Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Pharmaceutical industry wikipedia , lookup
Prescription costs wikipedia , lookup
Neuropharmacology wikipedia , lookup
Polysubstance dependence wikipedia , lookup
Adherence (medicine) wikipedia , lookup
Electronic prescribing wikipedia , lookup
Drug interaction wikipedia , lookup
Intravenous therapy wikipedia , lookup
Geriatric Pharmacology and Clinical Syndromes UNMC’s Division Of Geriatrics Why Was This Session Created? • Students requested and demonstrated need for application of learned information (physiology, pathology & pharmacology) to clinical situations. • Improve training in geriatric pharmacology in medical school curriculum • Address AAMC minimum geriatric competencies for medical school graduates • Improve students’ ability to function in teams AAMC Minimum Geriatric Competencies • Explain impact of age-related changes on drug selection and dose based on knowledge of agerelated changes in renal and hepatic function, body composition, and central nervous system sensitivity. • Identify medications including anticholinergic, psychoactive, anticoagulant, analgesic, hypoglycemic, and cardiovascular drugs that should be avoided or used with caution in older adults and explain the potential problems associated with each. Objectives On completion, the learner will be able to: • Apply pre-existing knowledge and critical thinking to clinical situations simulated through multiple choice questions, discussion, and answers. • Demonstrate knowledge of geriatric pharmacology and aging physiology, and apply this to clinical situations. • Demonstrate ability to work in teams in clinical decision-making situations. Process • Divide class into teams of 2-3 students. • Students may have and use any resources with them. • Students will be expected to explain why they chose an answer and reasons they did not choose the other answers in order to enhance their learning. • Each team can have only one answer. • Students will have approximately 1 minute or less to arrive at their answer. • Students should raise their hands when they have the answer. RESOURCES • Almost all of these are available through UNMC’s library page on mobile resources http://unmc.libguides.com/pda • Clinical Pharmacology….(comprehensive, easy to use) …………free, requires preregistration • MICROMEDEX….(comprehensive, easy to use) ………………..free, requires preregistration • Medscape ……(less comprehensive, easy to use)……… no cost • at http://www.medscape.com/public/mobileapp • ePocrates…..(less comprehensive, easy to use)………….no-cost, not in mobile resources Additional Resources • Beers list………. List of potentially inappropriate medications for the elderly. • Access….Google “Beers List” or go to • http://www.americangeriatrics.org/files/doc uments/beers/PrintableBeersPocketCard.p df The American Geriatrics Society 2012 Beers Criteria Update Expert Panel (2012), American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 60: 616–631. doi: 10.1111/j.1532-5415.2012.03923.x About the Questions • These questions are not designed to assess learning. • This is not a test. • This is an exercise to use questions to consolidate knowledge, develop critical thinking and acquire new knowledge through discussion with colleagues and faculty. • Multiple-choice format, one right answer. • These questions are challenging. You’re ready to start Question #1 • A 72-year-old woman presents with complaints of retrosternal pain and odynophagia. Three weeks ago she began taking alendronate 10 mg daily for the treatment of osteoporosis. She is otherwise in good health. • Endoscopy now shows a large, deep ulcer at the gastroesophageal junction. • Examination of biopsy specimens shows necroinflammatory material and acute esophagitis. • The final diagnosis is alendronate-induced esophagitis and ulceration. Which of the following factors would most likely increase her risk of developing this