Pharmacotherapeutics - Exam 1

Question 1

_______ is altered by individual’s diseases, environment, and other medications

Answer 1

Pharmacokinetics

Question 2

What are the 4 keys to pharmacokinetics?

Answer 2

Metabolism
Elimination
Absorption
Distribution

Question 3

Name some factors that influence medication absorption. Are they affected by age or diseases/medication?

Answer 3

Absorptive surface
gastric pH
splanchnic blood flow
GI tract motility

mostly NOT affected by age and GREATLY affected by certain diseases and medications

Question 4

Reduction in normal ______ leads to decreased absorption of some meds. Name 3 in particular

Answer 4

active transport mechanisms

B12, calcium and iron

Question 5

What are 3 age related changes that effect medication distribution.

Answer 5

reduced lean muscle mass

decreased total-body water content

decreased serum albumin

Question 6

How does having a reduced lean muscle mass change how medication is distributed?

Answer 6

Results in increased adipose tissue

Increased volume of distribution for lipophilic drugs (ex. BZDs).

Results in lower serum levels and prolonged clearance rates

Question 7

How does having decreased total- body water content change how medication is distributed?

Answer 7

Decreased volume of distribution for hydrophilic medications (Digoxin, lithium)

Results in higher serum levels

Question 8

How does having decreased serum albumin content change how medication is distributed?

Answer 8

Results in increased “free” drug levels which leads to increase risk of SE’s when high protein binding drugs are used

Question 9

Decreased serum albumin can be seen the elderly, name 2 other conditions in which you may also see decreased serum albumin

Answer 9

Can be seen in patients with poor nutritional states, impaired renal function, and many other chronic conditions

Question 10

How does ages effect the CYP450 metabolism? Why?

Answer 10

reduces CYP450 metabolism

Due to age related decrease in hepatic blood flow and overall liver size

Question 11

What happens when CYP450 enzyme is inhibited? Induced?

Answer 11

toxic accumulation of other drugs that require P450 for metabolism

rapid metabolism of P450 drugs leading to decreased efficacy

Question 12

_____ is most common cause of altered pharmacokinetics in elderly patients
_____ and ____ decrease with age. Serum creatinine may be _____ in geriatric patients despite renal impairment due to loss in ______

Answer 12

Renal impairment

Tubular function

GFR

normal

muscle mass

Question 13

When prescribe certain medications to the elderly, need to check ________.

T/F: You can have normal creatinine and abnormal CrCl.

Answer 13

creatinine clearance

True!!

Question 14

**What is the Cockcroft-Gault formula for estimating creatinine clearance?

Answer 14

Question 15

Define pharmacodynamics. How does it change with aging?

Answer 15

Defined as how a drug affects the body

Altered receptor affinity or numbers, postreceptor alterations, and/or impairment of homeostatic mechanisms

Question 16

**Specifically, geriatric patients are more sensitive to _______. What can it result in?

Answer 16

CNS depressants

delirium, confusion, agitiation

(example in class was Benadryl)

Question 17

Define polypharmacy

Answer 17

Defined as simultaneous use of multiple medications by a single patient (more than 5 meds)

Question 18

What re the risks/complications of polypharmacy

Answer 18

Increased adverse drug reactions, drug-drug interactions, drug-disease interaction

Increase cost burden

Increase risk of hospitalizations

Decreased quality of life

Adherence

Question 19

**What is an adverse drug reaction? Adverse drug event?

Answer 19

Unwanted effects of drugs at NORMAL DOSAGE AND USE!!

An injury/harm resulting from the use of a pharmacologic agent (adverse drug reactions fall into adverse drug events)
- unintentional overdose, withdrawal reaction

Question 20

Hospitalization rates due to adverse drug events are approximately ____ higher in geriatric patients

Answer 20

4x

Question 21

Adverse drug reactions are most often related to ______ and ________. _____and _____ are two common meds responsible for >60% of all medication-related hospitalizations

Answer 21

multiple medications

number of chronic illnesses present

Anticoagulants

hyperglycemics (insulin)

Question 22

(inhibiting/inducing) the P450 system is MC. Give one example. Why?

