due to adverse drug events are approximately ____ higher in geriatric patients
4x
Adverse drug reactions are most often related to ______ and ________. _____and _____ are two common meds responsible for >60% of all medication-related hospitalizations
multiple medications
number of chronic illnesses present
Anticoagulants
hyperglycemics (insulin)
(inhibiting/inducing) the P450 system is MC. Give one example. Why?
Inhibition of the P450 system
verapamil (CCB) and atorvastatin
Inhibition of P450 slows metabolism of atorvastatin leading to toxic levels of statin → liver dysfunction, myalgias, rhabdomyolysi
What does induction of the P450 result in? What are 4 common medications?
Results in rapid clearance and decreased effectiveness of drugs that are metabolized by P450
rifampin, barbiturates, carbamazepine, phenytoin
When considering drug-disease interactions. underlying disease _____ to unwanted physiologic effects of a drug. Give an example.
increases susceptibility
patient with severe COPD or asthma is prescribed a beta-blocker that may result in worse pulmonary symptoms but does NOT have to occur. NOT every potential interaction results in harm
Name 3 tools providers can use to help avoid misuse/overuse/underuse of prescription drugs
Beers criteria
STOPP: Screening Tool of Older Person’s Prescriptions
START: Screening Tool to Alert providers to Right Treatment
Name the medication classes that were listed on the Beers criteria in lecture
1st gen antihistamines
Digoxin >0.125 mg/day
TCAs
Antipsychotics
Benzos
Sleep medications (zolpidem, eszopiclone, etc)
Male androgens (testosterone)
Long-acting sulfonylureas ( glyburide, chlorpropamide)
Meperidine (Demerol) opioid pain med
NSAIDs (unless taken with PPI)
Skeletal muscle relaxants
What are the 5 categories of drugs in the Beers criteria.
- Medications that are potentially inappropriate (avoid)
- Medications that are potentially inappropriate in patients with certain diseases or syndromes
- Medications to be used with caution
- Potentially inappropriate drug-drug interactions
- Medications that require dosage adjustment based on renal function
What are some complications of nonadherence?
-Inadequate disease control
-Misdiagnosis
-Increased ER visits and hospitalizations
-Increased health care costs
-Higher mortality
What are some contributing factors to non-adherence?
-Asymptomatic disease
-Medication side effects
-Inadequate follow-up
-Lack of patient understanding of the value of treatment
-Missed appointments
-Transportation difficulties
-Complicated dosing regimens; polypharmacy
-Financial hardships
Give 3 examples of how we can make prescribing safer?
Thoroughly evaluate each patient individually
brown bag review
deprescribing or unprescribing
_____ is the MC medication implicated in ER visits and hospitalizations for ADRs. Why?
Warfarin
Complicated, frequently changing dosing and the need for close monitoring to keep pts in target range
Older age is associated with increased risk of drug-induced ______. ______ is the 2nd MC cause of ADRs the lead to ER visits
hypoglycemia
insulin
What are 3 factors that contribute to hypoglycemia in the elderly?
Diminished renal function
Medications that interact with insulin’s effects
Impaired cognitive function
Why do you want to avoid long-acting sulfonylureas in the elderly? If you have to give one choose ______ and avoid _____
greater risk of hypoglycemia due to decreased drug clearance that leads to an accumulation of the drug
give glipizide (short-acting sulfonylureas)
AVOID glyburide
_______ has a very narrow therapeutic window and toxicity common. What are the s/s of toxicity? What do you need to monitor?
Digoxin
fatigue, confusion, GI disturbances
serum levels
What are the potential risks of NSAIDs in the elderly? When are they contraindicated?
Peptic ulcer disease
Renal impairment
Exacerbate HTN
Promote fluid retention
Heart failure
Renal dysfunction
High risk of peptic ulcer induced GI bleeding
If NSAIDs have to be used, what are the prescribing guidelines? When do you need to f/u? What are the NSAID alternatives?
Use at the lowest dose, for the shortest duration possible
Co-administer PPI
Take ASA upon awakening, NSAID at least 2 hours later
Follow up in 2-4 weeks after starting NSAID to evaluate for renal dysfunction, fluid retention, BP elevation
Acetaminophen (Tylenol), diclofenac gel (Voltaren)
What are the antihistamines that should be avoided in the elderly?
Diphenhydramine (Benadryl)
Meclizine (Antivert)
dimenhydrinate (Dramamine)
What are the antidepressants that should be avoided in the elderly?
Amitriptyline (Elavil)
doxepin
paroxetine (Paxil)
What are the antipsychotics that should be avoided in the elderly?
Clozapine (Clozaril)
olanzapine (Zyprexa)
quetiapine (Seroquel)
What are the bladder/GI antispamodics that should be avoided in the elderly?
GU : oxybutynin (Ditropan), tolterodine (Detrol)
GI: dicyclomine (Bentyl)
the muscle relaxant _____ should be avoided in the elderly. The antiemetic ____ should be avoided in the elderly.
cyclobenzaprine
promethazine
Use of multiple anticholinergic drugs has been associated with increased risk of ______, ______ and ______.
Falls
Functional decline
Impaired cognition
______ have safety concerns for the elderly that include Psychomotor impairment, increased risk of delirium, impaired gait, falls, sedation, N/V/C, respiratory depression, central sleep apnea
opioids
antipsychotics are considered especially high risk in the elderly when used for ______. What is the preferred tx option? What happens if antipsychotics are deemed necessary?
dementia
non-pharm
discuss risks/benefits with family, document the discussion!!, use for minimum duration of therapy
using antipsychotics in dementia increases the pt’s risk of ? (6 things)
MI
Stroke
VTE (venous thromboembolism)
Falls
Fractures
Mortality
What age group defines the geriatric population?
65 and older
Define gerontology
The branch of science that deals with aging and the problems of aged persons
Why is the presentation of disease different in the elderly population?
Elderly patients have a decreased ability to respond to stress.
Name 3 factors that are considered critical for successful aging?
Regular exercise
Social engagement
Moderation of food intake
Define frailty (frailty phenotype)
Dysregulation of multiple organ systems due to distinct physiologic changes, increased vulnerability to stressors, and decreased ability to adapt to external stressors
What percent of the U.S. population age 65 to 79 years reports having two or more chronic diseases?
35%
List some common problems seen in the geriatric population
Immobility, Instability, Incontinence, Intellectual impairment, Infection, Impairment of vision and hearing, Irritable colon, Isolation (depression), Inanition (malnutrition), Iatrogenesis, Insomnia, Immune deficiency, Impotence
What are the major demographic trends in the geriatric population?
The geriatric population is growing (due to the baby boomer era and increased life span) with less population coming behind them - leading to a lack of financial support for Social Security and Medicare and fewer healthcare providers.
How will demographic trends affect future health care?
People are living longer - leads to higher geriatric population and longer management of chronic conditions - resulting in more patients who are classified as “disabled” resulting in higher healthcare costs
Name some factors that may affect an older person’s access to healthcare?
Access to transportation
Insurance coverage
Social support
Which entity pays for the majority of nursing home care?
Medicaid
List some predictors of nursing home placement
Older age, functional impairment prior to nursing home admission, lower perceived health, cognitive impairment, and lack of social supports
