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IMMUNOPHARMACOLOGY
TOPIC:SPECIAL ASPECTS OF GERIATRICS
PHARMACOLOGU
BY:
DR. SABA AHMED
M PHIL PHARMACOLOGY
UOS
 20% of hospitalizations for those >65 are due
to medications they’re taking
 Alzheimer`s disease
 Parkinsonism
 Stroke
 Vascular dementia
 Visual impairment specially cataracts and macular
degeneration
 Atherosclerosis
 Arthritis
 Heart failure
 Fractures
 Cancer
 Diabetes
 Heart failure
 Physiologic change
◦ Decreased gastric acidity
◦ Decreased gastrointestinal blood flow
◦ Delayed gastric emptying
◦ Slowed intestinal transit time
 General clinical effect
◦ None on passive diffusion or bioavailability for most drugs
◦ Decreased active transport: Decreased bioavailability for
some drugs
◦ Decreased first-pass effect: Increased bioavailability for
some drugs
 Decreased Total body water
◦ Increased Plasma Conc. of water soluble drugs
◦ Lower doses are required: Lithium, digoxin, ethanol, etc
 Decreased Lean body mass
◦ Increased Volume Distribution, Longer (t½) of water soluble
drugs
◦ Accumulation into fat of lipid soluble drugs: Benzos, etc
 Decreased Serum Albumin
◦ Increased unbound fraction of highly protein bound drugs
◦ Binds acidic drugs: warfarin, phenytoin, digitalis, etc
 Decreased Alpha1 Acid glycoprotein
◦ Increased unbound fraction of highly protein bound drugs
◦ -Binds basic drugs: lidocaine and propranolol, etc
 Difficult to predict, depends on
General health & nutritional status
 Use of alcohol, medications
Long term exposure to environmental toxins/pollutants
 Aging causes decreased liver mass/ hepatic blood
flow
Delayed/reduced metabolism of drugs
Higher plasma levels
Greatest changes in phase 1 reaction those carry out
microsomal p450 enzyme system
Decline in liver ability to recover from injury
 Lower serum protein levels
Loss of protein binding
 Idiosyncratic reactions
 Metabolic clearance of drugs by the liver may
be reduced due to:
◦ decreased hepatic blood flow
◦ decreased liver size and mass
 Examples: morphine, meperidine, metoprolol,
propranolol, verapamil, amitryptyline,
nortriptyline
 Determined
◦ Primarily by renal function
◦ Declines with age and is worsened by co-morbidities
◦ Decline is not reflected in an equivalent rise in
serum creatinine since creatinine production is
reduced due to lower muscle mass
 Physiologic change
◦ Decreased GFR
◦ Decreased renal blood flow
◦ Decreased renal mass
 General clinical effect
◦ Decreased clearance, Increased (t½) of renally
eliminated drugs
 Creatinine clearance (CrCl) is used to
estimate glomerular rate
 Serum creatinine alone not accurate in the
elderly
◦  lean body mass  lower creatinine production
◦  glomerular filtration rate
 Serum creatinine stays in normal range,
masking change in creatinine clearance
 Measure
◦ Time consuming
◦ Requires 24 hr urine collection
 Estimate
◦ Cockroft Gault equation
(IBW in kg) x (140-age)
------------------------------ x (0.85 for
females)
72 x (Scr in mg/dL)
 Pharmacodynamic changes in the elderly have
been less extensively studied
 Evidence of enhanced end-organ
responsiveness or “sensitivity” to medications
with aging
 Enhanced “sensitivity” may be due
◦ Changes in receptor affinity
◦ Changes in receptor number
◦ Post-receptor alteration
◦ Age-related impairment of homeostatic mechanisms
Example: decreased baroreceptor reflexes
 Age-related changes:
◦  sensitivity to sedation and psychomotor
impairment with benzodiazepines
◦  level and duration of pain relief with narcotic
agents
◦  drowsiness with alcohol
◦  sensitivity to anti-cholinergic agents
◦  cardiac sensitivity to digoxin
 Cognitive changes associated with vascular
and other pathology
 Economic stresses with greatly associated
with reduced income or due increased
expenses due to illness
 Loss of spouse
 Positive relationship between number of drugs
taken and incidence
 Overall incidence is estimated to be at least twice
that in the younger population
 Prescribing errors
◦ Polypharmacy