Answer 22

Inhibition of the P450 system

verapamil (CCB) and atorvastatin

Inhibition of P450 slows metabolism of atorvastatin leading to toxic levels of statin → liver dysfunction, myalgias, rhabdomyolysi

Question 23

What does induction of the P450 result in? What are 4 common medications?

Answer 23

Results in rapid clearance and decreased effectiveness of drugs that are metabolized by P450

rifampin, barbiturates, carbamazepine, phenytoin

Question 24

When considering drug-disease interactions. underlying disease _____ to unwanted physiologic effects of a drug. Give an example.

Answer 24

increases susceptibility

patient with severe COPD or asthma is prescribed a beta-blocker that may result in worse pulmonary symptoms but does NOT have to occur. NOT every potential interaction results in harm

Question 25

Name 3 tools providers can use to help avoid misuse/overuse/underuse of prescription drugs

Answer 25

Beers criteria STOPP: Screening Tool of Older Person’s Prescriptions START: Screening Tool to Alert providers to Right Treatment

Question 26

**Name the medication classes that were listed on the Beers criteria in lecture**

Answer 26

1st gen antihistamines Digoxin >0.125 mg/day TCAs Antipsychotics Benzos Sleep medications (zolpidem, eszopiclone, etc) Male androgens (testosterone) Long-acting sulfonylureas ( glyburide, chlorpropamide) Meperidine (Demerol) opioid pain med NSAIDs (unless taken with PPI) Skeletal muscle relaxants

Question 27

What are the 5 categories of drugs in the Beers criteria.

Answer 27

1. Medications that are potentially inappropriate (avoid) 2. Medications that are potentially inappropriate in patients with certain diseases or syndromes 3. Medications to be used with caution 4. Potentially inappropriate drug-drug interactions 5. Medications that require dosage adjustment based on renal function

Question 28

What are some complications of nonadherence?

Answer 28

-Inadequate disease control -Misdiagnosis -Increased ER visits and hospitalizations -Increased health care costs -Higher mortality

Question 29

What are some contributing factors to non-adherence?

Answer 29

-Asymptomatic disease -Medication side effects -Inadequate follow-up -Lack of patient understanding of the value of treatment -Missed appointments -Transportation difficulties -Complicated dosing regimens; polypharmacy -Financial hardships

Question 30

Give 3 examples of how we can make prescribing safer?

Answer 30

Thoroughly evaluate each patient individually brown bag review deprescribing or unprescribing

Question 31

_____ is the MC medication implicated in ER visits and hospitalizations for ADRs. Why?

Answer 31

Warfarin Complicated, frequently changing dosing and the need for close monitoring to keep pts in target range

Question 32

Older age is associated with increased risk of drug-induced ______. ______ is the 2nd MC cause of ADRs the lead to ER visits

Answer 32

hypoglycemia insulin

Question 33

What are 3 factors that contribute to hypoglycemia in the elderly?

Answer 33

Diminished renal function Medications that interact with insulin’s effects Impaired cognitive function

Question 34

Why do you want to avoid long-acting sulfonylureas in the elderly? If you have to give one choose ______ and avoid _____

Answer 34

greater risk of hypoglycemia due to decreased drug clearance that leads to an accumulation of the drug give glipizide (short-acting sulfonylureas) AVOID glyburide

Question 35

_______ has a very narrow therapeutic window and toxicity common. What are the s/s of toxicity? What do you need to monitor?

Answer 35

Digoxin fatigue, confusion, GI disturbances serum levels

Question 36

What are the potential risks of NSAIDs in the elderly? When are they contraindicated?

Answer 36

Peptic ulcer disease Renal impairment Exacerbate HTN Promote fluid retention Heart failure Renal dysfunction High risk of peptic ulcer induced GI bleeding

Question 37

If NSAIDs have to be used, what are the prescribing guidelines? When do you need to f/u? What are the NSAID alternatives?

