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PHM 704: gremlins and wizards > Witches and Wizards: Safe Med Use > Flashcards

Witches and Wizards: Safe Med Use Flashcards

1
Q

geriatric syndromes (example)

A
  • dementia, delirium
  • urinary incontence
  • falls
  • dizziness
  • syncope
  • malnutrition
  • pressure ulcers
  • sleep problems
  • polypharmacy
  • iatrogenesis
  • frailty

bolded syndromes are the classic geriatric syndromes

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2
Q

geriatric syndrome definition

A

multiple factors, organs, systems going wrong -> hard to get an exact dx -> treat te s/sx

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3
Q

delirium vs dementia onset

A
  • delirium: sudden, definite beginning point
  • dementia: slow, gradual, uncertain begining point
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4
Q

delirium vs dementia duration

A
  • delirium: days to weeks
  • dementia: permanent
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5
Q

delirium vs dementia cause

A
  • delirium: almost always another condition (infection, dehydration, withdrawal)
  • dementia: chronic brain disorder (AD)
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6
Q

delirium vs dementia course

A
  • delirium: usually reversible
  • dmeneita: permament
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7
Q

delirium vs dementiav effect at night

A
  • delirium: almost alwas worse at night
  • dementia: usually worse
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8
Q

delirium vs dementia attention

A
  • delirium: greatly ipaire
  • dementia: unimpaired until severe disease
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9
Q

delirium vs dementia level of consiousness

A
  • delirum: variably ipaired
  • dmenttia: unimpaired until severe disese
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10
Q

delirium vs dementia orientaiton to time and place

A
  • delirium: varies
  • dementia: impaired
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11
Q

delirium vs dementia use of language

A
  • delirium: slow, often incoherent and inapprorpatie
  • dementia: difficulty finding right word
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12
Q

delirium vs dementia memory

A
  • delirium: vaires
  • dementia: lost, esp for recent events
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13
Q

delirium vs dementia need for medical attnetion

A
  • delirium: immediate
  • dementia: required, but less urgently
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14
Q

frailty

A
  • wt loss > 4.5 kg or 5% of wt per year
  • self-reported exhaustion
  • low energy expenditure
  • slow gait
  • weak grip strength
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15
Q

5 Ms of geriatrisc

A
  • mentation/mind
  • mobility
  • meds
  • multicoplexity
  • matters most
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16
Q

Table 2 drugs: first-gen antihistamines - why bad

A
  • highly anticholinergic -> falls, delirium, dementia, dry mouth,, consitpation
  • diphenhydramine acceptable for acute treamtent of severe allergic reaction
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17
Q

Table 2 drugs: nitrofurantoin - why bad

A
  • avoid specifically in CrCl <30 or for long term suppression
  • potential for pulm tox, hepatotox, peripheral neuropathy
  • safer options available
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18
Q

Table 2 drugs: asa for primary prevention - why bad

A
  • bleed risk and not a ton of evidence for benefit
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19
Q

Table 2 drugs: warfarin - why bad

A
  • bleed risk > > DOACs
  • acceptable in: pts with CI or substantial barriers to DOACs AND pts who have been on warfarin long term
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20
Q

Table 2 drugs: xarelto - why bad

A
  • bleed > > > other DOACs, esp eliquis (still better than warfarin tho)
  • reasonable if: reasonable if QD dosing necessary for adherence
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21
Q

Table 2 drugs: dipyridamole - why bad

A
  • ADR oorthostatic hypotension
  • more effective altneratives available
  • acceptable in IV form acceptable for sue in stress testing AND PO combo version with asa for secondary prevention
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22
Q

Table 2 drugs: non-selective peripheral alpha blockers - why bad

-azosin

A
  • big no no for treatment of hypertension
  • ADR orhtostatic hypotension
  • alt agents aviailable with better risk/benefit profile
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23
Q

Table 2 drugs: central alpha agonst - why bad

clonidine, guanfacine

A
  • big no no for treatment of hypertension (clonidine acceptable but not as firsft line)
  • ADR CNS effects
  • may worsen brady cardia and orthostatic hypotension
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24
Q

Table 2 drugs: nifedipine IR - why bad

A
  • hypotension
  • risk of precipitating MI
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25
Q

Table 2 drugs: amiodarone - why bad

A
  • greatter tox than other agents (do NOT use as first line)
  • acceptable in pts with HF or substantial left ventricualr hypertrophy
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26
Q