side effect? A. Age-related decline in esophageal motility B. Age-related increase in gastroesophageal reflux C. Ingestion of alendronate with inadequate amounts of fluid and improper administration D. Ingestion of alendronate at a time other than a true fasting state Which of the following factors would most likely increase her risk of developing this side effect? A. B. C. D. Age-related decline in esophageal motility Age-related increase in gastroesophageal reflux Ingestion of alendronate with inadequate amounts of fluid and improper administration Ingestion of alendronate at a time other than a true fasting state Answer: C Primary points: • Clear instructions to patients on medication administration is critical For oral bisphosphonate (alendronate) • Ingest alendronate with full glass water • Remain upright-30 minutes Secondary points: • Age-related GI changes: (increased gastric pH, decreased gastric motility, decrease splanchnic blood flow occur, not a factor in this case) • Non-fasting state reduces absorption does not increase esophagitis Question # 2 • A 76-year-old woman has had progressive fatigue, lack of energy, and depressed mood for 5 weeks. She is currently taking medication for treatment of diabetes mellitus, hypertension, congestive heart failure, and inflammatory osteoarthritis. Which of the following drugs is the most likely cause of her symptoms? A. B. C. D. E. Lisinopril Hydrochlorothiazide Acetaminophen Glargine insulin Indomethacin Which of the following drugs is the most likely cause of her symptoms? A. B. C. D. E. Lisinopril Hydrochlorothiazide Acetaminophen Glargine insulin Indomethacin Answer: E Indomethacin Primary points: • Depression + polypharmacy always suspect drugs • NSAIDs & CNS effects common (dizziness, headache, cognitive, delirium, psychiatric) Secondary points: • HCTZ.-could only cause symptoms through electrolyte disturbance • ACE inhibitors-CNS effects-rare • Glargine would mediate symptoms through hypoglycemia only Question # 3 A 77-year-old woman is hospitalized for treatment of atrial fibrillation and urosepsis. She has bipolar disorder and a history of stress-related peptic ulcer. She weighs 50 kg (110 lb). Laboratory evaluation shows serum albumin level of 4.1 g/dL and serum creatinine level of 1.0 mg/dL. There is no evidence of liver disease. Does the patient need medication dosage adjustment based on her renal function? Q#1 Does the patient need medication dosage adjustment based on her renal function? Answer: Yes Primary points: • Creatinine declines with age (decreased muscle mass) • Creatinine under estimates renal dysfunction in elderly therefore must calculate CrCl) (Pt’s CrCl = 37 ( CKD III) Which of the following drugs can be used without dosage adjustment for age and renal function in this patient? A. B. C. D. E. Digoxin Gentamicin Lithium Metoprolol Ranitidine Which of the following drugs can be used without dosage adjustment for age and condition? A. B. C. D. E. Digoxin Gentamicin Lithium Metoprolol Ranitidine Answer: D Metoprolol PRIMARY POINTS: • Digoxin, ranitidine, gentamicin, lithium-reduced excretion due to declined renal clearance • Low therapeutic-toxicity ratio----monitor drug levels when able (digoxin, lithium, aminoglycosides) Secondary Points: • Metoprolol hepatic phase 1 metabolism, metabolites (inactive) renal excreted Question #4 • An 82-year-old obese woman with type 2 diabetes mellitus had been taking metformin 850 mg three times daily for 4 weeks when she reported a 5-day history of weakness, nonspecific abdominal pain, and myalgias. Laboratory data included a pH of 7.1 and an anion gap of 21 meq/L. Which of the following age-related physiologic factors most likely increased her risk of developing metformin-induced lactic acidosis? A. Decreased concentrations of albumin and other proteins B. Increased volume of distribution for lipophilic drugs C. Decreased rate of hepatic phase I metabolic