◦ Drug interactions with other prescriptions
◦ Unawareness of age related physiologic changes
 Drug usage errors
◦ “Hidden ingredients”: OTCs
Factors contributing to adverse drug reactions
in elderly patients
Polypharmacy
How many prescription medications are too many? >4 or >6
Many elderly people receive 12 medications per day
Heart, kidney, liver,
thyroid
 Economic factors
◦ May have to choose between food and medications
 OTCs instead of expensive doctor visits
 Use of outdated medications
 Use of home remedies
 Share medications
 Nutritional status may affect how body metabolizes
medications
 Concurrent use of multiple medications
◦ >65 = 12% of population
◦ Consume 30% of all prescription drugs [average
person takes 4-5 prescription meds]
◦ Consume 40% of OTCs
 Excessive use of drugs
 Overdose of a drug
 Risks of problems:
◦ Medication errors
 Wrong drug, time, route
◦ Adverse effects from each drug
 Polypharmacy primary reason for adverse reactions
◦ Adverse interactions between drugs
 CNS drugs
◦ Sedative-hypnotics: Benzodiazepines and barbiturates
◦ Analgesics: Opioids
◦ Antipsychotic, antidepressants: Haloperidol, lithium, TCAs
 Cardiovascular drugs
◦ Antihypertensives: Thiazides, beta-blockers
 Antiarrhythmic drugs
◦ Quinidine and procainamide:  clearance and  (t½)
 Antimicrobial drugs
◦ Beta-lactams and aminoglycosides:  clearance
 Anti-inflammatory drugs
◦ NSAIDs: GI bleed and irritation
Half life of many drugs benzodiazepine and barbiturates
increases 50-150% between age 30 and 70
Age related decline in renal and liver function both
contribute to to the reduction in elimination of these
compounds .
Lorazepam and oxazepam may be less affected by these
change.
It is generally believed that the elderly vary more in their
sensitivity to these sedatives on PD basis as well.
Adverse reactions like Ataxia and motor impairment
mostly present
 Elderly are often markedly more sensitive to
the respiratory effect of these agents because
of age related changes in respiratory function
like airways and tissues become less elastic .
 Narcotic analgesics
◦ Respiratory depression
◦ Constipation
◦ Urinary retention
◦ Hypotension,
◦ dizzines
◦ confusion
 Phenothiazines and Heloperidol have been
heavily used in the management of variety of
psychiatric diseases in elderly .
 Useful in treatments of some symptoms
associated with delirium, dementia, agitation,
combativeness however their use is not
satisfactory in geriatrics conditions.
 Much of these improvements are simply reflect
the sedative effects
 Phenothiazines often induce orhtostatic
hypotension because of their a-adrenergic
blocking effects.
 Antipsychotics
◦ Jaundice
◦ Extrapyramidal symptoms
◦ Sedation, dizziness (can lead to falls)
◦ Orthostatic hypotension
◦ Scaling skin on exposure to sunlight
(phenothiazines)
 Tricyclic antidepressants
◦ Dry mouth
◦ Constipation
◦ Blurred vision
◦ Postural hypotension
◦ Dizziness
◦ Tachycardia
◦ Urinary retention
 Antihypertensive drugs
 Systolic blood pressure increases with age in western
countries and in most culture in which salt intake is high
 Drugs used for it are Thiazides ,calcium channel blocker ,beta
blockers etc
 ADRS related to these drugs
◦ Dizziness and falls
◦ Orthostatic hypotension
 Diuretics
◦ Fluid/electrolyte disorders
◦ Dehydration
◦ Hypotension
◦ Thiazide diuretics can increase blood glucose levels
(more insulin for diabetics)
 Heart failure most common and lethal disease
in elderly
 Fear of this condition may be the one reason
why physicians overuse cardiac glycosides in
this age group
 Digoxin mostly used and clearence is mostly
decreased in elderly and half life increased so
following adverse reactions occur
◦ Fatigue
◦ Loss of appetite, nausea, vomiting
◦ Visual disturbances
◦ Nightmares, nervousness
◦ Hallucinations
◦ Bradycardia, arrhythmias
 Treatment of arrhythmias in elderly is
particularly challenging due to
 lack of good hemodynamic reserves'
 Frequency of electrolyte disturbance
 High prevalence of coronary disease