Table 2 drugs: dronederone - why bad

A
  • worse outcomes in pts with afib or severe HF
  • acceptable but cautioned use in pts with HfrEF
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27
Q

Table 2 drugs: digoxin - why bad

A
  • acceptable but NOT as firsst line for afib orr HF (if using avoid TDD >0.125mg)
  • safer and more effet alts
  • decreased renal clearance -> tox
28
Q

Table 2 drugs: antidepressants with strong anticholinergic activity - why bad

A
  • highly anticholinergic
  • sedating
  • orthsotatic hypotension

doxepin safety comparable to placebo at TDD < 6mg

29
Q

Table 2 drugs: antiparkinsonian agents with strong anticholinergic - why bad

benztropine, trihexyphenidyl

A
  • anticholinergic
  • more effective agents available
30
Q

Table 2 drugs: antipsychotics (first AND second gen) - why bad

A
  • risk of stroke
  • greater rate of cognitie decline
  • mortality in persons with dementia
  • acceptable in FDA approed indications (schizophrenia etc)
31
Q

Table 2 drugs: barbituates - why bad

butalbital, phenobarnital, primidone

A
  • high rate of physical dpendence
  • tolerance to sleep benefits
  • greater risk of overdose at low doses
32
Q

Table 2 drugs: benzos - why bad

A
  • risk of abuse, misuse, addition
  • conmittant use of opioids -> resp depression, coma, death
  • increased sensitivty and decreased metabolism ) physical dependence
  • risk of cog impairment, falls, fractures, and MVA
  • acceptable in seizure disorders, REM disorders, benzo withdrawal, EtOH withdrwal, severe GAD, periprocedural anesthesia
33
Q

Table 2 drugs: z-drugs - why bad

eszopiclone, zaleplon, zolpidem

A
  • ADR similar to benzos (delirium falls, fractures, increased visit to ER, hospitalzations, MVA)
  • miminal improvement in sleep latency and durtion
34
Q

Table 2 drugs: meprobamate - why bad

A
  • high rate of physical dependence
  • very sedaatng
35
Q

Table 2 drugs: ergot alkalids - why bad

A

lack of efficacy

36
Q

Table 2 drugs: androgens/testosterone - why bad

A
  • cardiac problems
  • risks in men with prosate cancer
  • acceptable in confirmed hypogonaidsm with clincal s/s
37
Q

Table 2 drugs: estrogens - why bad

A
  • carcinogenic potential
  • lack of cardioprotectie effect and lack of cognitive protection
  • increased risk of heart disease, stroke, blood clots, dementia
  • acceptable as low dose vaginal cream or tablets for treatment of vaginal s.s
38
Q

Table 2 drugs: insulin ss WITHOUT basal or long actig insulin - why bad

A

hypoglycemia

39
Q

Table 2 drugs: sulfonylureas - why bad

glimepiride, glipizide, glyburide

A
  • risk of CV events, all cause mortality, hypoglycemia (longer acting agents glyburide and glimepiride have a higher risk of hypoglycemia)
40
Q

Table 2 drugs: desiccated thyroid - why bad

armour thyroid

A
  • cardiac effects
  • safer alts
41
Q

Table 2 drugs: megestrol - why bad

A
  • minimal effect on weight
  • increased risk of thrmbotic events and death
42
Q

Table 2 drugs: growth horrmone - why bad

A
  • small impact
  • associaaed with edema, arthralgia, carpal tunnel gynecomastia, impaire fasting glucose
  • acceptable in pts rigorously dxed with evidence-based criteria with growth hormone deficiency
43
Q

Table 2 drugs: PPIs - why bad

A
  • specically avoid: scheduled use > 8 weeks
  • risk of c. diff infection, pneumonia, GI malignances, bone loss, fractures
  • acceptable chronic CS or NSAId use, Barrett’s or other conditions that demonatrate need for PPI
44
Q

Table 2 drugs: metoclopramide - why bad

A
  • ADR: EPS including tardive dyskinesia
  • acceptable in gastroparesis with an LOT < 12 weeks
45
Q