Answer 37

Use at the lowest dose, for the shortest duration possible Co-administer PPI Take ASA upon awakening, NSAID at least 2 hours later Follow up in 2-4 weeks after starting NSAID to evaluate for renal dysfunction, fluid retention, BP elevation Acetaminophen (Tylenol), diclofenac gel (Voltaren)

Question 38

What are the antihistamines that should be avoided in the elderly?

Answer 38

Diphenhydramine (Benadryl) Meclizine (Antivert) dimenhydrinate (Dramamine)

Question 39

What are the antidepressants that should be avoided in the elderly?

Answer 39

Amitriptyline (Elavil) doxepin paroxetine (Paxil)

Question 40

What are the antipsychotics that should be avoided in the elderly?

Answer 40

Clozapine (Clozaril) olanzapine (Zyprexa) quetiapine (Seroquel)

Question 41

What are the bladder/GI antispamodics that should be avoided in the elderly?

Answer 41

GU : oxybutynin (Ditropan), tolterodine (Detrol) GI: dicyclomine (Bentyl)

Question 42

the muscle relaxant _____ should be avoided in the elderly. The antiemetic ____ should be avoided in the elderly.

Answer 42

cyclobenzaprine promethazine

Question 43

Use of multiple anticholinergic drugs has been associated with increased risk of ______, ______ and ______.

Answer 43

Falls Functional decline Impaired cognition

Question 44

______ have safety concerns for the elderly that include Psychomotor impairment, increased risk of delirium, impaired gait, falls, sedation, N/V/C, respiratory depression, central sleep apnea

Answer 44

opioids

Question 45

antipsychotics are considered especially high risk in the elderly when used for ______. What is the preferred tx option? What happens if antipsychotics are deemed necessary?

Answer 45

dementia non-pharm discuss risks/benefits with family, document the discussion!!, use for minimum duration of therapy

Question 46

using antipsychotics in dementia increases the pt's risk of ? (6 things)

Answer 46

MI Stroke VTE (venous thromboembolism) Falls Fractures Mortality

Question 47

What age group defines the geriatric population?

Answer 47

65 and older

Question 48

Define gerontology

Answer 48

The branch of science that deals with aging and the problems of aged persons

Question 49

Why is the presentation of disease different in the elderly population?

Answer 49

Elderly patients have a decreased ability to respond to stress.

Question 50

Name 3 factors that are considered critical for successful aging?

Answer 50

Regular exercise Social engagement Moderation of food intake

Question 51

Define frailty (frailty phenotype)

Answer 51

Dysregulation of multiple organ systems due to distinct physiologic changes, increased vulnerability to stressors, and decreased ability to adapt to external stressors

Question 52

What percent of the U.S. population age 65 to 79 years reports having two or more chronic diseases?

Answer 52

35%

Question 53

List some common problems seen in the geriatric population

Answer 53

Immobility, Instability, Incontinence, Intellectual impairment, Infection, Impairment of vision and hearing, Irritable colon, Isolation (depression), Inanition (malnutrition), Iatrogenesis, Insomnia, Immune deficiency, Impotence

Question 54

What are the major demographic trends in the geriatric population?

Answer 54

The geriatric population is growing (due to the baby boomer era and increased life span) with less population coming behind them - leading to a lack of financial support for Social Security and Medicare and fewer healthcare providers.

Question 55

How will demographic trends affect future health care?

Answer 55

People are living longer - leads to higher geriatric population and longer management of chronic conditions - resulting in more patients who are classified as “disabled” resulting in higher healthcare costs

Question 56

Name some factors that may affect an older person's access to healthcare?

Answer 56

Access to transportation Insurance coverage Social support

Question 57

Which entity pays for the majority of nursing home care?

Answer 57

Medicaid

Question 58

List some predictors of nursing home placement

Answer 58

Older age, functional impairment prior to nursing home admission, lower perceived health, cognitive impairment, and lack of social supports