Scribd Logo
Upload

Welcome to Scribd!

  • 122 views

    Terapi Farmakologi Pada Geriatri

    Uploaded by

    Fauzi Satria
    This document discusses pharmacology therapy in geriatrics. It begins by defining geriatrics as those aged 65 years and older, and notes that geriatrics currently make up 13% of the population but use 33% of prescribed medications. The document then discusses various age-related changes to pharmacokinetics and pharmacodynamics that are important to consider when prescribing to older patients. It emphasizes starting with low doses and titrating slowly, monitoring closely, and considering non-pharmacological options when possible to minimize risks like adverse drug events.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd

    Terapi Farmakologi Pada Geriatri

    Uploaded by

    Fauzi Satria
    122 views41 pages
    This document discusses pharmacology therapy in geriatrics. It begins by defining geriatrics as those aged 65 years and older, and notes that geriatrics currently make up 13% of the population but use 33% of prescribed medications. The document then discusses various age-related changes to pharmacokinetics and pharmacodynamics that are important to consider when prescribing to older patients. It emphasizes starting with low doses and titrating slowly, monitoring closely, and considering non-pharmacological options when possible to minimize risks like adverse drug events.

    Original Title

    Terapi Farmakologi Pada Geriatri - Copy

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    PPT, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document discusses pharmacology therapy in geriatrics. It begins by defining geriatrics as those aged 65 years and older, and notes that geriatrics currently make up 13% of the population but use 33% of prescribed medications. The document then discusses various age-related changes to pharmacokinetics and pharmacodynamics that are important to consider when prescribing to older patients. It emphasizes starting with low doses and titrating slowly, monitoring closely, and considering non-pharmacological options when possible to minimize risks like adverse drug events.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    122 views41 pages

    Terapi Farmakologi Pada Geriatri

    Uploaded by

    Fauzi Satria
    This document discusses pharmacology therapy in geriatrics. It begins by defining geriatrics as those aged 65 years and older, and notes that geriatrics currently make up 13% of the population but use 33% of prescribed medications. The document then discusses various age-related changes to pharmacokinetics and pharmacodynamics that are important to consider when prescribing to older patients. It emphasizes starting with low doses and titrating slowly, monitoring closely, and considering non-pharmacological options when possible to minimize risks like adverse drug events.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    You are on page 1of 41

    TERAPI FARMAKOLOGI PADA GERIATRI

    dr. T. Mamfaluti, SpPD., M. Kes

    TERAPI FARMAKOLOGI PADA GERIATRI


    Geriatri 65 tahun, 75 s/d 85 (Old old), 85 tahun( Oldest old), Cabang kedokteran yg konsen thd aging proses:
    Pencegahan, diagnosis dan terapi.

    Objektif:
    Pengaruh usia thd farmakokinetik dan farmakodinamik Memahami prinsip-prinsip peresepan obat pd orang tua Multiple co-morbid state Polifarmasi Resiko adverse drug events Tingkat kepatuhan minum obat Biaya

    Fakta berkaitan dgn geriatri


    Pasien berumur 65 th atau lebih mencakup 13% dari populasi dan membelanjakan 33% obatobatan yg diresepkan. Tahun 2040, geriatri mencakup 25% populasi dan membelanjakan 50% obat-obat yg diresepkan.

    Pharmacokinetics (PK)
    Absorption
    bioavailability: the fraction of a drug dose reaching the systemic circulation

    Distribution
    locations in the body a drug penetrates expressed as volume per weight (e.g. L/kg)

    Metabolism
    drug conversion to alternate compounds which may be pharmacologically active or inactive

    Elimination
    a drugs final route(s) of exit from the body expressed in terms of halflife or clearance

    Efek usia thd Absorpsi


    Kecepatan absorpsi terlambat:
    Konsentrasi puncak obat lebih rendah Waktu mencapai konsentrasi puncak telambat

