Obat Pada Manula
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OBAT PADA MANULAOBAT PADA MANULA
Noor WijayahadiNoor WijayahadiApril 2007April 2007
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Medications Most Commonly Used Medications Most Commonly Used in the Communityin the Community
AnalgesicsAnalgesics
DiureticsDiuretics
CardiovascularCardiovascular
Sedative-hypnoticsSedative-hypnotics
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Medications Most Commonly Used Medications Most Commonly Used in the Nursing Homein the Nursing Home
AntipsychoticsAntipsychotics
Sedative-hypnoticsSedative-hypnotics
DiureticsDiuretics
AntihypertensivesAntihypertensives
AnalgesicsAnalgesics
CardiovascularCardiovascular
AntibioticsAntibiotics
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Manula Manula Resiko tinggi mengalami Resiko tinggi mengalami efek merugikan dari obatefek merugikan dari obat
Faktor penderitaFaktor penderita– Age-associated changes in Age-associated changes in pharmacokineticspharmacokinetics– Age-associated changes in Age-associated changes in pharmacodynamicspharmacodynamics– ComorbidityComorbidity: drug-disease interactions: drug-disease interactions– PolypharmacyPolypharmacy: drug-drug interactions: drug-drug interactions– Kemampuan homeostasis berkurangKemampuan homeostasis berkurang– Fungsi organ berkurangFungsi organ berkurang
Faktor sistem layanan medikFaktor sistem layanan medik– Fragmentation of care (Poly-doctoring)Fragmentation of care (Poly-doctoring)– Inadequate training in principles of geriatric practiceInadequate training in principles of geriatric practice
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Therapeutic Response
Toxic Response
Therapeutic Window
Age
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Increasing Age
“The Precipice”
PhysiologicReservesAvailable
PhysiologicReserves
Already In Use
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Masalah UtamaMasalah Utama
Pilihan obat atau dosis yang tidak tepatPilihan obat atau dosis yang tidak tepat
Concomitant disease Concomitant disease affect metabolism affect metabolism of or response to drugof or response to drug
Polypharmacy Polypharmacy drug - drug interactions drug - drug interactions
Patient behavioural factorsPatient behavioural factors
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Perubahan PHARMACOKINETICSPerubahan PHARMACOKINETICS
AbsorptionAbsorptionactive transferactive transfer
Body compositionBody compositionlean body masslean body mass
body fatbody fat
plasma albuminplasma albumin
Liver metabolismLiver metabolismoxidation / microsomal enzymesoxidation / microsomal enzymes
Renal clearanceRenal clearance
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Perubahan Perubahan PHARMACODYNAMICSPHARMACODYNAMICS
Brain sensitivity Brain sensitivity Benzodiazepines and Benzodiazepines and
narcotic analgesics more effectivenarcotic analgesics more effective
Coagulation mechanism control Coagulation mechanism control
Anticoagulants more potentAnticoagulants more potent
Adrenergic receptor sensitivity Adrenergic receptor sensitivity
B-blockers less effectiveB-blockers less effective
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Penurunan fungsi homeostasisPenurunan fungsi homeostasis
Baroreceptor sensitivityBaroreceptor sensitivitypostural hypotensionpostural hypotension
ThermoregulationThermoregulationhypothermiahypothermia
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COMMON PITFALLS 1 :COMMON PITFALLS 1 :Gagal mengobati kondisi yang seharusnya Gagal mengobati kondisi yang seharusnya
bisa diobati (treatable conditions)bisa diobati (treatable conditions)
Thrombolytic therapyThrombolytic therapythe older the patient, the greater the benefitthe older the patient, the greater the benefit
the older the patient, the less likely to be the older the patient, the less likely to be thrombolysedthrombolysed
HypertensionHypertension30 - 40% decrease in risk of CVA if ISH treated30 - 40% decrease in risk of CVA if ISH treated
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BLOOD PRESSURE AND AGEBLOOD PRESSURE AND AGE
0
20
40
60
80
100
120
140
160
30 40 50 60 70 80
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COMMON PITFALLS 2 :COMMON PITFALLS 2 :
Prescribing for symptom and not for Prescribing for symptom and not for
diagnosisdiagnosis
“ A pill for every ill ”
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NEW HYPNOTIC PRESCRIPTIONSNEW HYPNOTIC PRESCRIPTIONS(per percentage patient pop. per yr.)(per percentage patient pop. per yr.)