 Following ADRS observed due to decreased
clearance and increased half life of
antiarrhythmics
◦ Confusion
◦ Slurred speech
◦ Light-headedness, seizures
◦ hypotension
 Age related changes contributes to incidence
of infection in elderly patients
 Reduction in host defense manifested in the
increase in both serious infection and cancer
 In the lungs age dependent decrease in the
mucociliary clearance significantly increase in
susceptibility of infection
 In urinary tract,incidence of infections is
greatly increased by urinary retention
 Since 1940, antimicrobial have contributed
more to prolong the life because they can
compensate to some extent for this
deterioration in natural defenses
 Because most antibiotics are excreted renal
route so change in half life may occur so
adverse reactions takes place
 Osteoarthritis most commonly present in
elderly patients
 NSAIDs and corticosteroids are mostly used
 Corticosteroids are extremely useful in
elderly who cannot tolerate full doses of
NSAIDs however consistently cause increase
in osteoporosis
 NSAIDs
◦ Prolong bleeding
 Gastric discomfort, bleeding
◦ Increased risk of toxicity (with impaired renal
function)
 Corticosteriods
◦ Sodium retention (may worsen HTN & CHF)
◦ Insomnia
◦ Psychotic behavior
◦ osteoporosis
 Disease is characterized by progressive
impairment of memory and cognitive
function, prevalence increases with age
 Pathological changes includes increased
deposits of amyloid beta peptide in cerebral
cortex due to progressive loss of neurons
especially cholinergic neurons and thinning of
cortex
 Many methods of treatment of Alzheimer`s
disease has been explored
 Most attention has been focused on the
cholinomimetics drugs because of evidence
of loss of cholinergic neurons
 Tacrine, donepezil, rivastigmine, and
galantamine are used as these are
cholinesterase inhibitors
 ADRs include nausea, vomiting, and
peripheral cholinomimetics effects
 Memantine binds to NMDA and produce
noncompetitive blockade and better tolerated
and less toxic than cholinestrase inhibitors
 Glaucoma is most common in elderly but
treatment is same as that for glaucoma of earlier
onset
 Age-related macular degeneration(AMD) is the
most common cause of blindness in elderly
patients
 Two types
1.wet form
2.dry form
 Cause of AMD is not known but smoking and
oxidative stress has long been thought to play a
role
 So antioxidants have been used to prevent or
delay the onset of AMD
 Oral formulations of vitamins C and E, beta-
carotene, zinc oxide are available
 Now laser phototherapy and antibiotics are
used
 Antibiotics bevacizumab, ranibizumab and
pegabtanib are approved for AMD
 these agents are injected into vitreous for
local effect
 Balance between overprescribing and
underprescribing
◦ Correct drug
◦ Correct dose
◦ Targets appropriate condition
◦ Is appropriate for the patient
Avoid “a pill for every ill”
Always consider non-pharmacologic therapy
 Polypharmacy
 Multiple co-morbid conditions
 Prior adverse drug event
 Low body weight or body mass index
 Age > 85 years
 Estimated CrCl <50 mL/min
 Absorption may be  or 
 Drugs with similar effects can result additive
effects
 Drugs with opposite effects can antagonize
each other
 Drug metabolism may be inhibited or induced
Combination Risk
ACE inhibitor + potassium Hyperkalemia
ACE inhibitor + K sparing diuretic Hyperkalemia, hypotension
Digoxin + antiarrhythmic Bradycardia, arrhythmia
Digoxin + diuretic
Antiarrhythmic + diuretic
Electrolyte imbalance; arrhythmia
Diuretic + diuretic Electrolyte imbalance; dehydration
Benzodiazepine + antidepressant
Benzodiazepine + antipsychotic
Sedation; confusion; falls
CCB/nitrate/vasodilator/diuretic Hypotension
 Obesity alters Vd of lipophilic drugs
 Ascites alters Vd of hydrophilic drugs
 Dementia may  sensitivity, induce
paradoxical reactions to drugs with CNS or
anticholinergic activity
 Renal or hepatic impairment may impair
metabolism and excretions of drugs
 Drugs may exacerbate a medical condition