reactions D. Decreased glomerular filtration rate Which of the following age-related physiologic factors had most likely increased her risk of developing metformin-induced lactic acidosis? A. Decreased concentrations of albumin and other proteins B. Increased volume of distribution for lipophilic drugs C. Decreased rate of hepatic phase I metabolic reactions D. Decreased glomerular filtration rate Answer: D. Decreased glomerular filtration rate Teaching points-next slide Teaching Points Primary points: • Metformin excreted urine unchanged • Avoid in renal insufficiency, hypoxia, or with contrast dyes • Metformin at risk age > 80 • Advantage: no hypoglycemia. • Adverse effects: GI, rare-lactic acidosis Secondary points: • Not extensively bound to plasma proteins Aging physiology metabolism • Hepatic phase I slowed with age, hepatic phase II preserved. Question #5 An 83-year-old woman who lives in a nursing home is taking warfarin for atrial fibrillation, Trimethoprim-sulfa DS for bronchitis, ranitidine for reflux esophagitis, phenytoin daily for seizures, and carbidopa plus levodopa for Parkinson's disease. Which of her medications would decrease the therapeutic effect of warfarin and increase her risk of embolic ischemic stroke? A. B. C. D. Carbidopa/levodopa Trimethoprim-sulfa (TMP-SMX) Ranitidine Phenytoin Which of her medications increases her risk of embolic ischemic stroke? A. B. C. D. Carbidopa/levodopa Trimethoprim-sulfa (TMP-SMX) Ranitidine Phenytoin Answer: D. Phenytoin Which two of the following medications increases her risk of hemorrhagic stroke? A. B. C. D. Carbidopa plus levodopa Trimethoprim-sulfa (TMP-SMX) Ranitidine Phenytoin Which two of the following medications increases her risk of hemorrhagic stroke? A. B. C. D. Carbidopa plus levodopa Trimethoprim-sulfa (TMP-SMX) Ranitidine Phenytoin Answers: B. TMP-SMX C. Ranitidine Teaching points - next slide Teaching Points Explanation • Phenytoin - decreased warfarin level, through induction hepatic enzymes • Ranitidine – moderate increase serum warfarin level through (CYP450 competitive inhibition) • TMP-SMX-significantly increases warfarin level (CYP450 inhibition, protein displacement, vitamin K reduction in gut) Bottom line: Warfarin = most common ADE Phenytoin = hepatic enzyme induction, commonly reduces Phase I metabolized drug levels CYP450 metabolism - common place for drug-drug interaction Question #6 • A 79-year-old man who has coronary artery disease and congestive heart failure comes to the emergency department because of nausea, vomiting, headache, and abdominal pain. Symptoms began 3 days ago. • Current medications are warfarin, furosemide, digoxin, captopril, vitamin E, and a multivitamin. The regimen had been stable for 10 years until the furosemide dosage was increased last week to better control symptoms of heart failure. Which of the following medications is the most likely cause of this patient’s problems? A. B. C. D. E. Digoxin Furosemide Warfarin Vitamin E Captopril Which of the following medications is the most likely cause of this patient’s problems? A. B. C. D. E. Digoxin Furosemide Warfarin Vitamin E Captopril Answer: A. Digoxin PRIMARY POINTS: • Dig. toxicity - GI & neuro sx • Dig. toxicity due to hypokalemia (furosemide induced) • Elderly most susceptible Secondary points: • Digoxin level always keep < 0.8 • Digoxin use - minimize in the elderly • Vitamin E - bleeding risks Question #7 • An 80-year-old woman is hospitalized for repair of a hip fracture sustained in a fall. Which of the following medications found in her medicine cabinet at home is least likely to have contributed to her fall? A. B. C. D. E. Amitriptyline Chlorpromazine Flurazepam Hydrochlorothiazide Phenobarbital Which of the following medications found in her medicine cabinet at home is least likely to have contributed to her fall? A. B. C. D. E. Amitriptyline Chlorpromazine Flurazepam Hydrochlorothiazide