    Jumlah obat yg diabsorpsi (bioavailability) tidak berubah

    Hepatic First-Pass Metabolism


    For drugs with extensive first-pass metabolism, bioavailability may increase because less drug is extracted by the liver
    Decreased liver mass Decreased liver blood flow

    Faktor-faktor yg mempengaruhi absorpsi obat


    Route of administration What it taken with the drug
    Divalent cations (Ca, Mg, Fe) Food, enteral feedings Drugs that influence gastric pH Drugs that promote or delay GI motility

    Comorbid conditions Increased GI pH Decreased gastric emptying Dysphagia

    Effects of Aging on Volume of Distribution (Vd)


    Aging Effect
    body water lean body mass(bb) fat stores

    Vd Effect
    Vd for hydrophilic drugs Vd for for drugs that bind to muscle Vd for lipophilic drugs

    Examples
    ethanol, lithium digoxin diazepam, trazodone

    plasma protein (albumin)


    plasma protein (1-acid glycoprotein)

    % of unbound or free drug (active)


    % of unbound or free drug (active)

    diazepam, valproic acid, phenytoin, warfarin


    quinidine, propranolol, erythromycin, amitriptyline

    Aging Effects on Hepatic Metabolism


    Metabolic clearance of drugs by the liver may be reduced(menurun) due to:
    decreased hepatic blood flow(aliran) decreased liver size and mass

    Examples: morphine, meperidine, metoprolol, propranolol, verapamil, amitryptyline, nortriptyline

    Metabolic Pathways
    Pathway
    Phase I: oxidation, hydroxylation, dealkylation, reduction

    Effect
    Conversion to metabolites of lesser, equal, or greater

    Examples
    diazepam, quinidine, piroxicam, theophylline

    Phase II: glucuronidation, Conversion to inactive conjugation, or metabolites acetylation

    lorazepam, oxazepam, temazepam

    ** NOTE: Medications undergoing Phase II hepatic metabolism are generally preferred in the elderly due to inactive metabolites (no accumulation)

    Other Factors Affecting Drug Metabolism


    Gender Comorbid conditions Smoking Diet Drug interactions Race Frailty(kelemahan)

    Concepts in Drug Elimination


    Half-life
    time for serum concentration of drug to decline by 50% (expressed in hours)

    Clearance
    volume of serum from which the drug is removed per unit of time (mL/min or L/hr)

    Reduced elimination drug accumulation and toxicity

    Effects of Aging on the Kidney


    Decreased kidney size Decreased renal blood flow Decreased number of functional nephrons Decreased tubular secretion Result: glomerular filtration rate (GFR) Decreased drug clearance: atenolol, gabapentin, H2 blockers, digoxin, allopurinol, quinolones

    Estimating GFR in the Elderly


    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

    Determining 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)

    Example: Creatinine Clearance vs. Age in a 55 kg Woman


    Age 30 50 70 90 Scr 1.1 1.1 1.1 1.1 CrCl 65 53 41 30

    Pharmacodynamics (PD)
    Definition: the time course and intensity of pharmacologic effect of a drug Age-related changes:
    sensitivity to sedation and psychomotor impairment(perusakan) with benzodiazepines level and duration of pain relief with narcotic agents drowsiness and lateral sway with alcohol HR response to beta-blockers sensitivity to anti-cholinergic agents cardiac sensitivity to digoxin

    PK and PD Summary
    PK and PD changes generally result in decreased clearance and increased sensitivity to medications in older adults Use of lower doses, longer intervals, slower titration are helpful in decreasing the risk of drug intolerance and toxicity Careful monitoring is necessary to ensure successful outcomes

    Optimal Pharmacotherapy
    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

    Consequences of Overprescribing
    Adverse drug events (ADEs) Drug interactions Duplication of drug therapy Decreased quality of life Unnecessary cost Medication non-adherence

    Adverse Drug Events (ADEs)


    Responsible for 5-28% of acute geriatric hospital admissions Greater than 95% of ADEs in the elderly are considered predictable and approximately 50% are considered preventable Most errors occur at the ordering and monitoring stages

    Most Common Medications Associated with ADEs in the Elderly


    Opioid analgesics NSAIDs Anticholinergics Benzodiazepines Also: cardiovascular agents, CNS agents, and musculoskeletal agents

    Adverse Drug Reaction Risk Factors in Older Outpatients. Am J Ger Pharmacotherapy 2003;1(2):82-89.