Combination Risk
NSAIDs + CHF
Thiazolidinediones + CHF
Fluid retention; CHF exacerbation
BPH + anticholinergics Urinary retention
CCB + constipation
Narcotics + constipation
Anticholinergics + constipation
Exacerbation of constipation
Metformin + CHF Hypoxia; increased risk of lactic
acidosis
NSAIDs + gastropathy Increased ulcer and bleeding risk
NSAIDs + HTN Fluid retention; decreased
effectiveness of diuretics
 Avoid prescribing prior to diagnosis
 Start with a low dose
 Avoid starting 2 agents at the same time
 Reach therapeutic dose before switching or
adding agents
 Consider non-pharmacologic agents
 Review medications regularly and each time a
new medication started or dose is changed
 Maintain accurate medication records (include
vitamins, OTCs, and herbals)
 Suggest physician prescribe combination
drugs or long-acting forms
◦ Fewer pills to remember
 Suggest re-evaluation of medications
periodically
 Encourage client to use one pharmacy
 New medications
◦ Good information
◦ Encourage follow up
 There are several practical obstacles to
compliance that the prescriber must recognize
◦ Forgetfulness
◦ Prior experience
◦ Physical disabilities
 Recommendations to improve compliance
◦ Take careful drug history
◦ Prescribe only for a specific and rational indication
◦ Define goal of drug therapy
◦ High index of suspicion regarding drug reactions and
interactions
◦ Simplify drug regimen
 Avoid newer, more expensive medications
that are not shown to be superior to less
expensive generic alternatives
 Simplify the regimen
 Utilize pill organizers or drug calendars
 Educate patient on medication purpose,
benefits, safety, and potential ADEs
 Basic and Clinical Pharmacology by Bertram
G. Katzung Susan B. Master

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Geriatrics pharmacology

  • 1. IMMUNOPHARMACOLOGY TOPIC:SPECIAL ASPECTS OF GERIATRICS PHARMACOLOGU BY: DR. SABA AHMED M PHIL PHARMACOLOGY UOS
  • 2.  20% of hospitalizations for those >65 are due to medications they’re taking
  • 3.  Alzheimer`s disease  Parkinsonism  Stroke  Vascular dementia  Visual impairment specially cataracts and macular degeneration  Atherosclerosis  Arthritis  Heart failure  Fractures  Cancer  Diabetes  Heart failure
  • 4.  Physiologic change ◦ Decreased gastric acidity ◦ Decreased gastrointestinal blood flow ◦ Delayed gastric emptying ◦ Slowed intestinal transit time  General clinical effect ◦ None on passive diffusion or bioavailability for most drugs ◦ Decreased active transport: Decreased bioavailability for some drugs ◦ Decreased first-pass effect: Increased bioavailability for some drugs
  • 5.  Decreased Total body water ◦ Increased Plasma Conc. of water soluble drugs ◦ Lower doses are required: Lithium, digoxin, ethanol, etc  Decreased Lean body mass ◦ Increased Volume Distribution, Longer (t½) of water soluble drugs ◦ Accumulation into fat of lipid soluble drugs: Benzos, etc  Decreased Serum Albumin ◦ Increased unbound fraction of highly protein bound drugs ◦ Binds acidic drugs: warfarin, phenytoin, digitalis, etc  Decreased Alpha1 Acid glycoprotein ◦ Increased unbound fraction of highly protein bound drugs ◦ -Binds basic drugs: lidocaine and propranolol, etc
  • 6.  Difficult to predict, depends on General health & nutritional status  Use of alcohol, medications Long term exposure to environmental toxins/pollutants  Aging causes decreased liver mass/ hepatic blood flow Delayed/reduced metabolism of drugs Higher plasma levels Greatest changes in phase 1 reaction those carry out microsomal p450 enzyme system Decline in liver ability to recover from injury  Lower serum protein levels Loss of protein binding  Idiosyncratic reactions
  • 7.  Metabolic clearance of drugs by the liver may be reduced due to: ◦ decreased hepatic blood flow ◦ decreased liver size and mass  Examples: morphine, meperidine, metoprolol, propranolol, verapamil, amitryptyline, nortriptyline