Phenobarbital Answer: D. Hydrochlorothiazide PRIMARY POINT: Any medication that sedates or changes neurotransmitters increases fall risk Secondary points: A. Amitriptyline – anticholinergic-sedating B. Chlorpromazine - anti-dopaminergic, mildly anticholinergic-sedating C. Flurazepam & Phenobarbital - sedating D. HCTZ = nonsedating, orthostatic hypotension risk only Question # 8 • A 68-year-old male has a history of Parkinson’s disease, hypertension, and osteoarthritis. Current medications are carbidopa–levodopa selegiline; losartan; celecoxib; and a multivitamin. • In the past 3 weeks, he has been taking diphenhydramine at bedtime for insomnia. • The patient now reports the onset of urinary incontinence. • Post void residual (PVR) = 300 cc Which of the following is the most appropriate intervention and explain why you did not choose the other possible answers. A. B. C. D. E. Discontinue celecoxib Discontinue diphenhydramine. Discontinue losartan. Substitute fosinopril for losartan. Begin tolterodine. Which of the following is the most appropriate intervention and explain why you did not choose the other possible answers.. A. B. C. D. E. Discontinue celecoxib Discontinue diphenhydramine. Discontinue losartan. Substitute fosinopril for losartan. Begin tolterodine . Answer: B. Discontinue diphenhydramine. Explanation of answers • Patient has overflow incontinence due to diphenhydramine • Diphenhydramine – anticholinergic inhibits detrusor muscle contraction • Celecoxib and losartan – no effect on bladder function • Tolterodine – bladder antispasmadic – would add to overflow incontinence. Bottom-line: Anticholinergic medications = avoid in the elderly Avoid “negative cascade prescribing” Question # 9 JT is a 72 year old woman who presents to the geriatrics clinic. Her past medical history is significant for depression, insomnia, gastroesophageal reflux, benign positional vertigo and edema. Her family reports a rather sudden onset of problems with remembering appointments, misplacing her house keys, and paying bills on time. Her medication list includes sertraline 50mg/d, meclizine 25mg q. 6 hours for dizziness, omeprazole 20mg/d, and furosemide 20mg/d. Which of JT’s medications is MOST LIKELY to contribute to her cognitive complaints? A. B. C. D. Furosemide Meclizine Sertraline Omeprazole Explanation Explanation of answers ANSWER • Furosemide - possible dehydration or electrolyte/RF problems, not as high risk A. Furosemide delirium as meclizine B. Meclizine • Meclizine - Anticholinergic – significant C. Sertraline association with delirium, cognitive impairment. D. Omeprazole • Antidepressants – SSRIs without anticholinergic - low risk delirium/cognitive Answer: B. impairment Meclizine • Proton pump inhibitors – low risk confusion Bottom line: Anticholinergics = high risk CNS sxs. Manage BPV with canalith repositioning Question# 10 A 75 year old man has been experiencing insomnia due to the recent death of his son and due to the stress of caring for his wife who is in poor health. You are considering pharmacologic treatment for insomnia. Which of the following drugs is most appropriate ? A. B. C. D. Temazepam Amitriptyline Diphenhydramine Mirtazapine Which of the following drugs is most appropriate ? ANSWER A. Temazepam B. Amitriptyline C. Diphenhydramine D. Mirtazapine Correct: D. Mirtazapine A. Temazepam - accumulation, fall risk, tolerance B. Amitriptyline & diphenhydramine highly anticholinergic D. Mirtazapine – sleep, treats possible depression Bottom line: First choice - manage sleep disorders without medication Insomnia - choose medications with least side effects and additional benefits Question #11 • An 85 year old white male has a history of heart failure (EF ~35%), hypertension, mild Alzheimer’s disease and renal insufficiency. This “pleasantly confused” man complains of pain in his hips and knees. • He is allergic to sulfa. • He takes valsartan 80mg/d, furosemide 