1987 19890
1
2
3
4
5
6
1987 1989
Male 0-65
Female 0-65
Male >65
Female >65
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PRESCRIPTIONS BY AGEPRESCRIPTIONS BY AGE(Items per person per year)(Items per person per year)
42 46 50 54 58 62 66 70 74 78 82 86 900
5
10
15
20
25
30
35
40
42 46 50 54 58 62 66 70 74 78 82 86 90
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EFFECTIVE PRESCRIBING 1EFFECTIVE PRESCRIBING 1
Utamakan non-pharmalogical treatmentUtamakan non-pharmalogical treatmentmodify dietmodify diet
stop smoking, reduce alcoholstop smoking, reduce alcohol
physical exercisephysical exercise
walking aids, household adaptationswalking aids, household adaptations
social supportssocial supports
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EFFECTIVE PRESCRIBING 2EFFECTIVE PRESCRIBING 2
Treat conditions in order of Treat conditions in order of prioritypriorityPertimbangkan Pertimbangkan kegagalan fungsi organkegagalan fungsi organStart low Start low mulai dosis kecil mulai dosis kecil , naikkan , naikkan dengan hati-hatidengan hati-hatiGunakan Gunakan formulariumformularium yang terbatas yang terbatasMonitor Monitor compliance and responsecompliance and responseReviewReview pemakaian obat secara reguler pemakaian obat secara regulerIkut sertakan PENDERITAIkut sertakan PENDERITA
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Who Takes the Most Medications?Who Takes the Most Medications?
WomenWomen
Individuals with Individuals with multiple health multiple health conditionsconditions
Frail elderlyFrail elderly
Nursing home Nursing home residentsresidents
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Medications Most Commonly Used Medications Most Commonly Used in the Communityin the Community
AnalgesicsAnalgesics
DiureticsDiuretics
CardiovascularCardiovascular
Sedative-hypnoticsSedative-hypnotics
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Umur mempengaruhi Umur mempengaruhi metabolisme obat?metabolisme obat?
Pada manula:Pada manula:– Slower organ functionSlower organ function– Slower blood circulationSlower blood circulation– Increased body fat Increased body fat
obat bertahan lama di dalam tubuh obat bertahan lama di dalam tubuh resiko terkena efek samping obat resiko terkena efek samping obat meningkatmeningkat
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Age-Related Changes: Age-Related Changes:
Total body water menurun Total body water menurun konsentrasi dalam konsentrasi dalam darah obat yang larut-air meningkatdarah obat yang larut-air meningkat
Perubahan berat badan Perubahan berat badan mempengaruhi dosis mempengaruhi dosis yang diperlukan dan lama obat dalam tubuh: yang diperlukan dan lama obat dalam tubuh: – More body fat More body fat prolonged half-life prolonged half-life – Less lean body mass Less lean body mass increased drug concentration increased drug concentration
Perubahan sistem pencernaan Perubahan sistem pencernaan mempengaruhi kecepatan absorbsi obat mempengaruhi kecepatan absorbsi obat onset obat lebih lamaonset obat lebih lama
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Age-Related Changes: Age-Related Changes:
Slower circulation Slower circulation delay drugs getting to delay drugs getting to liver and kidneysliver and kidneys
Slow down of liver and kidneys Slow down of liver and kidneys affects affects time it takes for medication to break down time it takes for medication to break down and leave body and leave body
Less absorption from transdermal patchesLess absorption from transdermal patches
Drug “receptor” sites may be different in Drug “receptor” sites may be different in older adults older adults
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Changes in PharmacokineticsChanges in Pharmacokinetics
Perubahan fisiologis dan fungsi organ pada Perubahan fisiologis dan fungsi organ pada manula manula perubahan Farmakokinetik perubahan Farmakokinetik
Pharmacokinetics is the time course of a drug Pharmacokinetics is the time course of a drug and its metabolites through the body and its metabolites through the body
– AbsorptionAbsorption
– Distribution Distribution
– Clearance: elimination (renal), metabolism (liver) Clearance: elimination (renal), metabolism (liver)
2004: Cusack, Amer. J of Geriatric Pharmacotherapy 2004: Cusack, Amer. J of Geriatric Pharmacotherapy
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Volume of Distribution (Vd)Volume of Distribution (Vd)
Proporsi lemak meningkat dan volume otot Proporsi lemak meningkat dan volume otot berkurang berkurang merubah Vd merubah Vd
Vd obat larut lemak (Vd obat larut lemak (fat soluble drugfat soluble drug) ) meningkat meningkat waktu paro meningkat: waktu paro meningkat: diazepam,diazepam, thiopental, trazadonethiopental, trazadone
Vd obat larut air (Vd obat larut air (water soluble drugwater soluble drug) ) menurun menurun kadar obat dalam plasma kadar obat dalam plasma meningkat: meningkat: ethanol, lithium, ethanol, lithium, aminoglycosides, alcohol, digoxinaminoglycosides, alcohol, digoxin
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Protein BindingProtein Binding
albumin berkurang albumin berkurang chronic disease: chronic disease: e.g.,malnutrition, liver or kidney conditions.e.g.,malnutrition, liver or kidney conditions.
