This patient, an 80-year-old woman, presented with severe dizziness and blackouts. She was taking medications for hypertension and angina that can cause postural hypotension, including hydrochlorothiazide, isosorbide mononitrate, and nifedipine. On examination, her blood pressure was significantly lower when standing than supine. The underlying problem is symptomatic postural hypotension caused by the combined effects of the antihypertensive medications, which is made worse by age-related physiological changes. Drugs that reduce blood pressure or impair autonomic responses in the elderly can cause postural hypotension, so the smallest effective doses should be used.

1. CASE DISCUSSION
SESSION-1
#PharmD
Dr. S P Srinivas Nayak, PharmD, Rph, MSc, Dip.D
Assistant Professor, PIPR,
Parul University, Vadodara, Gujarat

2. CASE ON ELDERLY
• An 80-year-old woman presented to an out-
patient clinic with a history of severe giddiness
and a few episodes of blackouts. She was K/C/O
angina and hypertension. She had been on
1. Tab. Hydrochlorthiazide 20 mg od, and
2. Tab. isosorbide mononitrate 60 mg SR Od for a
few years.
• Her GP had recently added nifedipine SR 20 mg
twice daily for poorly controlled hypertension.
• On examination her blood pressure was 120/70
mmHg while supine and 90/60 mmHg on
standing up.

5. QUESTION
• What is the underlying problem in this
patient?

6. Points to remember
about Thiazides
• Thiazides cause electrolyte disturbances, which
include hypokalaemia, hyponatraemia, metabolic
alkalosis, hypomagnesaemia and hypercalcaemia.
• They may cause impotence; hence thiazides are not
the preferred antihypertensives in young males.
Others: Skin rashes,
• photosensitivity,
• gastrointestinal disturbances
• like nausea, vomiting,
• diarrhoea, etc.

8. ADVERSE EFFECTS OF NITRATES
• Has rapid firstpass metabolism
• Adverse effects are due to extensive
vasodilatation.
• They are headache, postural hypotension,
tachycardia, palpitation, weakness, flushing and
rarely syncope.
• To avoid these symptoms, the tablet may be spit
out as soon as the pain is relieved.
• Overdosage may cause methaemoglobinaemia.
• Tolerance to nitrates occurs on prolonged use.

9. Points to remember about Nifedipine
• All calcium channel blockers are well absorbed
through GI tract but undergo varying degree
of firstpass metabolism. All are highly bound
to plasma proteins, metabolized in liver and
excreted in urine
• Postural hypotension, Palpitation Reflex
tachycardia, Oedema, Flushing, Fatigue
Dizziness, Sedation.

10. ANSWER
• This patient obviously has significant postural
hypotension. All her drugs have the potential
to produce postural hypotension, and when
used together they may produce symptomatic
postural hypotension.

11. • It is important to recognise that some drugs such
as nifedipine and nitrates have impaired first-
pass metabolism in the elderly and that their
clinical effects are enhanced. In addition,
orthostatic circulatory responses are also
impaired in the elderly. The need for
antihypertensive drugs should be carefully
assessed in all elderly patients, and, if therapy is
indicated, the smallest dose of drug should be
commenced and increased gradually. Patients
should also be told to avoid sudden changes of
posture.

12. PHYSIOOGICAL Changes in elderly
• reduced gastric acid secretion
• • decreased gastro-intestinal motility
• • reduced total surface area of absorption
• • reduced splanchnic blood flow
• • reduced liver size
• • reduced liver blood flow
• • reduced glomerular filtration
• • reduced renal tubular filtration.

13. Drugs that cause hypotension
• Antihypertensive drugs, drugs with α receptor
blocking effects (e.g. tricyclic antidepressants,
phenothiazines and some butyrophenones),
drugs which decrease sympathetic outflow
from the central nervous system (e.g.
barbiturates, benzodiazepines,
antihistamines and morphine) and
antiparkinsonian drugs (e.g. levodopa and
bromocriptine)

15. Elderly population is more sensitive to
• Benzodiazepines
• Warfarin
• Digoxin
Risk for
Parkinsonism
Stroke
Osteoporosis
Arthritis
HTN
CVS-MI
Urinary incontinence, CONSTIPATION, LEG ULCERS

16. CASE-2
• An 80-year-old woman with a previous history
of hypothyroidism presented with a history of
abdominal pain and vomiting. She had not
moved her bowels for the previous 7 days.
Two weeks earlier her general practitioner had
prescribed a combination of paracetamol and
codeine to control pain in her osteoarthritic
hips.
• WHAT IS THE CAUSE OF HER PROBLEM?

17. ANSWER
• This patient developed severe constipation
after taking a codeine-containing analgesic.
• Ageing is associated with decreased gastro-
intestinal motility. Hypothyroidism, which is
common in the elderly, is also associated with
reduced gastrointestinal motility.
• Whenever possible, drugs that are known to
reduce gastro-intestinal motility should be
avoided in the elderly.

18. CASE-3
• A 70-year-old man was found by his general
practitioner to have hypertension and was
commenced on lisinopril 5 mg once a day. He
had a previous history of peripheral vascular
disease for which he had required angioplasty.
Two weeks after commencing antihypertensive
treatment, he presented with lack of appetite,
nausea and decreased urine output.
• WHAT MAY BE THE REASON FOT HIS PROBLEM?

19. ANSWER
• The patient is probably developing renal
failure.
• With a previous history of peripheral vascular
disease, he is likely to have bilateral renal
artery stenosis.
• ACE inhibitors can cause renal failure in the
presence of bilateral renal stenosis by
reducing blood supply to the kidneys.

20. THANK YOU..
A DRUG CAN NOT ONLY CURE THE
DISEASE BUT ALSO CAN AGGREVATE THE
CONDITION WITHOUT #PharmDoctor
---MED EASY