Prescribing in Special Populations: Older adults, pregnancy, lactation, children

Question 1

Medications with Significant Systemic Anticholinergic Effects

Answer 1

First-generation antihistamines
–Chlorpheniramine (Chlor-Trimeton®)
–Diphenhydramine (Benadryl®)
–Hydroxyzine (Atarax®)
–Cyproheptadine (Periactin®)
–Promethazine (Phenergan®)

Doxepin (Sinequan®, Silenor®)

Question 2

Commonly Used Meds in Elder with Systemic Anticholinergic Effects

Answer 2

Overactive bladder medications
Tricyclic antidepressants *Amitriptyline vs. nortriptyline

Question 3

Oxybutynin patch (Oxytrol®) for women indication

Answer 3

Overactive bladder

Question 4

Potential Adverse Effects from Select Medications with Significant Systemic Anticholinergic Effect

Answer 4

Dry mouth, skin *Blurred vision *Urinary retention–Usually w/BPH *Sedation *Agitation *Tachycardia *Hyperpnea *Mydriasis *Flushing *Psychosis *Seizure *Coma *Hyperthermia

Question 5

SSRI’s

Answer 5

Paroxetine Sertraline Escitalopram Citalopram Fluoxetine

Question 6

Paroxetine half life

Answer 6

21 h

++ anticholinergic efects

Question 7

Sertraline half life

Answer 7

26 h

Question 8

Sertraline half life

Answer 8

26

0 Sedation +/++ Activation

Question 9

Escitalopram half life

Answer 9

27−32 h
0 anticholinergic effects

Question 10

Citalopram half life

Answer 10

33 h

0 anticholinergic effects

Question 11

Fluoxetine half life

Answer 11

84 h, metabolite=7−15 days
+ Sedation ++/+++ Activation

Question 12

Creatinine

Answer 12

–Breakdown product of muscle creatine phosphate and is usually produced at a fairly constant rate by the body (depending on muscle mass)

Question 13

Blood Urea Nitrogen (BUN evaluates

Answer 13

the amount of nitrogen in the blood in urea form *Urea=Metabolism by-product of proteins by liver, removed from the blood by kidneys

Question 14

BUN to creatinine ratio in presence of proper hydration

Answer 14

Usually ≤20:1 in the presence of appropriate hydration

Question 15

Higher MW=

Answer 15

More difficult passage
Greater than 1000 d‒ Virtually no passage *Insulin, UF heparin, LMWH
*500‒1000 d‒ Difficult
*250‒500 d‒ Easily passed–The bulk of clinically useful drugs–The lower, the easier

Question 16

Category A
pregnancy risk

Answer 16

Well-controlled human study fails to demonstrate fetal risk in 1st trimester *No evidence of risk in 2d, 3d trimesters *Risk to fetus appears remote

Question 17

category risk A med example

Answer 17

Vitamins
Synthroid

Question 18

Category B

Answer 18

Animal studies have not demonstrated fetal risk but no controlled study in humans.

Question 19

Category B risk meds

Answer 19

Beta-lactam antibiotics
–Penicillins–Cephalosporins

*Macrolides
–Azithromycin, erythromycin, but not clarithromycin

Acetaminophen
*Ibuprofen–Caution at end of pregnancy at high dose

*Diphenhydramine–Often cited as safest sleep aid during pregnancy

Nitrofurantoin (Macrodantin®, Macrobid®)

Select inhaled corticosteroids–Budesonide (Pulmicort®) but not fluticasone (Flovent®)

Question 20

Category C

Answer 20

C=Caution
Studies in animals have revealed adverse effects on the fetus
.–Embryocida
l–Teratogenic
–Other

Question 21

Category C risk meds

Answer 21

Clarithromycin (C=C)
–Fluoroquinolones (ciprofloxacin=C) *-floxacin suffix
Most SSRIs exc paroxetine, atypical antidepressants

Question 22

Category D

Answer 22

D=Danger
Positive evidence of human fetal risk
*Benefit from use in pregnancy might be acceptable despite the risk –Is the condition potentially lifethreatening disease vs. life-altering?

Question 23

Category D risk meds

Answer 23

ACEI (-pril suffix),

ARB (-sartan)

The tetracyclines–Doxycycline=D due to teeth staining

Carbamazepine
–Tegretol®–Benefit might outweigh risk in seizure disorder

Lithium