obat dengan ikatan protein tinggi obat dengan ikatan protein tinggi kadar kadar obat bebas meningkat.obat bebas meningkat.
ceftriaxone,diazepam, phenytoin, ceftriaxone,diazepam, phenytoin, warfarin.warfarin.
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Eliminasi Obat menurunEliminasi Obat menurun
Fungsi ginjal menurun Fungsi ginjal menurun eliminasi oleh ginjal eliminasi oleh ginjal berkurang.berkurang.Even in the absence of kidney disease renal clearance Even in the absence of kidney disease renal clearance may be reduced 35-50%.may be reduced 35-50%. therapeutic effect dan resiko toksisitas meningkattherapeutic effect dan resiko toksisitas meningkat perlu pengurangan dosis atau perubahan interval perlu pengurangan dosis atau perubahan interval pemberian obat.pemberian obat.
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Metabolisme hepar berkurangMetabolisme hepar berkurang
•Phase I, terutama reaksi oksidatif menurun
•Phase II, terutama reaksi konjugasi relatif tidak berubah.
diazepam is metabolized via Phase I reactions in the liver, at least initially.
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Drugs with Cytochrome P450 EffectsDrugs with Cytochrome P450 Effects(partial)(partial)
Inhibitors Inducers
Allopurinol Metronidazole Barbiturates
Amiodorone Quinolones Carbamazepine
Azole antifungals Phenytoin
Cimetidine Rifampin
INH Tobacco
SSRIs
Tacrine
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Hepatic MetabolismHepatic Metabolism
Decreased liver size and hepatic blood flow.Decreased liver size and hepatic blood flow.Regional blood flow to the liver at age 65 is Regional blood flow to the liver at age 65 is reduce by 40-45% compared to a 25 year old.reduce by 40-45% compared to a 25 year old.Metabolic clearance of drugs by the liver may be Metabolic clearance of drugs by the liver may be reduced.reduced.Disease effects: liver congestion from heart Disease effects: liver congestion from heart failure decreases warfarin metabolism and an failure decreases warfarin metabolism and an increased pharmacologic response.increased pharmacologic response.Environmental effects: smoking stimulates Environmental effects: smoking stimulates monoxygenase enzymes and increases monoxygenase enzymes and increases clearance of theophylline. clearance of theophylline.
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Changes in PharmacodynamicsChanges in Pharmacodynamics
Older patients may have more sedation and Older patients may have more sedation and impaired function after a single dose of impaired function after a single dose of benzodiazepines than younger persons. benzodiazepines than younger persons.
After single dose of nitrazepam older patients After single dose of nitrazepam older patients made more mistakes on psychomotor testing made more mistakes on psychomotor testing compared to placebo while younger patients compared to placebo while younger patients had no impairment .had no impairment .
