Aspirin and Sta,ns and Benzos! Oh My! Polypharmacy in the Older Adult

Transcription

1 Aspirin and Sta,ns and Benzos! Oh My! Polypharmacy in the Older Adult Valerie Zamudio, MD Advanced Fellow, Geriatric Medicine UCLA Bureau of Health Professions Faculty Training Program February 25, 2015 Adapted from presentabon by Dr. Emiley Chang

2 Objec,ves Master defini,ons pertaining to polypharmacy Review pharmacokine,c and pharmacodynamic changes associated with normal aging Provide examples of the four (4) types of interac,ons to avoid and watch out for Discuss common medica,on adherence challenges Review basic safe prescribing,ps

3 Back to Basics: Defini,ons No one single defini,on exists 1. Polypharmacy 2. Pharmacokine3cs 3. Pharmacodynamics 4. Drug interac3on What the body does to the drug What the drug does to the body Drug- drug, drug- disease, drug- food/drink, & drug- herbals/supplements

4 Beers Criteria Most widely used criteria to assess inappropriate drug prescribing Most recent update medica,ons (some OTC) designated to one of three categories Should always be avoided Poten,ally inappropriate in older adults with par,cular health condi,ons or syndromes Should be used with cau,on Being used to monitor quality of care for older adults

5 Pharmacokine3cs in Ac3on Medical Cases

6 Pharmacokine,c Changes & Aging Distribu,on and Body Composi,on body water and lean mass body fat albumin and protein- binding capacity Hepa,c Metabolism hepa,c mass and hepa,c blood flow Renal Excre,on glomerular filtra,on and tubular excre,on

7 Mr. V is a healthy 84 yo man who takes no medica,ons and only occasionally drinks alcohol. During a rou,ne visit to your office, he men,ons that when he was thirty, he was able to drink a six pack of beer without feeling any effect. Now, he no,ces that he feels intoxicated ader two beers. Why?

8 A few months later, Mr. V s son suddenly dies. Both he and his healthy grandson are distressed and suffer from insomnia. Both of them get prescrip,ons for diazepam 5 mg. While both note improvements in sleep, Mr. V feels groggy well into the next 2 days ader taking diazepam. Why?

9 Mrs. P is a 78 yo woman with lung ca who requires 50 mcg of fentanyl for analgesia during her bronchoscopy. Six months later, ader her disease progressed, this same dose caused apnea. Why?

10 Mr. H is a 78 yo man who is in the CCU ader an episode of Vfib. He is in normal sinus rhythm, on a lidocaine drip. Twelve hours later, he suffers MI and becomes slightly hypotensive. Over the next 24 hours, he becomes increasingly confused. Why?

11 Mrs. R is an 88 yo woman who has hypertension. She has been on a stable regimen of atenolol, aspirin, and simvasta,n for over 10 years. During this,me, her res,ng pulse has decreased from 64 to 48. Why?

12 Pharmacodynamics in Ac3on Medical Cases

13 Pharmacodynamic Changes & Aging Autonomic Nervous System baroreceptor response blood pressure sensi,vity to vasodilatory agents (e.g., CCB) Central Nervous System Benzodiazepines and narco,cs produce increased drug effects Gastrointes,nal System Xerostomia GI blood flow + gastric ph absorp,on because GI mo,lity à longer,me for absorp,on, therefore there the net effect on absorp,on is negligible

14 Mrs. A is a 78 y woman with HTN who is given verapamil. At her follow- up visit, her blood pressure has responded well but she complains of lightheadedness when going from a supine to a standing posi,on. Why?

15 Mrs. X is a 65 yo woman with HTN, diabe,c neuropathy, and mild Parkinson s disease. She is well controlled on HCTZ, carbidopa/ levodopa, nortryp,line, enalapril, and insulin. She develops 4 dental caries over a period of a year. Why?

16 Drug Interac3ons Medical Cases

17 Drug Interac,on Types Drug- Drug Drug- Food/Drink Drug- Disease Drug- Herbal/Supplement

18 Drug- Drug & Drug- Supplement Interac3on Mrs. A is a 74 yo woman with osteoporosis and new onset dysuria. She takes alendronate weekly and daily calcium and vit D supplements. She begins ciprofloxacin for UTI, but calls you 3 days later when her symptoms have not improved. Why?

19 Drug- Drug Interac3on Mr. A is a 78 yo man who is hospitalized for treatment of PNA and hypernatremia. He experiences seizures which do not respond to the phenytoin added to his IV solu,on of D5W. Why?

20 Drug- Drug Interac3on Mr. C is an 84 yo man with afib & BPH. He takes tamsulosin, warfarin, and atenolol. He develops new dysuria & is treated with TMP/SMX a UTI. Three days later, he calls because he has developed hematuria. Why?

21 Drug- Drug Interac3on Mrs. D is a 67 yo woman with depression well treated with fluoxe,ne. She falls and suffers a compression fracture of L4. She is given acetaminophen with codeine for analgesia. Ader 4 days, she calls you concerned that her pain has not improved. Why?

22 Drug- Food/Drink Interac3on Mr. M is a 75 yo man whose HTN is well- controlled with felodipine. While apending a citrus conven,on in Orlando, he begins to feel lightheaded and fa,gued. His blood pressure is noted to be 80/40. Why?

23 Drug- Drug & Drug- Disease Interac3on Mrs. E is a 75 yo woman with afib (rate- controlled with digoxin) who twists her ankle at yoga class. She takes ibuprofen and achieves adequate analgesia. Five days later, she becomes confused. Why?

24 Drug- Disease Interac3on Mr. B is an 84 yo man with stable nocturia (2-3 x nightly) who develops a URI. He begins to take an over the counter cold medicine. Thirty six hours later, he is in the emergency room for abdominal pain and inability to urinate. Why?

25 Medica3on Adherence Challenges

26 Mr. A is an 82 yo man with HTN, osteoarthri,s, DM 2 with neuropathy who presents for follow- up. He lives alone since wife died 6 months ago. His medica,on list includes 12 different drugs, including 5 for hypertension. His BP today is 185/100 and he has a slight headache. Why?

27 Risk Factors for Rx Inadherence Regimen complexity/high number of drugs Cost Cogni,ve impairment Living alone Low literacy Poor understanding Communica,on difficul,es

28 Basic Safe Prescribing Tips Gather complete informa,on on medica,on use Review prior adverse reac,ons, allergies, alcohol use Start low and go slow but treat adequately Know dosage limita,ons of certain meds Develop a personal formulary & avoid bad medica,ons Be familiar with common tools available for safe prescribing (Beer s criteria, START, STOPP) Watch for drug- drug, drug- disease, and drug- food, drug/herbal medica,on interac,ons Remember risk factors for ADEs Beware of the prescribing cascade

29 Ques,ons and/or Comments

30 Partners in Care has been generously funded by the Good Hope Medical Founda,on, with funds matched by Kaiser Founda,on Hospitals Partners in Care would like to acknowledge our clinic partners: