Block 4

Question 1

IMPORTANT

Biphosphonates

Answer 1

• First line treatment
• Used to treat disorders of bone and calcium homeostasis, osteoporosis, Paget’s, hypercalcaemia of malignancy.
• Administered orally
• Generic Drug Names: alendronate (alendronic acid), pamidronate, risedronate
• Mechanism of Action: Promotion of osteoclast apoptosis/ inhibition. Reduction of calcium release from bone- they are absorbed onto the hydroxyapatite crystals which s then taken up by osteoclasts and interferes with their function or attachment to bone via the ruffled borders thus slowing down rate of bone remodelling
• Side effects: asymptomatic hypocalcaemia, general GI disturbance, oesophageal reactions, osteonecrosis of jaw and EAM, atypical femoral fractures

Question 1

Synthetic hormone, Animal-derived hormone (for osteoporosis and calcium balance)

Answer 1

• Used to treat disorders of bone and calcium homeostasis
• Generic Drug Names: parathyroid hormone (recombinant) and calcitonin (derived from salmon)
• Mechanism of Action: Modulation of calcium metabolism and bone resorption

Question 2

Essential nutrients (for calcium and bone deficiency)

Answer 2

• Used to treat disorders of bone and calcium homeostasis
• Vitamin D (cholecalciferol), also calcetriol (1, 25-dihydroxyvitamin D), IV calcium gluconate
• Mechanism of action: restoration of active Vitamin D or plasma calcium levels

Question 3

IMPORTANT

Selective Oestrogen Receptor Modulator (SERM)

Answer 3

• Used to treat disorders of calcium and bone metabolism, osteoporosis
• Generic Drug Name: Raloxifene - usually prescribed for postmenopausal osteoporosis if bisphosphonates are not tolerated
• Administration: Oral
• Mechanism of action: Activates the oestrogen receptor (ER) in the bone to retain bone mineralisation. These are anticatabolic and act by reducing cytokines that cause osteoclast activation and function
• Side Effects: hot flushes, leg cramps, increased risk of DVT and stroke

Question 4

IMPORTANT

Biologic (monoclonal antibody) for osteoporosis treatment

Answer 4

• Used to treat disorders of bone and calcium homeostasis, osteoporosis and malignancy involving bones
• Generic Drug Name: Denosumab - recombinant human monoclonal antibody that inhibits RANKL so inhibits osteoclast formation and function
• Mechanism of Action: Inhibition of release of calcium from bone, inhibition of osteoclast activity
• Administration: subcutaneous injections twice yearly
• Side effects hypocalcaemia, hypophosphataemia, altered bowel habit, dyspnoea, osteonecrosis of the jaw

Question 5

Anti-proliferative agents

Answer 5

• Used as disease modifying anti-rheumatic drugs (DMARDS)
• Generic Drug Name: methotrexate, azathioprine
• Mechanism of Action: Reduces lymphocyte proliferation

Question 6

Immunosuppressive agents

Answer 6

• Used as disease modifying anti-rheumatic drug
• Generic Drug Name: sulphasalazine, penicillamine
• Mechanism of action: immunosuppressive (precise mechanism is unclear)

Question 7

Biologics (monoclonal antibodies for treating inflammation)

Answer 7

• Used as a disease-modifying anti-rheumatic drugs
• Generic Drug Names: infliximab, rituximab
• Mechanism of Action: binds and blocks pro-inflammatory function of TNF-alpha (infliximab)/ depletion of B cells via CD20 binding (rituximab)

Question 8

Beta lactams - penicillin

Answer 8

• Antibiotic and antimicrobial drugs
• Generic Drug Name: Flucloxacillin, benzylpenicillin, amoxicillin, co-amoxiclav
• Mechanism of Action:: Bactericidal - cell lysis by blocking cell wall synthesis

Question 9

Beta lactase - cabapenems

Answer 9

• Antibiotic and antimicrobial drugs
• Generic Drug Name: meropenem
• Mechanism of Action: bactericidal - cell lysis by blocking cell wall synthesis