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Suboptimal Quality Suboptimal Quality
Typology of Quality Problems:Typology of Quality Problems:– Overuse (Polypharmacy)Overuse (Polypharmacy)– UnderuseUnderuse– Misuse (Inappropriate Prescribing)Misuse (Inappropriate Prescribing)– ErrorsErrors
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Suboptimal PrescribingSuboptimal Prescribing
PolypharmacyPolypharmacy
Underuse of Effective MedicationsUnderuse of Effective Medications
Drug-Drug InteractionsDrug-Drug Interactions
Drug-Disease InteractionsDrug-Disease Interactions
Inadequate MonitoringInadequate Monitoring
Inappropriate DosingInappropriate Dosing
Inappropriate DurationInappropriate Duration
Drugs to AvoidDrugs to Avoid
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Drug-Drug InteractionsDrug-Drug InteractionsPenyebab tersering ESO pada manulaPenyebab tersering ESO pada manulaJumlahnya sangat banyak Jumlahnya sangat banyak Almost Almost countless countless peresepan elektronik peresepan elektronik Some common examplesSome common examples– Statins and erythromycin and other antibioticsStatins and erythromycin and other antibiotics– TCAs and clonidine or type 1Anti-arrythmicsTCAs and clonidine or type 1Anti-arrythmics– Warfarin and multiple drugs Warfarin and multiple drugs – ACE inhibitors increase hypoglycemic effect of ACE inhibitors increase hypoglycemic effect of
sulfonylureassulfonylureas
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Drug-disease InteractionsDrug-disease Interactions
Patient with PD have increased risk of drug Patient with PD have increased risk of drug induced confusioninduced confusionNSAIA (and COX-2’s) s can exacerbate CHFNSAIA (and COX-2’s) s can exacerbate CHFUrinary retention in BPH patients on Urinary retention in BPH patients on decongestants or anticholinergicsdecongestants or anticholinergicsConstipation worsened by calcium, Constipation worsened by calcium, ahticholinergics, calcium channel blockersahticholinergics, calcium channel blockersNeuroleptics and quinolones lower seizure Neuroleptics and quinolones lower seizure thresholdsthresholds
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PolypharmacyPolypharmacy
Polypharmacy = pemberian banyak Polypharmacy = pemberian banyak obat melebihi indikasi penggunaanobat melebihi indikasi penggunaan
59% manula mendapat obat tanpa 59% manula mendapat obat tanpa indikasi yang jelas.indikasi yang jelas.
55% manula mendapat obat 55% manula mendapat obat tanpa tanpa indikasiindikasi, 32.7% mendapat , 32.7% mendapat obat yang obat yang tidak efektiftidak efektif, 16.8% mendapat , 16.8% mendapat obat obat duplikasiduplikasi2001: Hanlon, JAGS2001: Hanlon, JAGS
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UnderuseUnderuse
Among patients elderly patients with Among patients elderly patients with cardiovascular disease and diabetes, only cardiovascular disease and diabetes, only 19.1% of patients were prescribed statins. In 19.1% of patients were prescribed statins. In patients 66 to 74 years old, the adjusted patients 66 to 74 years old, the adjusted probabilities of statin prescription were 37.7%, probabilities of statin prescription were 37.7%, 26.7%, and 23.4% in the categories of low, 26.7%, and 23.4% in the categories of low, intermediate, and high baseline risk, intermediate, and high baseline risk, respectively. respectively.
The likelihood of statin prescription was 6.4% The likelihood of statin prescription was 6.4% lower (adjusted odds ratio, 0.94; 95% lower (adjusted odds ratio, 0.94; 95% confidence interval, 0.93-0.95) for each year of confidence interval, 0.93-0.95) for each year of increase in age and each 1% increase in increase in age and each 1% increase in predicted 3-year mortality risk.predicted 3-year mortality risk.2004: Ko, JAMA2004: Ko, JAMA
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Inappropriate Prescribing Inappropriate Prescribing
20-27% manula mendapat resep yang 20-27% manula mendapat resep yang tidak diperlukan (inappropriate). tidak diperlukan (inappropriate).
Inappropriate prescribing meningkatkan Inappropriate prescribing meningkatkan resiko jatuh, fraktur femur, cognitive resiko jatuh, fraktur femur, cognitive impairment, diminished independence, impairment, diminished independence, dan mortalitasdan mortalitas
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inappropriate drug prescribing to inappropriate drug prescribing to the elderly?the elderly?
The Beers ListThe Beers List.
a list of medications identified by an expert panel as being inappropriate for older persons because of ineffectiveness or because they pose a high risk for adverse drug events.
