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Phase 3a geriatrics > Polypharmacy > Flashcards

Polypharmacy Flashcards

1
Q

Define pharmacokinetics and explain in simple terms

A

the bodily absorption, distribution, metabolism, and excretion of drugs (DAME)

What the body does the to the drug

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2
Q

Define pharmacodynamics and explain in simple terms

A

the biochemical and physiological effects of drugs

what the Drug does to the body (pharmacoDynamics)

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3
Q

Define polypharmacy

A

taking more than 4 medications, or the concurrent use of multiple medications by one person

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4
Q

What is appropriate polypharmacy?

A

Optimisation of medication for patients with complex conditions or comorbidities

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5
Q

What is inappropriate/problematic polypharmacy?

A

When multiple medications are prescribed inappropriately, increasing risk of side effects

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6
Q

Why do we have problematic prescribing?

A
  1. Multimorbidity – as clinical trials only include single-disease pts
  2. Incremental prescribing/prescribing cascade – where medications are given as a result of side effects of others – iatrogenic
  3. End of life – pts staying on meds beyond the point at which they get benefit from them
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7
Q

Give an example of inappropriate prescribing?

A

Patient on several antihypertensives leading to postural hypotension

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8
Q

What are the risk factors for polypharmacy?

A
  • chronic disease
  • comorbidity
  • cognitive impairment/dementia
  • renal or liver impairment
  • end of life
  • past or current non-adherence
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9
Q

Why might older patients find it hard to take many medications?

A

Cognitive impairment - Pts may not understand instructions
Visual impairment - unable to read instructions
Lack of treatment supervision leads to non-adherance

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10
Q

What is a drug-disease interaction and give an example?

A

When a medication makes management of a disease more difficult

NSAIDs making hypertension worse

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11
Q

What about a drugs pharmacokinetics mean that older people more sensitive to the adverse effects of polypharmacy?

A

Distribution

  • Increase in body fat and decrease in body water
  • Increased permeability of the blood brain barrier
  • Malnutrition

Absorption
- increased gastric pH

Metabolism

  • reduced hepatic perfusion
  • changes in CYP450

Elimination
- reduced renal perfusion

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12
Q

How does an increase in body fat and decrease in body water affect the pharmacokinetics of a drug?

A

lipophilic drugs eg Benzodiazepines eg Diazepam and Chlordiazepoxide accumulate due to increased volume of distribution, so still have an effect after the medication has been stopped – takes longer to be eliminated (increased elimination half life) so more likely to have drowsiness and confusion for longer and increased risk of side effects if given multiple doses.

Volume of distribution of water-soluble drugs decreases eg Digoxin, so need a lower loading dose

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13
Q

Define volume of distribution

A

the theoretical volume that would be necessary to contain the total amount of an administered drug at the same concentration that it is observed in the blood plasma (smaller volume of distribution, means need less drug)

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14
Q

How does increased permeability of the blood brain barrier affect the pharmacokinetics of a drug?

A

causes cognitive affects, as drugs can pass through thre BBB

eg older patients get confused and sleepy for longer with buprenorphine patches than younger pts even after you take it off

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15
Q

How does malnutrition affect the pharmacokinetics of a drug?

A

Serum concentrations of unbound (free) drug increase, due to reduced serum albumin. this enhances drug effects and toxicity

eg Phenytoin and warfarin

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16
Q

Why are older patients more likely to have an increased gastric pH (ie more alkaline)?

A

due to PPIs and atrophic gastritis

17
Q

How does increased gastric pH affect the pharmacokinetics of a drug?

A

medications that are meant to be absorbed in acidic conditions don’t get absorbed as well

eg calcium carbonate reduced so may need a higher dose of calcium replacement or use a capsule

and enteric coated tablets may be released early in the stomach, causing GI adverse effects eg enteric coated aspirin or erythromycin

18
Q

How does reduced hepatic perfusion affect the pharmacokinetics of a drug?

A

reduced clearance

eg amitriptyline, propranolol and nifedipine (a CCB for angina and hypertension)

BUT may also result in reduced first-pass metabolism in the liver, which occurs before a drug reaches systemic circulation also decreases

19
Q

How are CYP450 enzymes affected in older patients?

A

More likely to be taking CYP450 inducers or inhibitors which increases the chance of drug-drug interactions

AND

Hepatic metabolism of many drugs through the CYP450 enzyme decreases with age, which causes a decrease in hepatic clearance by 40%

20
Q

Name 3 CYP450 inducers

A

SCRAP GP - a few are:

  1. Rifampicin
  2. alcohol (chronic)
  3. Carbamazepine
  4. phenytoin
21
Q

Name 3 CYP450 inibitors

A

SICKFACES.COM - a few are:

  1. sodium valproate
  2. alcohol (acute)
  3. Erythromycin
  4. omeprazole
22
Q

How does reduced renal perfusion affect the pharmacokinetics of a drug?