    The Beers Criteria


    High Potential for Severe ADE amitriptyline chlorpropamide digoxin >0.125mg/d disopyramide GI antispasmodics meperidine methyldopa pentazocine ticlopidine High Potential for Less Severe ADE antihistamines diphenhydramine dipyridamole ergot mesyloids indomethacin muscle relaxants

    Patient Risk Factors for ADEs


    Polypharmacy Multiple co-morbid conditions Prior adverse drug event Low body weight or body mass index Age > 85 years Estimated CrCl <50 mL/min

    Drug-Drug Interactions (DDIs)


    May lead to adverse drug events Likelihood as number of medications Most common DDIs:
    cardiovascular drugs psychotropic drugs

    Most common drug interaction effects:


    confusion cognitive impairment hypotension acute renal failure

    Concepts in Drug-Drug Interactions


    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

    Common Drug-Drug Interactions


    Combination
    ACE inhibitor + potassium ACE inhibitor + K sparing diuretic

    Risk
    Hyperkalemia Hyperkalemia, hypotension

    Digoxin + antiarrhythmic
    Digoxin + diuretic Antiarrhythmic + diuretic Diuretic + diuretic Benzodiazepine + antidepressant Benzodiazepine + antipsychotic

    Bradycardia, arrhythmia
    Electrolyte imbalance; arrhythmia Electrolyte imbalance; dehydration Sedation; confusion; falls

    CCB/nitrate/vasodilator/diuretic

    Hypotension

    Doucet J, Chassagne P, Trivalle C, et al. Drug-drug interactions related to hospital admissions in older adults: a prospective study of 1000 patients. J Am Geriatr Soc 1996;44(9):944-948.

    Drug-Disease Interactions
    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

    Common Drug-Disease Interactions


    Combination
    NSAIDs + CHF Thiazolidinediones + CHF

    Risk
    Fluid retention; CHF exacerbation

    BPH + anticholinergics
    CCB + constipation Narcotics + constipation Anticholinergics + constipation Metformin + CHF NSAIDs + gastropathy NSAIDs + HTN

    Urinary retention
    Exacerbation of constipation

    Hypoxia; increased risk of lactic acidosis Increased ulcer and bleeding risk Fluid retention; decreased effectiveness of diuretics

    Principles of Prescribing in the Elderly


    Avoid prescribing prior to diagnosis Start with a low dose and titrate slowly Avoid starting 2 agents at the same time Reach therapeutic dose before switching or adding agents Consider non-pharmacologic agents

    Peu di tuleh nyou.

    Prescribing Appropriately
    Determine therapeutic endpoints and plan for assessment Consider risk vs. benefit Avoid prescribing to treat side effect of another drug Use 1 medication to treat 2 conditions Consider drug-drug and drug-disease interactions Use simplest regimen possible Adjust doses for renal and hepatic impairment Use least expensive alternative

    Preventing Polypharmacy
    Review medications regularly and each time a new medication started or dose is changed Maintain accurate medication records (include vitamins, OTCs, and herbals)

    Non-Adherence
    Rate may be as high as 50% in the elderly
    Factors in non-adherence
    Financial, cognitive, or functional status Beliefs and understanding about disease and medications

    Enhancing Medication Adherence


    Avoid newer, more expensive medications that are not shown to be superior to less expensive generic alternatives Simplify the regimen Utilize drug calendars Educate patient on medication purpose, benefits, safety, and potential ADEs

    Summary
    Successful pharmacotherapy means using the correct drug at the correct dose for the correct indication in an individual patient Age alters PK and PD ADEs are common among the elderly Risk of ADEs can be minimized by appropriate prescribing

    You might also like