Beers MH Arch Intern Med 1997
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The Beers ListThe Beers List
The Beers List, berisi 33 obat dalam The Beers List, berisi 33 obat dalam 3 kategori:3 kategori:
3. Drugs with some indications, but that are often misused.
2. Drugs that are rarely appropriate.
1. Drugs that should always be avoided.
Zhan et al. JAMA 2001
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Drugs And Dosages to AvoidDrugs And Dosages to Avoid
MeperidineMeperidine
DiphenhydramineDiphenhydramine
The most anticholinergic tricyclics: The most anticholinergic tricyclics: amitryptiline, doxepin, imipramine amitryptiline, doxepin, imipramine
Long acting benzodiazepines such as Long acting benzodiazepines such as diazepamdiazepam
Long acting NSAIDs such as piroxicamLong acting NSAIDs such as piroxicam
High dose thiazides (>25mg)High dose thiazides (>25mg)
Iron: 325 mg once daily is enoughIron: 325 mg once daily is enough
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11 drugs that should always be 11 drugs that should always be avoided in the elderly:avoided in the elderly:
BarbituratesBarbiturates
ChlorpropamideChlorpropamide
FlurazepamFlurazepam
MeperidineMeperidine
MeprobamateMeprobamate
PentazocinePentazocine
Belladonna alkaloidsBelladonna alkaloids
DicyclomineDicyclomine
HyoscyamineHyoscyamine
PropanthelinePropantheline
TrimethobenzamideTrimethobenzamide
Zhan et al. JAMA 2001
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Tangga Peresepan Tangga Peresepan (Prescribing Cascade)(Prescribing Cascade)
The prescribing cascade terjadi bila satu obat diresepkan,
Menyebabkan timbulnya efek samping obat / adverse drug event (ADE),
Mendorong peresepan obat kedua untuk mengatasi ESO sebelumnya
Drug 1
Drug 2
ADE
Rochon PA et al, BMJ 1997
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The Prescribing CascadeThe Prescribing Cascade
Metoclopramide
Extrapyramidal Effects
Levodopa Rx
There are numerous examples of the prescribing cascade in the medical literature.
For example, it has been observed that patients prescribed metoclopramide ( a gastric motility agent) are more likely to be initiated on treatments generally reserved for the management of idiopathic Parkinson’s Disease (e.g. Drugs containing Levodopa).
In this case, metoclopramide use can lead to extrapyramidal symptoms, which may be misdiagnosed as Parkinson’s Disease.
Avorn J et al, JAMA 1995
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NSAID Rx
Antihypertensive Rx
Blood Pressure
The Prescribing CascadeThe Prescribing CascadeAnother example relates to the fact that older persons who have been prescribed NSAIDs appear to be at increased risk for being initiated on antihypertensive therapy.
In this case, NSAID use increases blood pressure leading to the need for blood pressure lowering therapy.
In both examples, the initiation of new drug treatments in older persons could have been avoided if there was recognition of the risks of certain drug treatments (e.g. metoclopramide and NSAIDs) in elderly patients.
Gurwitz JH et al, JAMA 1994
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The “Prescribing Cascade”The “Prescribing Cascade”
Penyebab utama polypharmacy pada Penyebab utama polypharmacy pada manulamanula Some common examplesSome common examples– NSAID ->HTN->antihypertensive therapyNSAID ->HTN->antihypertensive therapy– Metoclopromide ->Parkinsonism ->SinemetMetoclopromide ->Parkinsonism ->Sinemet– Dihydropyridine -> edema ->furosemideDihydropyridine -> edema ->furosemide– NSAIA ->H2 blocker ->delirium ->haldolNSAIA ->H2 blocker ->delirium ->haldol– HCTZ ->gout->NSAIA ->2nd antihypertensiveHCTZ ->gout->NSAIA ->2nd antihypertensive– Sudafed ->urinary retention ->alpha blockerSudafed ->urinary retention ->alpha blocker– Antipsychotic ->akithesia ->more medsAntipsychotic ->akithesia ->more meds
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NSAID (Anti-inflamasi non-steroid)NSAID (Anti-inflamasi non-steroid)
Efektifitas Parasetamol = NSAIDs pada Efektifitas Parasetamol = NSAIDs pada osteoartritis ringanosteoartritis ringan
NSAIDs side effectsNSAIDs side effects
– GI hemorrhageGI hemorrhage
– Decline in GFR Decline in GFR
Decreased effectiveness of diuretics, anti-Decreased effectiveness of diuretics, anti-hypertensive agentshypertensive agents
Indication should justify the increased Indication should justify the increased toxicity of NSAIDstoxicity of NSAIDs
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Drugs and Cognitive ImpairmentDrugs and Cognitive Impairment
Anticholinergic drugs are common Anticholinergic drugs are common offenders (TCAs, benadryl and other offenders (TCAs, benadryl and other antihistamines, many others)antihistamines, many others)Other offenders cimetidine, steroids, Other offenders cimetidine, steroids, NSAIAs NSAIAs Medical Letter 2000 Drug Safety 1999 Drugs and Aging 1999 Medical Letter 2000 Drug Safety 1999 Drugs and Aging 1999