A

reduced eGFR, so water soluble drugs (to be cleared in the urine) are cleared slower

eg diuretics, digoxin and NSAIDs - digoxin may accumulate in renal failure to cause toxicity

23
Q

What are the signs of digoxin toxicity?

A

o N+V
o Abdo pain
o Yellow discolouration of vision
o Arrythmias

24
Q

What pharmakoDynamic changes occur in older patients?

A
  1. changes in receptor binding
  2. post-receptor effects
  3. pathological changes in organs
25
Q

Give an example of where receptor binding is interfered with in older age

A

salbutamol less effective due to calcification of blood vessels, calcification changes the beta-adrenoceptor receptor itself and post-receptor effects

26
Q

Name some drugs which are have a particularly high anticholinergic burden

A

Antidepressants: Amitryptilline
Antipsychotics: clozapine
(ALL) Opioids: codeine, morphine, fentanyl
blAdder drugs - oxybutinin

27
Q

Name some anticholinergic side effects

A

a. Brain: Hallucinations, cognitive impairment, delirium
b. Heart: tachycardia, orthostatic hypotension
c. Eyes: dry eyes, light sensitivity
d. Mouth: dry mouth, difficulty swallowing
e. Skin: decreased sweating, dry skin
f. Bladder/bowel: difficulty starting urination, urinary retention, constipation

28
Q

Why are anticholinergic side effects problematic for older patients and what does this mean for their use?

A

Older adults are particularly sensitive to anticholinergic effects
Older adults with cognitive impairment are more likely to get CNS effects from anticholinergics

older adults should avoid drugs with anticholinergic effects if possible

29
Q

What medications apart from anticholinergics also cause problems in older people?

A

sedatives

30
Q

What are the geriatric giants (in terms of Is)?

A
  • Incontinence
  • Intellectual impairment
  • Iatrogenesis
  • Instability (falls)
  • immobility
31
Q

What is the significance of cognitive impairment as a result of being on anticholinergics?

A

pts may be referred to the memory clinic when it is actually a side effect of a medication they are on

32
Q

What scale can be used to measure anticholinergic burden?

A

the anticholinergic burden scale

33
Q

What are the common causative drugs for adverse drug reactions?

A
  1. Cardiovascular drugs
    - Diuretics
    - Digoxin
    - Antihypertensives
  2. CNS drugs
    - Hypnotics
    - Antipsychotics
    - Antidepressants
  3. Opioids
  4. NSAIDs
34
Q

When looking at someone’s medications, how can you decide which are the most important and therefore not to deprescribe?

A
  1. Drugs providing immediate relief of distressing symptoms
    eg pain relief, antiemetics, antianginals esp in end of life care
  2. Modify an acute condition that is life-threatening or will soon result in distressing symptoms if untreated
    eg antibiotics for pneumonia or sepsis, diuretics for heart failure, Parkinson’s drugs, antiepileptics
  3. Modify a chronic condition that may progress to become life-threatening or cause significant symptoms if not treated
    eg methotrexate for RA
35
Q

When looking at someone’s medications, how can you decide which are the least important and therefore consider deprescribing?

A
  1. Can prevent serious disease without symptomatic benefit
    eg antiplatelets, antihypertensives, statins
  2. Unlikely to be useful in short or long-term eg fish oil
  3. Where non-pharmacological therapy is just as good eg physio
  4. drugs that address a problem that is no longer present
36
Q

What is it important to remeber before deprescribing drusg?

A

Consult with the patient and have a clear discussion about your reasoning nad explore their preferences

Some drugs can only be deprescribed by a specialsit
eg antiepileptic meds, antiparkinsons drugs

37
Q

What tools are there to aid in deprescribing?

A

 STOPP START Toolkit
 Beer criteria
 STOPP FRAIL
 NO TEARS – designed to be used in a 10 minute primary care consultations

38
Q

List some barriers to deprescribing

A

Doctor factors:
 Concern from clinicians to discontinue medications started by someone else
 Fear of losing dr-pt relationship
 Fear of drug-withdrawal side effects
 Time and resource constraints – eg explaining to pt why you are doing this or resources such as mental health support vs antidepressants
 Research studies often do not include older people or only include pts with a single disease

Patient factors:
 Resistance from pts or family

Phase 3a geriatrics (13 decks)

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