Download Medication Use in Older Adults

Medication Use in Older Adults
Nebila Kasse, Pharm.D.
Robert Hunt, Pharm.D.
PGY1 Pharmacy Residents
Kaiser Permanente West Los Angeles
DEPARTMENT NAME PLACEHOLDER (OPTIONAL)
Agenda Slide
Medication Review
Physiologic changes with normal aging
Drug-drug and drug disease interactions
Common disease states overview
Medication disposal & compliance tips
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Medication Review
Purpose
▪ To increase communication between patients
and pharmacists
▪ To promote safe and effective medication use
▪ To improve health outcomes for patients
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Physiologic Changes with Normal Aging
▪Less Water
▪More Fat
▪Less muscle mass
▪Slowed liver metabolism
▪Decreased kidney excretion
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Absorption
▪ Least affected by
▪ Can
the normal aging process
be altered by drug interactions
– Antacids
– Iron
▪ Can
be affected by disease
– Lack
of intrinsic factor (B12 absorption)
– Delayed
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gastric emptying
© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Distribution
▪ Less water = ↓ volume of distribution
–Higher concentration of water soluble drugs
▪ More fat = ↑ volume of distribution
–Prolonged action of fat-soluble drugs (increased half-life)
▪ Lower serum proteins (like albumin) increases the
concentration of unbound (free or active) form of
drugs
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Metabolism
Elimination
▪Decreased kidney function
▪Decreased drug elimination
▪Active drug metabolites may accumulate
–Prolonged action
–Increased risk of side effects
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Adjusting Medications
▪Two ways to adjust medications depending on type of
medication
–Takes a smaller amount of the medication but keep the
same schedule
–Take the same amount of the medication but take it less
often
▪Remind your providers that you have reduced kidney
function when they prescribe medications
Medications that need to be adjusted
▪Examples:
–Heart drugs- Digoxin
–Antibiotics- penicillin derivatives (ampicillin), Cipro,
Bactrim
–Antivirals- Acyclovir
–Antigout- Allopurinol
–Antiulcer- Zantac, Tagamet
Adverse Drug Reactions
▪ Unwanted and/or harmful effects that can occur at
standard doses
▪ Risks for adverse drug reactions
–Polypharmacy, multi-morbidity, dementia, low body
weight, vision or hearing impairment, regimen
complexity
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Medications with Higher Risk of Side Effects in
Older Adults
▪ There are certain medications that can cause more serious
side effects in older adults because we become more
sensitive to them
–They can be over-the-counter or prescription
– Always let your doctor know if you experience side effects
from any your medications
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Medications with Higher Risk of Side Effects in
Older Adults
▪ Anticholinergic medications (allergy medications, muscle
relaxants, antidepressants, others)
–Examples: carisoprodol (Soma), cyclobenzaprine (Flexeril), amitriptyline
(Elavil), doxepin (Sinequan), diphenhydramine (Benadryl),
chlorpheniramine (Chlor-Trimenton), others
–↑ risk of drowsiness,dry mouth, confusion, falls
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Medications with Higher Risk of Side Effects in
Older Adults
▪ NSAIDs (for pain and fever):
– Examples: ibuprofen (Advil, Motrin), naproxen (Aleve),
high-dose aspirin (Bayer Aspirin)
–↑ risk of bleeding and ulcers, kidney issues, drug
interactions (warfarin, low dose aspirin)
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Medications with Higher Risk of Side Effects in
Older Adults
▪ Decongestants (for cough and cold):
–phenylephrine and pseudoephedrine (Sudafed)
–↑ blood pressure
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Medications with Higher Risk of Side Effects in
Older Adults
▪ Anxiety and Sleep medications : lorazepam (Ativan),
alprazolam (Xanax), diazepam (Valium), zolpidem (Ambien),
eszopiclone (Lunesta)
–↑ sleepiness, confusion and falls (can mimic alcohol
effects), can ↑ agitation in some patients
▪Estrogens (for hormone replacement)
– ↑ risk for blood clots
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
What is a medication that can
cause more side effects in older
adults?
