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Download 2013 Medication Issues and Laboratory Results - C. Tsang
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MEDICATION AND LABORATORY MONITORING GEM Conference 2013 September 17th, 2013 Clara Tsang RN (EC) Agenda • • • • • • • • Background Pharmacology Issues Among the Elderly Clinical Management & Medication Issues Diagnostic Testing Case Study/Quiz Our Role as GEM Nurses High Risk Drugs to Avoid Take Home Message Background Takes 1+ meds 4 out of 5 seniors (age 75+) take at least ONE type of medicine On average, seniors take 4.5 prescription, and 3.5 over the counter drugs at any point in time 1/3 have ~ PADI in ED 31% of elderly patients in the emergency room have at least 1 potential adverse drug interaction (PADI) 10% adverse drug-related events lead to ED visits for patients > 65 Pharmacology Issues Among the Elderly • • • • • • Administration Absorption Distribution Hepatic metabolism Excretion Pharmacokinetic/pharmacodynamic Clinical Management & Medication Issues • Many types… for today’s discussion: – – – – – – – – – Cardiovascular Respiratory Gastrointestinal Hematological Musculoskeletal Endocrine Neurologic Skin Renal/Urological Clinical Management & Medication Issues • Cardiovascular: B/P, Cr, e’ – – – – – – – – ACEI/ARB (K, Scr, coughing) Antiarrhythmics (QTs, GI, TSH, Scr) Anticoagulant/Antiplatelet (bleeding, plt, hb) Beta Blocker(bradycardia, brochospasm, cold extremities/pain, hypoglycemia), CCB (constipation, peripheral edema) Diuretic (e’, Scr, orthostatic, gout, hyperglycemia) Vasodilator (headache, orthostatic) Lipid lowering (muscle discomfort, CK, LFT) Clinical Management & Medication Issues • Respiratory: – – – – OTC cough med (B/P) Hydrocodone (CNS side effects) Theophylline (arrhythmia, narrow therapeutic range) Antibiotic (GI, QTs, C-Diff, ulcerative stomatitis) • Gastrointestinal: – – – – PPI (pneumonia, C-Diff, mal-absorption) Antacids (Mg, Ph, absorption) H2 blocker (arrhythmia, AV block) Laxative (e’) Clinical Management & Medication Issues • Hematological: – Anti-coagulants/platelets, Iron, B12 (INR, plt, Hb, ferritin, TIBC, Scr (for pradaxa, xarelto, LMWH) • Musculoskeletal: – Analgesic (Tylenol/narcotics) (CNS, constipation, N/V) – Anti-inflammatory (edema, B/P, bleeding, Scr) • Endocrine: – Antidiabetic (hypo, BUN/Scr) – Thyroid (Ca) – Corticosteroids (edema, B/P, GI bleeding, CNS, Blood sugar, osteoporosis, glaucoma) Clinical Management & Medication Issues • Neurologic – – – – Cholinesterase Inhibitor (GI, bladder/bowel incontinence) Parkinson med (B/P, hallucination, sedation) Anti-psychotic (QTs, EPS, sedation, diabetes, dyslipidemia) Anti-depressant (CNS, hypoNa, anticholinergic side effects, bleeding) – Anti-convulsants (toxicity, CNS, LFT, Scr) – Benzodiazepines (CNS, ataxia) • Skin: Anti-pruritius (CNS, anticholinergic effect) • Renal/Urological: – Anti-spasmodic & Adrenergic antagonist (B/P, CNS) Diagnostic Testing • • • • • • • • • • • Risk of diagnostic tests: preparation, procedure, and tolerance Alkaline phosphatase BUN/Creatinine CBC: Hb, HCT, MCV D-dimer Drug level (Dilantin, INR, Digoxin) Electrolytes (Na, K, Ca, Mg) ESR HbA1C/serum glucose Troponin TSH CASE STUDY #1: 80-Yr-Old Male 80 yrs male with glaucoma having angina visited ED, prescribed Diltiazem 30mg qid, ASA 81 od in addition to his Timoptic eye drop. He would have risk for… A. Bleeding episodes B. Fainting episodes and falls C. Rebound supraventricular tachycardia D. Blurred vision The answer? CASE STUDY #2: 75-Yr-Old Female 75 yrs old female with hypertension visited ED due to dizziness and falls, Ixs r/o infection, cardiac, CVA. Drug review found Niacin 1mg PO tid was prescribed 2 weeks ago for high cholesterol. What