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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 2 * | © 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 3 * | © 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 4 * | © 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 5 * | 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 6 * | © 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 8 * | © 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 11 * | © 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 12 * | © 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 13 * | © 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) 14 * | © 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 15 * | © 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 16 * | © 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 18 * | © 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) 22 * | © 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 23 * | © 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! 24 * | © 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. 25 * | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. What is your blood pressure goal? 26 * | © 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 27 * | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. What is A1c? 28 * | © 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? 31 * | © 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? 34 * | © 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. 37 * | © 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 38 * | © 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) 40 * | © 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 41 * | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. Questions? Thank you for your time!