20mg/d, metoprolol 25mg BID, and EC ASA 81mg/d. • His pain is present upon awakening in the morning, but resolves after he begins his daily activities. • X-ray shows joint space narrowing of the hips and the presence of osteophytes on the knees. Which one of the following is the best choice for pharmacologic pain management in this patient? A. B. C. D. Acetaminophen Ibuprofen Celecoxib Tramadol Which one of the following is the best choice for pain management in this patient? Teaching points ANSWER A. Acetaminophen B. Ibuprofen C. Celecoxib D. Tramadol A. Acetaminophen - well-tolerated < 4 gm/d, dose adjustments needed in liver disease B. Ibuprofen - ”G.I. toxicity, renal, HTN, edema, CNS Correct: A. Acetaminophen C. Celecoxib – “ditto” plus avoid in sulfa allergic D. Tramadol - limited maximum daily dose, drug interaction SSRI’s Bottom line: Always include nonpharmacologic modalities to reduce medication need Choose safest medications & use scheduled doses Question # 12 (two-part question) Part One Which of the following changes normally occurs in the elderly? A. Increase in lean body mass B. Significant decline in serum albumin C. Increase in percent body fat D. Increase in plasma volume Which of the following changes normally occurs in the elderly? A. B. Increase in lean body mass Significant decline in serum albumin C. Increase in percent body fat D. Increase in plasma volume Correct: C. Increase in percent body fat Primary points: • Aging leads to increase % body fat (decreased lean body mass) Leads to: • Decreased vol. of distribution (Vd) of hydrophilic drugs • Increased Vd of lipophilic drugs. Additional points: - albumin changes minimally if at all with age, but significantly with disease. - plasma volume moderate decrease with age (~ 8%) Question # 12 part two Due to Vd changes in the elderly, which two of the following drugs will take longer to reach steady concentration and longer to be eliminated from the body? A. B. C. D. E. Digoxin Ethanol Diazepam Trazodone Lithium Due to Vd in the elderly, which two of the following drugs will take longer to reach steady concentration and longer to be eliminated from the body? A. B. C. D. E. Digoxin Ethanol Diazepam Trazodone Lithium Correct: C. Diazepam D. Trazodone Teaching points: RE: digoxin, ethanol, lithium - all hydrophilic, require less loading dose, lower dosages & reach earlier steady-state. RE: diazepam, trazodone - all lipophilic - longer time to steadystate, longer elimination & increased total body drug. Bottom line: Hydrophilics = need less drug, easily toxic Lipophilics = longer side effects Prescribing rule: “Start Low, Titrate Slow” Question # 13 87-year-old Master Gardener presents with low back muscle pain from planting his spring garden. He is taking scheduled acetaminophen 650 mg TID as you suggested, but he needs something stronger to treat his sore muscles so he can finish his garden. Which of the following medications is the best choice to relieve his back pain? Why? A. B. C. D. Ketorolac ( Toradol) Cyclobenzaprine (Flexeril) Tramadol (Ultram) Hydrocodone with acetaminophen (Vicodin) Which of the following medications is the best choice to relieve his pain? Why? Explanation of answers ANSWER A. B. C. D. Ketorolac (Toradol) Cyclobenzaprine (Flexeril) Tramadol Hydrocodone with acetaminophen (Vicodin) Correct: C. Tramadol • • Ketorolac - risks outweigh benefits Cyclobenzaprine (Flexeril) - anticholinergic, does not treat underlying problem • Tramadol - safest of the medications listed • Hydrocodone with acetaminophen (Vicodin) – excess acetaminophen risk Bottom-line: Muscle relaxers = anticholinergic, do not treat source (OA) Avoid narcotic/acetaminophen combos when using scheduled acetaminophen Question # 14 75-year-old male diabetic receiving cisplatin for prostate cancer. After his first infusion he had problems with nausea and vomiting. He is very concerned about side effects of