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Drugs and FallsDrugs and Falls
Biggest risk drugs are long acting benzodiazepines Biggest risk drugs are long acting benzodiazepines and other sedative-hypnoticsand other sedative-hypnoticsBoth SSRIs and TCAs associated with increased Both SSRIs and TCAs associated with increased risk of fallingrisk of fallingBeta blockers NOT associated with increased risk Beta blockers NOT associated with increased risk of falling in published literatureof falling in published literatureMild increase in fall risk from diuretics, type 1A Mild increase in fall risk from diuretics, type 1A anti-arrythmics, and digoxinanti-arrythmics, and digoxinLeipzig, JAGSLeipzig, JAGS
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Drug-Food InteractionsDrug-Food Interactions
Interactions between drugs and foodInteractions between drugs and food– warfarin and Vitamin K containing foods warfarin and Vitamin K containing foods
(remember green tea, as well)(remember green tea, as well)– Phenytoin & vitamin D metabolismPhenytoin & vitamin D metabolism– Methotrexate and folate metabolismMethotrexate and folate metabolism
Drug impact on appetiteDrug impact on appetite– Digoxin may cause anorexiaDigoxin may cause anorexia– ACE inhibitors may alter tasteACE inhibitors may alter taste
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Anticipate Side EffectAnticipate Side EffectNarcoticsNarcotics– Begin lactulose or sorbitol and a stimulant laxativeBegin lactulose or sorbitol and a stimulant laxative– Colace is NOT sufficient in most instancesColace is NOT sufficient in most instances
SteroidsSteroids– Think about osteoporosis preventionThink about osteoporosis prevention– Remember steroid induced diabetesRemember steroid induced diabetes
LevothyroxineLevothyroxine– Calcium interferes with absorption of Calcium interferes with absorption of
levothyroxinelevothyroxine
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Drug DiscrepanciesDrug Discrepancies
Difference between medical record and Difference between medical record and medication bottles in 76% of casesmedication bottles in 76% of cases– 51% of time medication not recorded51% of time medication not recorded– 29% medication recorded that patient not 29% medication recorded that patient not
takingtaking– 20% dosage discrepancy20% dosage discrepancy
Risk Factors: Age, number of medicationsRisk Factors: Age, number of medications– Bedell et al Arch Intern Med 160, 2000Bedell et al Arch Intern Med 160, 2000
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High Risk SituationsHigh Risk Situations
Patient seeing multiple providersPatient seeing multiple providers
Patient on multiple drugsPatient on multiple drugs
Patient lives alone and/or has Patient lives alone and/or has cognitive impairmentcognitive impairment
Discharge from hospital or any Discharge from hospital or any change in venuechange in venue
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Hospitalization: A High Risk TimeHospitalization: A High Risk Time
At hospitalization:At hospitalization:
40% of admission medications stopped40% of admission medications stopped
45% of discharge medications were started45% of discharge medications were started
Serious prescribing problems in 22%Serious prescribing problems in 22%
Other prescribing problems in 66%Other prescribing problems in 66%– Beers JAGS 1989, Lipton Medical Care 1992Beers JAGS 1989, Lipton Medical Care 1992
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NonadherenceNonadherence
Lack of understanding of how to takeLack of understanding of how to take– High risk times: Hospital discharge, new meds High risk times: Hospital discharge, new meds
added, complex regimensadded, complex regimens
Unable to takeUnable to take
Conscious nonadherenceConscious nonadherence– Side effectsSide effects– Lack of understanding of benefits of drugLack of understanding of benefits of drug– FinancialFinancial
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Complementary TherapiesComplementary Therapies
Very commonly used in the elderlyVery commonly used in the elderly
Some common herbs and alternative therapies:Some common herbs and alternative therapies:– ““Anti-aging”Anti-aging” DHEA, growth hormoneDHEA, growth hormone– DementiaDementia Gingko bilobaGingko biloba– BPHBPH Saw palmetto, PC-SPESSaw palmetto, PC-SPES– OAOA Chondroiton sulfate, Chondroiton sulfate,
glucosamine glucosamine – DepressionDepression St. John’s wort, SAMeSt. John’s wort, SAMe