specific education should be included upon patient discharge? A. limiting fluid intake B. measures to minimize orthostatic hypotension C. administration of the drug an hour after eating D. slight modifications in diet that are required with drug therapy The answer? CASE STUDY #3: 78-Yr-Old Male 78 yrs old man with chronic asthma visited ED due to vomiting, stomach cramps and confusion. He is on Theophylline 400 mg od and hypertensive medications. What diagnostic study should be obtained? A. Serum electrolytes B. Digoxin level C. Theophylline level D. Arterial blood gases The answer? QUIZ QUESTION #1 What anti-hypertensive drug classifications tend to reduce insulin sensitivity? A. Diuretics & CCB B. Diuretics & Beta-blockers C. CCB and ACEI D. Alpha-blockers & ACEI The answer? QUIZ QUESTION #2 When a patient is on Metformin, what do we need to closely monitor for? A. Significant increase of body weight B. Elevation of LDL cholesterol level C. Lactic acidosis D. Increase insulin requirement The answer? QUIZ QUESTION #3 An elderly man has BPH, which medication will likely aggravate this condition? A. Glyburide B. Oral buspirone C. Inhaled ipratropium (Atrovent) D. Ophthalmic timolol (Timoptic) The answer? Our Role as GEM Nurses How can we help? INFORMATION accurate list of meds with the contact information of providers INSTRUCTION Offer proactive education on indications, potential adverse efforts, potential interaction with other meds/foods, proper medicine administration, and advise to use one pharmacy for clear records ORGANIZATION Teach / offer suggestions for how to manage/store/dispose of medicines, and to avoid sharing HEALTH LITERACY Drugs to Avoid • Non-Steroidal Antiinflammatory Drugs (NSAIDs) • Certain Anti-cholinergic Drugs • Digoxin • Certain over the counter drugs (such as cold regime) • Certain Diabetic Drugs • Muscle Relaxants • Certain anti-anxiety/antiinsomnia • Demerol • Anti-psychotics if not for psychosis • Estrogen replacement (HRT) http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf AGS Beers Criteria 2012 High Risk for Drug-Drug Interactions • • • • Cardiac Med: Digoxin, CCB Oral Anticoagulant Theophyllin derivatives Endocrine therapies: Glyburide, Pioglitazone, Simvastatin • Opioid analgesics • Immunosuppresants • Psychiatric Med: Lithium, SSRI, MAOI • Anticonvulsants • Antimicrobials: Macrolide, Quinolone, Oral Antifungals, Antiretrovirals • Anithistamine http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf AGS Beers Criteria 2012 Key Take Home Messages 1) Consider the possibility that a drug could exacerbate an existing condition, or even lead to a new consider… then evaluate all alternatives 2) Recognize a change of function as an early sign of ADR 3) Avoid using drugs to correct a drug-induced problem Reference • • • • • • • American Geriatrics Society 2012 Beers Criteria Update Expert Panel (2012) American Geriatric Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. JAGS 2012 Durso S. C, Bowker L. K., Price J. D. & Smith S. C. (2010) Oxford American Handbook of Geriatric Medicine Oxford University Press Fick D. M. & Semla T. P. (2012) 2012 American Geriatrics Society Beers Criteria: New Year, New Criteria, New Perspective. JAGS 2012 Kazer M. D. & Grossman S. (2011) Gerontologyical Nurse Practitioner: Certification Review. Springer Publishing Company Vega C. P. (2013) PIM: The Real Drug Problem in Seniors Retrieved on Aug 20/2013 from www.medscap.com/viewarticle/802898 Woodfruff. K (2010) Preventing Polypharmacy in Older Adults. American Nursing Today 2010:5(10) Wotten J.M.(2012) Pharmacotherapy Considerations in Elderly Adults South Med. Journal 2012; 105(8);437-445. Thank You Questions? GEM Conference 2013 September 17th, 2013 Clara Tsang RN (EC)