medications. Which of the following would be your first choice as an anti-emetic? Why? A. B. C. D. E. Promethazine (Phenergan) Ondansetron (Zofran) Metoclopramide (Reglan) Hydroxyzine (Vistaril) Lorazepam (Ativan) Which of the following would be your first choice as an anti-emetic? Why? A. Promethazine (Phenergan)A. B. C. D. E. Promethazine (Phenergan) Ondansetron (Zofran) Metoclopramide (Reglan) Hydroxyzine (Vistaril) Lorazepam (Ativan) Correct: B. Ondansetron (Zofran) anticholinergic, not CTZ effective B. Ondansetron (Zofran) - safest, 5HT, expensive. C. Metoclopramide (Reglan) - antidopaminergic D. Hydroxyzine (Vistaril) - anticholinergic, not CTZ effective E. Lorazepam (Ativan) - confusion, falls, best for anxiety/anticipatory N/V. Bottom line: Medication induced nausea = CTZ Choose anti-emetics based on etiology nausea, mediating neurotransmitter, side effects & routes of administration Question # 15 78-year-old male with URI symptoms; cough, runny nose, sore throat. PmHx: Alz Dz-mild, HTN, Depression, BPH. Medications; sertraline VS: 36.6-18-80-120/70 Orpharynx; mild erythema, clear nasal discharge Lungs clear Please choose 2 acceptable treatments for his symptoms. Why? Why not the others? A. Chlorpheniramine B. Saline nasal spray and irrigation four times a day and prn congestion C. Guafenesin D. Pseudoephedrine E. Dextromethorphan Please choose 2 acceptable treatments for his symptoms. Explain the reasons for your choices. A. B. C. D. E. Chlorpheniramine Saline nasal spray and irrigation four times a day and prn congestion Guafenesin Pseudoephedrine Dextromethorphan Correct: B. Saline nasal spray and irrigation C. Guafenisin A. Chlorphenarmine - anticholinergic B. Saline nasal spray and irrigation – safe, effective C. Guafenisin – side effects at higher doses only D. Pseudoephedrine - urinary retention, HTN E. Dextromethorphan - sedation, fatigue, DDI ->serotonin syndrome with SSRI Bottom line: Manage symptoms with safest modalities OTC often have significant side effects & drug-drug interactions Question # 16 82 year old frail male; 3 days diarrhea, no recent antibiotics, no vomiting, no blood or melena, no abdominal pain. 3-5 stools per day. Difficulty keeping up with hydration and getting to the bathroom. Wants something to slow it down What do you want to do on physical exam? Here are your findings: 0; 36.6-18-80-lying120/80; standing 118/80 Wt : 150# (152# two months prior) Adequately hydrated, alert, normal attention Abdomen-benign DRE-negative, with fecal occult blood negative What would be your laboratory evaluation? (you may choose more than one) A. B. C. D. E. Stool cultures Stools for C. Dif. BMP (basic metabolic profile) CBC Stool sample for Cysts, Ova and Parasites What would be your evaluation? (you may choose more than one) A. B. C. D. E. Stool cultures Stools for C. Dif. BMP (basic metabolic profile) CBC Stool sample for Cysts, Ova and Parasites Answer: C and D. BMP +/- CBC TEACHING POINTS: A. Stool cultures - too early, sx do not indicate bacterial dz. B. Stools for C. Dif. - sx pattern does not fit C. BMP (basic metabolic profile) screen for metabolic/renal prob. D. CBC - marginal indication E. Stool sample for Cysts, Ova and Parasites - no exposures, shortterm diarrhea Laboratory Evaluation RESULTS BMP (basic metabolic profile) Electrolytes-normal Blood sugar-110 BUN- 30 Cr- 1.1 CBC ( marginally indicated but if requested) WBC-6000 Hgb-14 Remainder of the profile normal Besides increasing fluids, what would be your initial dietary therapy? Choose one answer A. B. C. D. E. Clear liquid diet Bananas, rice, apples and tea Regular diet High fiber diet Gatorade Besides increasing fluid intake, what would be your initial dietary therapy? Choose one answer A. B. C. D. E. Clear liquid diet Bananas, rice, apples and tea Regular diet High fiber diet Gatorade Answer: C. Regular diet A. B. C. D. E. Clear liquid diet - no impact diarrhea, reduces calorie intake