Kidney Function and Medications
▪ As we age, our kidneys can’t get rid of waste or medications as easily
as before
–Therefore certain medications need to be adjusted to accommodate this
–In addition, uncontrolled diabetes and high blood pressure can contribute to
worsening kidney function.
▪There are also certain OTC medication you should avoid taking
without being monitored by a healthcare professional
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Medications to Avoid in Kidney Disease
▪ NSAIDs: ibuprofen, naproxen, high-dose aspirin (>325mg a day)
– Can reduce blood flow to the kidneys
▪ Herbal supplements:
– Can contain many things inside of them
– Can interact with your other medications or contain things that might be
harmful to healthy people or people with kidney disease (such as high doses
of potassium or phosphates which can build up in the body when your
kidneys don’t work)
Medications to Avoid in Kidney Disease
▪ Heartburn, antacids, and upset stomach medications:
– Milk of Magnesia, Mylanta: contain high doses of magnesium, aluminum, and
phosphorus which can also build up in the body
– Alka seltzer: has high doses of sodium which can cause your body to retain
fluid
▪ Multivitamins (Centrum, others):
– General one-a-day multivitamins can have high levels of certain vitamins or
minerals which might be too much for your kidneys to handle
– Check with your doctor which vitamins you should be taking
What is an example of a
medication you should avoid if
you have kidney disease?
Drug interactions
▪ Drug/Drug, Drug/Disease, Drug/Food, Drug/Alcohol
– Includes prescriptions, over-the-counter medications,
vitamins, supplements, herbals
▪ Examples
–Warfarin and antibiotics
–Calcium and antibiotics (doxycycline)
–Warfarin and green leafy vegetables
–Grapefruit juice and multiple medications (Simvastatin)
–Alcohol and pain medicines (tramadol, hydrocodone)
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Drug interactions cont.
▪ Blood thinners and over the counter pain medications (NSAIDs)
–Warfarin, Pradaxa, Xarelto, Eliquis, Plavix
–Avoid Ibuprofen, Advil, Aleve, Naproxen
–Aspirin 81-325 mg/day for heart & stroke protection are appropriate
under doctor's approval
▪ Pain medications and Tylenol (Acetaminophen)
–Norco, Tylenol #3, and Tylenol
–No more than 3,000mg of Tylenol per day (2,000mg if on warfarin)
▪Arrhythmias and triggers
–Avoid caffeine, alcohol
▪Medications that increase drowsiness
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Herbal Supplements
▪ Not very well studied
▪ May contain contaminants and minerals that may be harmful
▪ Be aware of herbal & drug interactions, herbal & disease
interactions
▪ Avoid any products with claims to protect or restore
kidneys/livers (cleansers, rejuvenators)
▪ Always check with your doctor or pharmacist before you decide
to start
Natural does not mean safe!
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Hypertension Control
▪ Control of high blood pressure is very important factor in slowing the
progression of kidney disease and reducing risk of heart attack and
stroke
▪ Blood pressure goal: <150/90 if above 60 years old
–<140/90 if you have diabetes, kidney disease or less than 60 years old
▪Know your blood pressure! Monitor and keep a record to share with
your doctor
▪Many patients are on at least 1 medication for blood pressure.
Multiple medications with different mechanisms of action work
together to lower blood pressure.
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
What is your blood pressure goal?
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Controlling Diabetes
▪ Good control of diabetes helps to prevent and delay complications
(kidney disease, blindness, limb amputations, heart disease, strokes)
▪It is important to check your blood sugars as directed by your doctor.
▪Medications together with healthy eating habits and exercise keeps
diabetes under good control.
▪Additional therapies: Statins, Aspirin
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
What is A1c?