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Adulterants in ProductsAdulterants in ProductsCalifornia Department of Health California Department of Health Services, Food and Drug BranchServices, Food and Drug Branch– screened 250 Asian herbal productsscreened 250 Asian herbal products– collected from herbal stores in Californiacollected from herbal stores in California– assayed products using gas chromatography, assayed products using gas chromatography,
mass spectrometry, and atomic-absorption mass spectrometry, and atomic-absorption techniquestechniques
– Ko, NEJM 1998; 339; 847Ko, NEJM 1998; 339; 847
32% contained unlabeled medications, 32% contained unlabeled medications, 14% mercury, 14% arsenic, 10% lead14% mercury, 14% arsenic, 10% lead
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Herbals and Supplements: Herbals and Supplements: RegulationRegulation
Demonstration of safety is NOT required prior to Demonstration of safety is NOT required prior to marketingmarketing
Manufacturing standards are not requiredManufacturing standards are not required
Can have Can have health health claims, but not claims about claims, but not claims about treating, preventing, or curingtreating, preventing, or curing
For glucosamine/chondroitin, on third of For glucosamine/chondroitin, on third of combinations did not contain listed ingredientcombinations did not contain listed ingredient
www.consumerlabs.com has some drug www.consumerlabs.com has some drug informationinformation
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Herbals and Supplements:Potential Herbals and Supplements:Potential interactions with Rx Drugsinteractions with Rx Drugs
SAMe may increase homocysteine SAMe may increase homocysteine levelslevels
St. John’s wort and Oral contraceptivesSt. John’s wort and Oral contraceptives
Ginkgo may increase anticoagulant Ginkgo may increase anticoagulant effects of ASA, warfarin, NSAIAs, effects of ASA, warfarin, NSAIAs, ticlopidine, and may interact with ticlopidine, and may interact with MAOIsMAOIs
Bottom line: Try to know what your Bottom line: Try to know what your patient is taking, and ask in a patient is taking, and ask in a nonjudgmental waynonjudgmental way
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Prinsip Manajemen ObatPrinsip Manajemen Obat
Riwayat pemakaian obat yang lengkap, Riwayat pemakaian obat yang lengkap, termasuk obat herba/tradisional/obat bebastermasuk obat herba/tradisional/obat bebasHindari pemberian obat bila Hindari pemberian obat bila keuntungan/benefit kecil , atau ada alternatif keuntungan/benefit kecil , atau ada alternatif pengobatan non-farmakologis pengobatan non-farmakologis Pertimbangkan hargaPertimbangkan hargaStart low, go slow, but get there!Start low, go slow, but get there!Buat cara pemberian yang sederhanaBuat cara pemberian yang sederhanaTulis cara pemakaian sejelas mungkinTulis cara pemakaian sejelas mungkinMinta penderita membawa seluruh obat yang Minta penderita membawa seluruh obat yang sedang diminum setiap kali periksasedang diminum setiap kali periksa
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Principles (continued)Principles (continued)Pertimbangkan pemakaian kotak obat harian Pertimbangkan pemakaian kotak obat harian atau “mediset”atau “mediset”
Hentikan pemakaian obat yang tidak jelas Hentikan pemakaian obat yang tidak jelas keuntungannya atau resiko efek sampingnya keuntungannya atau resiko efek sampingnya lebih merugikanlebih merugikan
Hati-hati pemakaian obat baru (newer drugs)Hati-hati pemakaian obat baru (newer drugs)
Hindari penggunaan obat > 5 macam Hindari penggunaan obat > 5 macam Consider if the benefit of the 7th or 8th drug is Consider if the benefit of the 7th or 8th drug is sufficient to justify the cost, increase in sufficient to justify the cost, increase in complexity of regimen, and risk of side effectscomplexity of regimen, and risk of side effects
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Newer drugsNewer drugs
What is unique about this compound?What is unique about this compound?
What clinical data is available?What clinical data is available?
How does it compare with traditional How does it compare with traditional therapy?therapy?
How expensive is it?How expensive is it?
With third party payers cover this With third party payers cover this product?product?
Does the potential advantage of this new Does the potential advantage of this new drug justify the risk of using a new drug?drug justify the risk of using a new drug?
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The Message for TodayThe Message for Today
Start lowStart low
Go slow (but get to therapeutic levels)Go slow (but get to therapeutic levels)
Sometimes say no (how about other non-Sometimes say no (how about other non-drug treatments?)drug treatments?)