Bananas, rice, apples and tea - not necessary to change diet in the elderly Regular diet - maintains calories, protein High fiber diet - for constipation, occasional IBS Gatorade - for perspiration induced fluid loss, not G.I. Would you add pharmacologic therapies? If so, what would they be? A. Loperamide B. Bismuth subsalicylate; C. Diphenoxylate/atropine D. Dicyclomine Would you add pharmacologic therapies? If so, what would they be? A. B. C. D. Loperamide Bismuth subsalicylate; Diphenoxylate/atropine Dicyclomine Answer: B. Bismuth subsalicylate; 15-after each diarrhea stool. max.240 ml/day A. Loperamide - dizziness, mild CNS side effects, bladder dysfunction B. Bismuth subsalicylate - low risk side effects C. Diphenoxylate/atropine - anticholinergichigh risk CNS SE D. Dicyclomine - anticholinergic Bottom line: - treat diarrhea with hydration - if adding pharmacologic treatment, choose low side effect ( Bismuth Salicylate) Options • Stop and call it a day • Go to the Bonus round Summary • Thank you for your efforts • Continue to develop astute prescribing skills • Additional geriatric resources: - Geriatrics at Your Fingertips (GAYF) - M3 ambulatory medicine rotation - M4 sub internship - M4 Hospice And Palliative Medicine Rotation - M4 basic science selective - website; geriatrics.unmc.edu - GERI pearls - geriatric resources THE END Bonus Question # 1 • RF is an 83 year old man with a history of Type II diabetes, GERD, osteoarthritis, and hypothyroidism. • He is currently taking a multivitamin daily, glyburide, acetaminophen, omeprazole, and levothyroxine Question: Which medication places RF at the greatest risk for an adverse drug event? Which medication places RF at the greatest risk for an adverse drug event? A. B. C. D. Acetaminophen Omeprazole Glyburide Levothyroxine Which medication places RF at the greatest risk for an adverse drug event? ANSWER A. Acetaminophen B. Omeprazole C. Glyburide D. Levothyroxine Correct: C. Glyburide Return to last slide (summary) • All drugs have potential side effects • Hypoglycemia in the elderly less aware • Most common drug class with adverse events; cardiovascular agents, sedative/hypnotics, and anticoagulants Bonus Question # 2 84-year-old female highly functional diabetic who wishes good control of her diabetes. PHx: heart failure. Follows her diet well. Medications: Metformin. Lisinopril, ASA, Simvastatin VS 134#, 126/68, Creatinine 1.7, Hgb A1c 9.5%. Which of her medications is the highest risk of side effects for her? What is your next step in management? Which of her medications is the highest risk of side effects for her? Why? A. B. C. D. Metformin Lisinopril ASA Simvastatin Which of her medications is the highest risk of side effects for her? Why? ANSWER • Metformin • Lisinopril • ASA • Simvastatin Correct: A. Metformin A. Metformin – risk; age > 80, chronic kidney disease. B. Lisinopril – indicated in DM, renal protective, HTN C. ASA – indicated prevention ASCVD D. Simvastatin - lipid control What is your next step in management of her diabetes? Besides stopping metformin, which of the following would you add? Why? A. B. C. D. Glyburide Glargine Insulin Rosiglitazone Acarbose Besides stopping metformin, which of the following would you add? Why? ANSWER A. Glyburide B. Glargine Insulin C. Rosiglitazone D. Acarbose Correct: B. Glargine Insulin at HS Return to last slide (summary) A. Glyburide - contra indicated in CKD B. Glargine Insulin at HS - most effective, but pt high functioning, motivated C. Rosiglitazone - contra indicated, heart failure D. Acarbose - complicated, costly, limited reduction A1c Bottom-line: • Sulfonyreas - avoid in CKD III-V • Rosiglitazone – avoid in heart failure • Insulin (although requires subcutaneous administration, may be best choice Bonus Question # 3 • BH is a 70 year old female diagnosed with depression. • Her medical history includes hypertension, insomnia, constipation, and a seizure