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Heart Failure
▪ Heart failure is a chronic condition of the heart that can sometimes
cause “exacerbations”
– Symptoms = shortness of breath, cough, swelling
▪ You might be on several medications to help reduce symptoms and
improve heart muscle function
– A beta-blocker (like metoprolol), an ACE inhibitor (like lisinopril),
and a water pill (like furosemide)
– Taking your medications as directed is critical to help prevent
exacerbations
Heart Failure
▪ Limit salt (high levels are found in: processed foods, restaurant and
fast food)
– This is to help prevent fluid retention
– Limit sodium to 2000mg a day
▪ Limit fluids if directed by your healthcare provider
– For example you might need to limit fluids to 2 quarts a day
▪ Weigh yourself everyday and write it down
– Let your provider know if you gain weight quickly (for example: 2-3 lbs in one
day, or 5 lbs over a week)
What is the sodium intake limit for
people with heart failure?
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Chronic Obstructive Pulmonary Disease
(COPD)
▪ COPD (chronic obstructive pulmonary disease) is another chronic
disease that can have “exacerbations”
– Symptoms include: shortness of breath, wheezing, increased
phlegm
▪ Important to take your medications as directed
– Ensure that you are taking any corticosteroid inhalers everyday
(even if you are not having symptoms)
– Make sure to rinse your mouth out after each corticosteroid
inhaler use
– Make sure to talk to your doctor if you symptoms are no longer
controlled
Chronic Obstructive Pulmonary Disease
(COPD)
▪ Avoid triggers, such as pollen, animal dander, harsh chemicals that
can worsen symptoms
– Stopping smoking is a great way to slow the progression of
COPD
What is a way to help control
symptoms of COPD?
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Medication Administration
▪ Certain medications needs to be taken a specific way
▪ Take on an empty stomach
–
–
–
–
Levothyroxine (Synthroid)
Omeprazole (Prilosec), pantoprazole (Protonix)
Alendronate (Fosamax), ibandronate (Boniva)
Iron tablets (ferrous sulfate, ferrous gluconate)
–
–
–
–
Allopurinol
Amiodarone
Potassium
Metformin
▪ Take with food
▪ Always check with your physician or pharmacist to see how you
should take your medications
Medication Administration
▪ Certain medications are often best taken at specific times
▪ Take in the morning:
– Levothyroxine (Synthroid)
– Alendronate (Fosamax), ibandronate (Boniva)
– Water pills [furosemide (Lasix),
hydrochlorothiazide, others]
▪ Take in the evening:
– Certain cholesterol medications (simvastatin (Zocor))
– Others as directed
Brand vs. Generic Medications
▪ Many medications are available as either brand or generic
–Brand and generics formulations of the medications have the same amount of
the active ingredient
–They only differ in some of the inactive ingredients
▪Generics are usually cost less than brand name
–This can help prevent getting into the Medicare “Donut Hole”
–In the Medicare “Donut Hole,” the cost you pay for your medications goes up
until you spend enough on medications to get out of the “Donut Hole”
–The government sets the limits each year for Medicare plans
▪Make sure to ask for generic versions of your medications, especially
if you are in or close to the donut hole.
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Medication Disposal
▪ It’s not recommended to throw away expired, unused, or
unneeded medications in the regular garbage
–They should be taken to an authorized disposal center or drug take back
programs
–The DEA sponsors 2 Drug Take Back Days each year (in April and
October)
–Certain medications can be flushed down the toilet if you are unable to
dispose of them quickly (mainly potent controlled substances)
–If none of these are an option, medications can be disposed of in the
trash
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Medication Disposal
Needle and Syringe Disposal
▪ Just like medications, it is not recommend to throw away
“sharps” (syringes and needles, lancets, others) in the regular
trash because they can pose a hazard to household members
and sanitation workers
–Throw all sharps into a red sharps container (or thick plastic jug)
immediately when finished administering the medication (do not recap
the needle)
–Take all sharps containers to authorized disposal site
(many different sites: police stations, public health
centers, senior centers, others)
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Medication Tips
▪Know why you are taking medications
▪Let your doctor know of any over-the-counter
meds, herbs, vitamin supplements you are
taking
▪Keep a medication list & update
▪Use pill boxes, calendars, alarms
▪Do not stop your medications unless
directed by doctor
▪Communicate side effects & concerns with
your providers
▪Plan ahead! Do not run out of medications
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Questions?
Thank you for your time!