Question 10

Cephalosporins

Answer 10

• Antibiotic and antimicrobial drugs
• Generic Drug Name: ceftriaxone
• Mechanism of Action: bactericidal - cell lysis by blocking cell wall synthesis

Question 11

Fluoroquinolones

Answer 11

• Antibiotic and antimicrobial drugs
• Generic Drug Name: ciprofloxacin
• Mechanism of Action: bacteriostatic - inhibition of bacterial DNA coiling

Question 12

Lincosamides

Answer 12

• Antibiotic and antimicrobial drugs
• Generic Drug Name: clindamycin
• Mechanism of Action: bacteriostatic - inhibition of bacterial protein synthesis

Question 13

Macrolides

Answer 13

• Antibiotic and antimicrobial drugs
• Generic Drug Name: erythromycin
• Mechanism of Action: bacteriostatic - inhibition of bacterial protein synthesis

Question 14

Anti-folate antibiotic

Answer 14

• Antibiotic and antimicrobial drugs
• Generic Drug Name: trimethoprim
• Mechanism of Action: bacteriostatic - inhibition of bacterial folic acid synthesis, affecting bacterial DNA synthesis

Question 15

Tetracycline

Answer 15

• Antibiotic and antimicrobial drugs
• Generic Drug Name: tetracycline, doxycycline
• Mechanism of Action: Bacteriostatic - inhibition of bacterial protein synthesis

Question 16

IMPORTANT

Parathyroid Hormones

Answer 16

• Used to stimulate bone formation - anabolic drug
• Drug name: Teriparatide - the peptide fragment of recombinant PTH
• Use: Osteoporosis
• Mechanism of Action: Continuous PTH causes bone loss however its been found that PTH given in doses paradoxically stimulate osteoblast activity and enhance bone formation. It increases bone mass, structural integrity and bone strength by increasing osteoblasts and by activating the osteoblasts. It can reduce osteoblast apoptosis
• Adminstration: subcutaneous injection once daily
• Side effects: Mild hypercalcaemia, transient orthostatic hypotension, muscle cramp, nausea and vomitting

Question 17

What are the consequences of falling?

Answer 17

Biological consequences:

• Fractures - femur, wrist, humerus, vertebrae, pelvis
• Head Injury - subdural haematoma
• Soft tissue injuries - carpet burns, bruising
• Burns - fall onto fire or radiator
• Long lies on floor (more than 1 hour) - pressure sores, rhabdomyolysis - breakdown of muscle tissue, hypothermia, pneumonia

Psychological consequences:

• Fear of further falls leading to loss of confidence
• Depression due to reduced independence and reduced social interaction
• Anxiety disorders such as panic disorder, agoraphobia and social anxiety disorder
• Anxiety in carers can lead to elder abuse, and movement from a familiar home to an unfamiliar residential home.

Social consequences:

• Loss of independence due to hobbies, social interaction and dependence on others
• Impact on others- if patient is unable to care for others, family tension and stress
• Need to move to safer surroundings - residential/ nursing homes, financial impact, restriction to one room

Question 18

When do falls more often occur?

Answer 18

Afternoon, as there is a dip in alertness in the afternoon - night times are also a risk

Question 19

What are the major intrinsic causes of falls in the older adult?

Question 20

What are the major extrinsic causes of falls in the older adult?

Question 21

How are falls assessed?

Question 22

How are falls managed?

Question 23

What are the mechanisms of antibiotics?

Question 24

What factors affect antibiotic choice?

Question 25

What are adverse drug reactions?

Question 26

What are dose-related adverse drug reactions?

Question 27

What are time-course related adverse drug reactions?

Question 28

What are patient susceptibility adverse drug reactions?

Question 29

What can cause adverse drug reactions?

Question 30

What are the changes of ageing in pharmacokinetics?

Question 31

What are the changes of ageing in pharmacodynamics?

Question 32

What are the changes of ageing in homeostasis?

Question 33

What is polypharmacy?

Question 34

What are the issues associated with prescribing for older adults?

Question 35

How can concordance be improved?

Question 36

What are medication reviews?

Question 37

What strategies can minimise adverse drug reactions?