disorder. • Her medications are amlodipine, senna, phenytoin • Laboratories: Na = 128 , K = 3.7, Cl = 98, CO2 = 23, anion gap + 5, BUN = 19, SCr = 1.0 mg/dL. Which of the following is the most appropriate intervention for treating BH’s depression? Which of her present medications adds to her constipation? Which of the following is the most appropriate intervention for treating BH’s depression? A. B. C. D. Amitriptyline Citalopram Mirtazapine Bupropion Which of the following is the most appropriate intervention for treating BH’s depression? ANSWER • Amitriptyline • Citalopram • Mirtazapine • Bupropion XL Correct: C. Mirtazapine A. Amitriptyline – anticholinergic constipation C. Citalopram – SIADH hyponatremia D. Bupropion - lowers seizure threshold Bottom-line: Choose antidepressants based on additional benefits, lowest side effects & least risk drug-drug interaction Which of her present medications adds to her constipation? A. Amlodipine B. Senna C. Phenytoin Which of her present medications adds to her constipation? Answer A. Amlodipine B. Senna C. Phenytoin Correct: A. Amlodipine constipation A. Amlodipine - all calcium blockers - constipation, peripheral edema B. Senna - if you chose this drug, you must repeat M1 C. Phenytoin - many drug-drug interactions, not constipation Return to last slide (summary) Bonus Question # 4 • 75-year-old female sees you as a new patient, Pmhx; HTN Troubled by daytime sedation, mild problems concentrating, urinary incontinence & constipation. Medications: Clonidine 0.1 mg BID, prazosin 5 mg/day, HCTZ 12.5 mg/day, nifedipine 30 mg/day Which one of her medications does not contribute to her side effects? Which one of her medications does not potentially cause some of her current symptoms? A. B. C. D. Clonidine Prazosin HCTZ Nifedipine Also must explain other medications side effects and mechanisms. Which one of her medications does not potentially cause some of her current symptoms? Also must explain other medications side effects and mechanisms. ANSWER • Clonidine • Prazosin • HCTZ • Nifedipine Correct: C. HCTZ Return to last slide (summary) A. Clonidine - central alpha blocker sedation, confusion B. Prazosin - alpha blocker - internal sphincter sympathetic inhibition. C. HCTZ D. Nifedipine - constipation, potentially inappropriate medication elderly Bottom-line: - HCTZ most effective, best tolerated, first choice antihypertensive Question # 5 82-year-old female has fallen, has a Colles fracture right arm. Needs pain control. Pain significant 8/10. Please choose the most effective and safest for the patient. You may choose 2 items from the following list. Please choose the most effective and safest for the patient. You may choose 2 items from the following list. Why and why not the others? A. B. C. D. E. F. Tramadol 50 mg QID Codeine 30 mg every six hours prn pain Acetaminophen 650 milligrams TID Ibuprofen 600 mg TID Oxycodone 2.5 mg every four hours prn pain Acetaminophen/oxycodone 5/500 1 every six hours prn pain Please choose the most effective and safest for the patient. You may choose 2 items from the following list. A. B. C. D. E. F. Tramadol 50 mg QID Codeine 30 mg every six hours prn pain Acetaminophen 650 milligrams TID Ibuprofen 600 mg TID Oxycodone 2.5 mg every four hours prn pain Acetaminophen/oxyco done 5/500 1 every six hours prn pain Answer A. Acetaminophen 650 milligrams TID B. Oxycodone 2.5 mg every four hours prn pain Return to last slide (summary) Tramadol - dose too high for this patient - Codeine too constipating Ibuprofen - side effects too extensive (HTN, CKD, UGI ) Acetaminophen/oxycodone - potential acetaminophen toxicity, unable to use scheduled, oxycodone dose too high Acetaminophen schedule dose - better than PRN, least risk toxicity Oxycodone 2.5 milligram - starting dose, every four hours best interval Bottom line: best pain management elderly: - acetaminophen scheduled dose plus - low dose PRN narcotic