Table 2 drugs: GI antispasmodics with strong anticholinergic - why bad

dicyclomine, scopolmine, hyoscyamine

A
  • highlly anticholinergic
  • uncertain effectiveness
46
Q

Table 2 drugs: PO mineral oil - why bad

A
  • potential for aspiration and other ADR
  • safer alts
47
Q

Table 2 drugs: desmopressin - why bad

antidiuretic

A
  • specifcially avoid for treatment of nocturia
  • high risk of hyponatremia
  • safer alts

hypoNa=confusion,brain swelling, coma,death

48
Q

Table 2 drugs: NSAIDs - why bad

including asa TDD > 325mg

A
  • PUD and bleed risk (increased in pts: >75, CS use, anticoag, or antiplatelet use)
  • CV risk (increased bp, increased risk of MI, heart attack and stroke -> avoid in pts with hx of stroke or CAD)
  • kidney injury (decreased blood flow, Na and H2O retention -> avoid in HF)
  • short term scheduled use (while on interacting med) or chronic use acceptable if no other alternatives available and pt can take a stomach protective agent

ketorolac and indomethacin are a hard no

49
Q

stomach protective agents for NSAIDs use

A
  • misoprostol: high dose needed for efficacy but ADR
  • H2RA: double standard dose needed
  • PPI: gold standard

hgih risk pts: try COX-2 selectie (celebrex) + PPI

50
Q

Table 2 drugs: mepiridine - why bad

opioid pain med (demerol)

A
  • not effective in commonly used doses
  • high risk of neurotx (including delrium)
  • safer alts
51
Q

Table 2 drugs: skeletal muscle relaxants - why bad

cyclobenzaprine, metaxalone, methocarbamol

A
  • anticholinergic ADR
  • sedation
  • increased risk of fractures

does NOT apply to baclofen or tizanidine (even tho they have substantial ADR)

52
Q

consequencces of poly pharmacy

A
  • ADR
  • DDI
  • cog impairment
  • functional decline
  • non adherance
  • increased healthcaare cost
  • falls
53
Q

which two anticholingeric medications have very similar structures despite being used for two very very different indicaions

A

cyclobenzaprine and amitriptyline

54
Q

anticholingergic ADRs

A
  • vision impairment (blind as a bat) -> falls
  • dry mouth (dry as a bone) -> nutrition, communicaton, nfection
  • CV -> disease worsening (hot as a hare, red as a beet)
  • GU -> incontinence, infection, loss of independence
  • CNS -> cognition (mad as a hatter)
55
Q

T/F: all antidepressants carry a fall risk

A

T, but not all are anticholingergic, anticholinergics have additional ADR

56
Q

barriers to deprescribing

A
  • individual/patient factors: personal uncertanity, “md knows best”, impaired cognition
  • sociocultural factors: med culture of prescribing
  • personal and relational factors: fear/accountability, not wanting to mess with another provider’s work
  • organizational factors: not enough time or funding, fragmented care
57
Q

facilitators of deprescribing

A
  • individual/patient factors: awareness of potetnial harm, disccusion of goals of care
  • sociocultural factors: less is mroe, acknowledging complexity of multimorbidity and frailty
  • personal and relational factors: continuatiion of care, communication between providers
  • organizational factors: reimmbursement, access to support resources
58
Q

process of describing

A
  1. comprehensive med hx (if med stopped, why stopped)
  2. identifiy PIMs
  3. determine eligibility for deprescrbing and prioritize
    - greatest harm and least benefit
    - easiest to dc without rebound s/s or withdrawal
    - what is pt most willing to dc
  4. plan and initiate withdrawal
  5. monitor, support, document
59
Q

meds that are good canditates for dc include

A
  • no valid indication
  • part of prescribing cascade
  • harm clearly outweighs benefit
  • preventative med unlikely to confer benefit in pt remaining lifespan
  • drug imposes unacceptable treatment burden
60
Q

intense glucose cotrol in DM ttb and tth

A
  • ttb(time to benefit): 10 yrs
  • tth (time to harm: minutes
61
Q

bisphosphanates for osteoporisis TTB

A

8-19 months

62
Q

statins for primary prevention TTb

time to benefit

A

2-5 yrs

63
Q

HTN primary preention TTB

A

1-2 yrs

64
Q

asa for primary prevention TTB

A

10 yrs

65
Q

how to taper off a benzo

A

reduce by 25% of original dose q2w with 12.5% reductions towards end if possible
- incoporate drug free days at end if possible

PHM 704: gremlins and wizards (16 decks)

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