  • 8.  Determined ◦ Primarily by renal function ◦ Declines with age and is worsened by co-morbidities ◦ Decline is not reflected in an equivalent rise in serum creatinine since creatinine production is reduced due to lower muscle mass
  • 9.  Physiologic change ◦ Decreased GFR ◦ Decreased renal blood flow ◦ Decreased renal mass  General clinical effect ◦ Decreased clearance, Increased (t½) of renally eliminated drugs
  • 10.  Creatinine clearance (CrCl) is used to estimate glomerular rate  Serum creatinine alone not accurate in the elderly ◦  lean body mass  lower creatinine production ◦  glomerular filtration rate  Serum creatinine stays in normal range, masking change in creatinine clearance
  • 11.  Measure ◦ Time consuming ◦ Requires 24 hr urine collection  Estimate ◦ Cockroft Gault equation (IBW in kg) x (140-age) ------------------------------ x (0.85 for females) 72 x (Scr in mg/dL)
  • 12.  Pharmacodynamic changes in the elderly have been less extensively studied  Evidence of enhanced end-organ responsiveness or “sensitivity” to medications with aging  Enhanced “sensitivity” may be due ◦ Changes in receptor affinity ◦ Changes in receptor number ◦ Post-receptor alteration ◦ Age-related impairment of homeostatic mechanisms Example: decreased baroreceptor reflexes
  • 13.  Age-related changes: ◦  sensitivity to sedation and psychomotor impairment with benzodiazepines ◦  level and duration of pain relief with narcotic agents ◦  drowsiness with alcohol ◦  sensitivity to anti-cholinergic agents ◦  cardiac sensitivity to digoxin
  • 14.  Cognitive changes associated with vascular and other pathology  Economic stresses with greatly associated with reduced income or due increased expenses due to illness  Loss of spouse
  • 15.  Positive relationship between number of drugs taken and incidence  Overall incidence is estimated to be at least twice that in the younger population  Prescribing errors ◦ Polypharmacy ◦ Drug interactions with other prescriptions ◦ Unawareness of age related physiologic changes  Drug usage errors ◦ “Hidden ingredients”: OTCs
  • 16. Factors contributing to adverse drug reactions in elderly patients Polypharmacy How many prescription medications are too many? >4 or >6 Many elderly people receive 12 medications per day Heart, kidney, liver, thyroid
  • 17.  Economic factors ◦ May have to choose between food and medications  OTCs instead of expensive doctor visits  Use of outdated medications  Use of home remedies  Share medications  Nutritional status may affect how body metabolizes medications
  • 18.  Concurrent use of multiple medications ◦ >65 = 12% of population ◦ Consume 30% of all prescription drugs [average person takes 4-5 prescription meds] ◦ Consume 40% of OTCs  Excessive use of drugs  Overdose of a drug
  • 19.  Risks of problems: ◦ Medication errors  Wrong drug, time, route ◦ Adverse effects from each drug  Polypharmacy primary reason for adverse reactions ◦ Adverse interactions between drugs
  • 20.  CNS drugs ◦ Sedative-hypnotics: Benzodiazepines and barbiturates ◦ Analgesics: Opioids ◦ Antipsychotic, antidepressants: Haloperidol, lithium, TCAs  Cardiovascular drugs ◦ Antihypertensives: Thiazides, beta-blockers  Antiarrhythmic drugs ◦ Quinidine and procainamide:  clearance and  (t½)  Antimicrobial drugs ◦ Beta-lactams and aminoglycosides:  clearance  Anti-inflammatory drugs ◦ NSAIDs: GI bleed and irritation
  • 21. Half life of many drugs benzodiazepine and barbiturates increases 50-150% between age 30 and 70 Age related decline in renal and liver function both contribute to to the reduction in elimination of these compounds . Lorazepam and oxazepam may be less affected by these change. It is generally believed that the elderly vary more in their sensitivity to these sedatives on PD basis as well. Adverse reactions like Ataxia and motor impairment mostly present
  • 22.  Elderly are often markedly more sensitive to the respiratory effect of these agents because of age related changes in respiratory function like airways and tissues become less elastic .
