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Summer Disciplines > Pharmacotherapy > Flashcards

Pharmacotherapy Flashcards

1
Q

What are key issues and challenges in geriatric pharmacotherapy

A 
more drugs are available each year 
FDA and off label indications are expanding 
formularies change frequently 
multiple providers prescribe meds 
knowledge of med advances 
drugs change from Rx to OTC status 
use of nutraceuticals and increasing 
effects of aging physiology on drug therapy
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2
Q

What is polypharmacy

A

the use of multiple medications (>5)

the more drugs, the higher the risk of ADEs/hospitalization

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3
Q

What is the “prescribing cascade”

A

When ADE are misinterpreted as new medical condition, causing even more meds to be Rx

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4
Q

What are pharmacokinetics

A

How a drug moves through the body

Absorption, Distribution, Metabolism, Excretion

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5
Q

What are pharmacodynamics

A

The effects a drug has on the body

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6
Q

In Absorption, the GI tract relies heavily on

A

passive diffusion

with age: decreased gastric acid secretion= delayed gastric emptying (slower/decreased, but still complete)

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7
Q

What is “time of peak concentration”

A

time for a drug to reach it’s peak, usually in hours
helps estimate rate of absorption
ex: digoxin peak in 38 hrs in young, 69 hours in old

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8
Q

What age related changes occur in topical absorption

A

epidermis thins and subQ fat decreases= INCREASED absorption

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9
Q

What is Vd

A

volume of distribution; ratio of dose present in body and it’s concentration

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10
Q

how is volume of distribution affected

A

Decreased body water= lower Vd (if hydrophilic)= higher serum level of drug
Dec. LBM= lower Vd for muscle binding drugs
Increased fat stores: higher Vd (if lipophilic)= prolonged half life
Dec. plasma protein (albumin)= more unbound and active

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11
Q

What is the MC site of drug metabolism

A

LIVER; rate of clearance may be reduced 2/2 aging (decreases liver blood flow, enzyme activity, and mass

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12
Q

What is the Phase I pathway of metabolism

A

Drugs are converted to active metabolites (CYP450, CYP3A4)

This pathway is the most affected by age (decreases in elderly)

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13
Q

Where are most drugs excreted

A

KIDNEY!
can be affected by aging and common geriatric d/o
if elimination is reduced, drugs accumulate and can cause toxicity

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14
Q

CHF (common geriatric d/o) is associated with

A

hypoperfusion to the liver and kidneys
reduced Vd
impaired clearance
increased plasma concentration of drugs

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15
Q

What are the effects of aging on the kidneys

A 
Decrease size 
Decrease renal plasma flow 
Decrease renal tubular secretion 
Decrease # of functioning nephrons (glomeruli) 
=LOW GFR, even if w/o kidney disease
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16
Q

What is half life

A

time for serum concentration of drug to decline by 50%

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17
Q

What is clearance

A

volume of serum from which drug is removed per unit of time

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18
Q

What are the stages of kidney disease, based on GFR

A

1: 90+
2: 60-89
3: 30-59
4: 15-29
5: <15

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19
Q

Is dig a first line for AFib or HF?

A

NO! “avoid as first line therapy”

dose based on LBM and renal fxn

20
Q

MC meds involved in ADEs are

A 
CV drugs 
Diuretics 
NSAIDs
Hypoglycemics 
Anticoags 
Meds with narrow margin of safety
21
Q

What are some predictors of ADE

A 
6+ concurrent conditions 
9+ meds 
12+ doses of drugs/day 
prior ADE 
Low body weight/BMI 
85+ 
EGFR <50
22
Q

How do you select the proper drug

A

Based on effectiveness, safety, convenience, and cost

23
Q

Why ask yourself “is each med necessary?”

A

They can be on 4 drugs, and two can be doing the same thing. This way, you can eliminate one drug!
*Dont assume a drug is indicated because it has been prescribed- always monitor for over/under prescribing

24
Q

Commonly UNDERprescribed drugs include

A 
ACE-I (for DM) 
ARB 
Anticoags 
Anti-HTN/diuretics 
BB (for HF/ s/p MI) 
Bronchodilators 
PPI/misoprostol (to protect from NSAIDS) 
Statins 
Vitamin D/Calcium
25
Q

What is something not many pt know about vicodin

A

it has tylenol in it (paracetamol); so dont take Tylenol if you are taking Vicodin!