  • 23.  Narcotic analgesics ◦ Respiratory depression ◦ Constipation ◦ Urinary retention ◦ Hypotension, ◦ dizzines ◦ confusion
  • 24.  Phenothiazines and Heloperidol have been heavily used in the management of variety of psychiatric diseases in elderly .  Useful in treatments of some symptoms associated with delirium, dementia, agitation, combativeness however their use is not satisfactory in geriatrics conditions.  Much of these improvements are simply reflect the sedative effects  Phenothiazines often induce orhtostatic hypotension because of their a-adrenergic blocking effects.
  • 25.  Antipsychotics ◦ Jaundice ◦ Extrapyramidal symptoms ◦ Sedation, dizziness (can lead to falls) ◦ Orthostatic hypotension ◦ Scaling skin on exposure to sunlight (phenothiazines)
  • 26.  Tricyclic antidepressants ◦ Dry mouth ◦ Constipation ◦ Blurred vision ◦ Postural hypotension ◦ Dizziness ◦ Tachycardia ◦ Urinary retention
  • 27.  Antihypertensive drugs  Systolic blood pressure increases with age in western countries and in most culture in which salt intake is high  Drugs used for it are Thiazides ,calcium channel blocker ,beta blockers etc  ADRS related to these drugs ◦ Dizziness and falls ◦ Orthostatic hypotension
  • 28.  Diuretics ◦ Fluid/electrolyte disorders ◦ Dehydration ◦ Hypotension ◦ Thiazide diuretics can increase blood glucose levels (more insulin for diabetics)
  • 29.  Heart failure most common and lethal disease in elderly  Fear of this condition may be the one reason why physicians overuse cardiac glycosides in this age group  Digoxin mostly used and clearence is mostly decreased in elderly and half life increased so following adverse reactions occur
  • 30. ◦ Fatigue ◦ Loss of appetite, nausea, vomiting ◦ Visual disturbances ◦ Nightmares, nervousness ◦ Hallucinations ◦ Bradycardia, arrhythmias
  • 31.  Treatment of arrhythmias in elderly is particularly challenging due to  lack of good hemodynamic reserves'  Frequency of electrolyte disturbance  High prevalence of coronary disease
  • 32.  Following ADRS observed due to decreased clearance and increased half life of antiarrhythmics ◦ Confusion ◦ Slurred speech ◦ Light-headedness, seizures ◦ hypotension
  • 33.  Age related changes contributes to incidence of infection in elderly patients  Reduction in host defense manifested in the increase in both serious infection and cancer  In the lungs age dependent decrease in the mucociliary clearance significantly increase in susceptibility of infection  In urinary tract,incidence of infections is greatly increased by urinary retention
  • 34.  Since 1940, antimicrobial have contributed more to prolong the life because they can compensate to some extent for this deterioration in natural defenses  Because most antibiotics are excreted renal route so change in half life may occur so adverse reactions takes place
  • 35.  Osteoarthritis most commonly present in elderly patients  NSAIDs and corticosteroids are mostly used  Corticosteroids are extremely useful in elderly who cannot tolerate full doses of NSAIDs however consistently cause increase in osteoporosis
  • 36.  NSAIDs ◦ Prolong bleeding  Gastric discomfort, bleeding ◦ Increased risk of toxicity (with impaired renal function)
  • 37.  Corticosteriods ◦ Sodium retention (may worsen HTN & CHF) ◦ Insomnia ◦ Psychotic behavior ◦ osteoporosis
  • 38.  Disease is characterized by progressive impairment of memory and cognitive function, prevalence increases with age  Pathological changes includes increased deposits of amyloid beta peptide in cerebral cortex due to progressive loss of neurons especially cholinergic neurons and thinning of cortex  Many methods of treatment of Alzheimer`s disease has been explored
  • 39.  Most attention has been focused on the cholinomimetics drugs because of evidence of loss of cholinergic neurons  Tacrine, donepezil, rivastigmine, and galantamine are used as these are cholinesterase inhibitors  ADRs include nausea, vomiting, and peripheral cholinomimetics effects  Memantine binds to NMDA and produce noncompetitive blockade and better tolerated and less toxic than cholinestrase inhibitors
  • 40.  Glaucoma is most common in elderly but treatment is same as that for glaucoma of earlier onset  Age-related macular degeneration(AMD) is the most common cause of blindness in elderly patients  Two types 1.wet form 2.dry form  Cause of AMD is not known but smoking and oxidative stress has long been thought to play a role
  • 41.  So antioxidants have been used to prevent or delay the onset of AMD  Oral formulations of vitamins C and E, beta- carotene, zinc oxide are available  Now laser phototherapy and antibiotics are used  Antibiotics bevacizumab, ranibizumab and pegabtanib are approved for AMD  these agents are injected into vitreous for local effect
  • 42.  Balance between overprescribing and underprescribing ◦ Correct drug ◦ Correct dose ◦ Targets appropriate condition ◦ Is appropriate for the patient Avoid “a pill for every ill” Always consider non-pharmacologic therapy
  • 43.  Polypharmacy  Multiple co-morbid conditions  Prior adverse drug event  Low body weight or body mass index  Age > 85 years  Estimated CrCl <50 mL/min
  • 44.  Absorption may be  or   Drugs with similar effects can result additive effects  Drugs with opposite effects can antagonize each other  Drug metabolism may be inhibited or induced
  • 45. Combination Risk ACE inhibitor + potassium Hyperkalemia ACE inhibitor + K sparing diuretic Hyperkalemia, hypotension Digoxin + antiarrhythmic Bradycardia, arrhythmia Digoxin + diuretic Antiarrhythmic + diuretic Electrolyte imbalance; arrhythmia Diuretic + diuretic Electrolyte imbalance; dehydration Benzodiazepine + antidepressant Benzodiazepine + antipsychotic Sedation; confusion; falls CCB/nitrate/vasodilator/diuretic Hypotension
  • 46.  Obesity alters Vd of lipophilic drugs  Ascites alters Vd of hydrophilic drugs  Dementia may  sensitivity, induce paradoxical reactions to drugs with CNS or anticholinergic activity  Renal or hepatic impairment may impair metabolism and excretions of drugs  Drugs may exacerbate a medical condition
  • 47. Combination Risk NSAIDs + CHF Thiazolidinediones + CHF Fluid retention; CHF exacerbation BPH + anticholinergics Urinary retention CCB + constipation Narcotics + constipation Anticholinergics + constipation Exacerbation of constipation Metformin + CHF Hypoxia; increased risk of lactic acidosis NSAIDs + gastropathy Increased ulcer and bleeding risk NSAIDs + HTN Fluid retention; decreased effectiveness of diuretics
  • 48.  Avoid prescribing prior to diagnosis  Start with a low dose  Avoid starting 2 agents at the same time  Reach therapeutic dose before switching or adding agents  Consider non-pharmacologic agents
  • 49.  Review medications regularly and each time a new medication started or dose is changed  Maintain accurate medication records (include vitamins, OTCs, and herbals)
  • 50.  Suggest physician prescribe combination drugs or long-acting forms ◦ Fewer pills to remember  Suggest re-evaluation of medications periodically  Encourage client to use one pharmacy  New medications ◦ Good information ◦ Encourage follow up
  • 51.  There are several practical obstacles to compliance that the prescriber must recognize ◦ Forgetfulness ◦ Prior experience ◦ Physical disabilities  Recommendations to improve compliance ◦ Take careful drug history ◦ Prescribe only for a specific and rational indication ◦ Define goal of drug therapy ◦ High index of suspicion regarding drug reactions and interactions ◦ Simplify drug regimen
  • 52.  Avoid newer, more expensive medications that are not shown to be superior to less expensive generic alternatives  Simplify the regimen  Utilize pill organizers or drug calendars  Educate patient on medication purpose, benefits, safety, and potential ADEs
  • 53.  Basic and Clinical Pharmacology by Bertram G. Katzung Susan B. Master