26
Q

How do you know if a drug is appropriate for the elderly

A

BEERS CRITERIA for potentially inappropriate meds (PIM)

PIM have limited effectiveness in elderly and are associated with delirium, GI bleeds, falls, and Fx

27
Q

What is beers criteria

A

evidence based guide for clinicians to use (NOT to sub for professional judgement) when prescribing old people meds
-Tells you which classes to avoid, and what to use caution with

28
Q

Commonly used INAPPROPRIATE drugs on BEERS criteria include

A 
antihistamine 
anticholinergics 
GI/antispasmodic 
Benzos 
TCA
Sedative/hypnotics 
Anticoags
29
Q

Warnings with duplicate medications

A

multiple meds can have the same active ingredient (tylenol PM and vicodin)
more than one drug comes from the same class (advil and aleve)

30
Q

Who should NO take hydrochlorothiazide

A

pregnant moms
nursing moms
peds
-caution if with renal or hepatic disease

31
Q

Effective dosing depends on

A 
patient's age, functional status, renal and hepatic fxn 
comorbidities 
concurrent drug regimen 
goals of care 
**Start low go slow**
32
Q

ALWAYS ensure before prescribing a new med

A

that it is a true disease state, and not an ADE from another medication

33
Q

Examples of drugs that are high risk in geriatrics (65+)

A

Glyburide
Diuretics
Naproxen

34
Q

When trying to simplify a drug regimen

A 
use the fewest meds possible, in the simplest form to achieve desired Tx 
try non-pharm options if possible 
d/c unnecessary or expired drugs 
give ER to decrease admin frequency 
use combo products
35
Q

Some consequences of drug-drug interactions include

A

decreased efficacy
unexpected ADE (confusion, delirium, cog impairment, hypotension, acute renal failure)
increased activity of drug

36
Q

What are common drug-drug interactions

A 
ACE + K sparing diuretic: hyperkalemia 
ACE/ARB + Bactrim: hyperkalemia 
Benzo + Sedative/hypnotic: CNS depression 
Digoxin + Macrolide: Dig toxicity 
Lithium + ACE/loop diuretics: Lithium toxicity 
Warfarin + antimicrobial: high/low INR 
Warfarin + NSAID: bleeding risk 
Phenytoin + Bactrim: Phenytoin toxicity 
Sulfonylurea + Abx: hypoglycemia
37
Q

If you have CHF, do NOT take

A

non-DHP CCB

38
Q

Common drug-food interactions are

A 
dairy products 
coffee
grapefruit juice 
coke 
alcohol 
tra
charcoal broiled foods 
green leafy veggies 
licorice 
ginseng
39
Q

NSAIDS (meloxicam, ibuprofen, etc) have this black box warning

A

increased risk of serious/fatal CV and thrombotic events (MI, stroke)
increased risk of serious GI events (bleeding, ulcer, intestinal perforation

40
Q

Non-adherence can be 2/2

A

Clinicians not considering patients financial, cognitive, or functional status
Patient’s beliefs and understanding of drugs/diseases

41
Q

What do many elderly patients do (stupidly)

A

take non-prescription meds

share medication

42
Q

Principles of rational prescribing include

A 
ask pt to bring in all meds for review 
consider non-pharm approaches 
avoid starting 2 drugs at the same time 
ask about ADE 
screen for drug and disease interactions 
eliminate unnecessary drugs 
simplify dosing regimens
43
Q

Final tips!!!

A

Help patient create a med list, and date it
review each med to see if it is on beers list
consider d/c: bisphosphanates (if >5 yr), PPI (if no longer taking NSAID), iron, anti-psychotics, antidepressants

44
Q

Rational presribing is

A

choosing correct dose and drug for the condition

45
Q

Age alters

A

pharmacokinetics (ADME)

46
Q

How can common ADE be minimized

A

strict attentino to risk factors
drug-drug interactions
drug-disease interactions

Summer Disciplines (6 decks)

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