Download SHEET L.13 SLIDE 5 (IV drug preparation guidelines)

SHEET L.13 SLIDE 5 (IV drug preparation guidelines)
March 28, 2017
Page | 1
SHEET L.13 SLIDE 5 (IV drug preparation guidelines)
March 28, 2017
We must be aware when choosing drugs in geriatrics, we have certain criteria called "Beers
criteria" upon which we decide which drugs must be avoided in geriatrics.

We have 2 articles:
1-American geriatric society 2015 updated beers criteria or potentially inappropriate
medications used in older adults which provides the drugs and the alternative ones.
-based on which criteria to decide what are the drugs that are appropriate to be used in
geriatrics, and what are the things that must be avoided?
A- Bleeding: the age itself is a risk factor for bleeding.
B- Hypotension (especially orthostatic hypotension): any medications that cause hypotension
we must avoid.
C- Osteoporosis.
D- Any drug that causes cognitive impairment and decreases the level of consciousness or
increases sedation ---- this increases the risk of fractures.
- this list was first written based on expert's opinions but now it is based on evidence.

Tables that we are going to discuss:
Page 2231: (for memorizing):
1- Anticholinergic drugs
((first generation antihistamines)):
-
Chlorpheniramine: Allerfine
We must know that certain drugs used in geriatrics have no indication to be used. All common
cold drugs contain first generation antihistamines which reduce the symptoms of common cold
like sneezing. These drugs must be avoided in geriatrics due to the strong side effects that they
cause (clearance of drugs reduces with the increase of age).
((Second generation antihistamines)) will not be useful as there is no histamine release in
common cold, decongestants also play a risk factor in those who have hypertension.

What are the alternative drugs that can be used safely in geriatrics for reducing the
symptoms of common cold?
-- Intranasal saline
Page | 2
SHEET L.13 SLIDE 5 (IV drug preparation guidelines)
March 28, 2017

What are the other indications for the use of first generation antihistamines?
B) for allergies (fever/allergic rhinitis), that's why we use second generation antihistamines as
an alternative drug for first generation antihistamines in geriatrics and children.
c) used as hypnotics: geriatrics in general they either sleep too much or they have little sleep,
first generation antihistamines can be used as hypnotics and can be sold as OTC medications,
but this on the other hand will increase the level of sedation and decreases the efficacy as they
develop tolerance.

What are the alternative drugs for first generation antihistamines that can be used as
hypnotics in geriatrics?
Doctors usually give antihistamines then they give benzodiazepines. Benzodiazepines, nonbenzodiazepines and antihistamine increase the risk of fractures, falling, accidents and
sedation, so there is NO ALTERNATIVE.
2- Anti-spasmodic
They are anti-muscarinic so they are considered unsafe in geriatrics, they increase the level of
sedation and thus increase the risk of fractures and falling. Anti-spasmodic also have no certain
effectiveness.

Examples on drugs that can't be used in geriatrics (with no alternatives):
- BusCopan: hyoscine, anti-spasmodic.
- Librax: it consists of chlordiazepoxide and clidinium, is a medication that may be effective in
treating irritable bowel syndrome.
3- Antithrombotic
Dipyridamole (antiplatelet): in ischemic strokes patients are given antiplatelet therapy lifelong
for the secondary prevention of strokes, we can give:
aspirin OR Aspirin + Ticagrelor OR Aspirin + Clopidogrel OR Aspirin+ dipyridamole
Some hospitals give dipyridamole alone in geriatrics and this increases the risk of orthostatic
hypotension. Alternatives include: Ticagrelor, aspirin and Clopidogrel.
Dipyridamole can be effective and useful when it is combined with aspirin (more effective than
aspirin alone), so if we want an alternative for dipyridamole, we give it in a combination with
aspirin in an extended release formulation (they are usually given twice daily and they decrease
the risk of orthostatic hypotension). Aspirin and dipyridamole are sold in one formulation (they
don't come separated) and this is considered safe to be used in geriatrics as a secondary
prevention of ischemic strokes.
Page | 3
SHEET L.13 SLIDE 5 (IV drug preparation guidelines)
March 28, 2017
4- peripheral alpha 1 blockers
(doxazocin/terazosin/prazosin): they are used in the treatment of HTN but they cause
significant hypotension, ACEI's and ARB's are better alternatives for the treatment of HTN (they
are useful in the treatment of BPH).
5- central alpha blockers
(clonidine/guanaben/garfacine/methyldopa/reserpine): some doctors use reserpine with 3
different drugs. These drugs must be avoided in geriatrics because they cause:
1- CNS side effects
2- increase the risk of orthostatic hypotension and bradycardia
3- many different side effects that are not well tolerated by geriatrics.
 Alternatives include first line antihypertensive agents.
6- digoxin: used in HF geriatrics, has no effect on mortality rates and may increase the
hospitalizations. Usually it is not used as a first line therapy in HF (first line therapy: BB
and diuretics) but can be used to reduce the symptoms, in geriatrics it must be avoided
(it has a narrow therapeutic window and needs for close monitoring and dose
adjustment in patients with impaired kidney function "geriatrics are expected to have
impaired kidney function").
Digoxin increases the mortality in atrial fibrillation patients and increases the
hospitalizations in HF patients. Digoxin is used as a second line in patients with HF or atrial
fibrillation.


7-
8-
ABCD-
In HF: the first line therapy is: ACEI's, ARB's, BB's and CCB's
in atrial fibrillation: the first line therapy is: amiodarone and CCB's (we have rate
control and rhythm control, if we want the rate control we use CCB or BB and if we want
the rhythm control we use amiodarone).
Nifedipine: immediate release (not use neither in geriatrics nor in children, but the risk
is much higher in geriatrics): it is unsafe to be used in younger adults, we must use the
extended or the sustained release one as the immediate release can cause a reflex
tachycardia and precipitate the patient for MI.
Amiodarone: not preferred to be used as it prolongs the QT waves.
 Black warning box for the use of Amiodarone:
increases the risk of hypo and hyper thyroidism.
paresthesia and tremor risks.
makes ocular deposits.
discoloration of the skin.
Page | 4
SHEET L.13 SLIDE 5 (IV drug preparation guidelines)
March 28, 2017
All these side effects cannot be well tolerated by geriatrics and young adults, so they should be
avoided when treating arrhythmias (preferably use CCB or BB as a first line therapy, and
amiodarone can be used as a second line therapy if the first line was not effective in controlling
heart's function unless the patient has HF so the first line treatment would be amiodarone).
9- Antidepressants: drugs are to be memorized: they are like the anticholinergic agents so

they mostly have the same side effects in addition to the orthostatic hypotension side
effect.
First line treatment of depression is SSRI's (they don't have the same side effects of
tricyclic antidepressants and can be used as alternatives). Tricyclic antidepressants are
also used as hypnotics with no alternatives.
Paroxetine is an SSRI that has the most significant anticholinergic activity among other SSRI's so
it's considered to be as a TCA (the only exception).
10- antipsychotics:
-
first: conventional
second: atypical generation.
They have many uses and considered unsafe to be used in geriatrics. Their uses are:
A) schizophrenia
B) bipolar disorders.
C) short term use as an antiemetic agent in cancer patients who receive chemotherapy to
avoid chemotherapy-induced vomiting.
- In these 3 situations, they can be used in geriatrics because they are the only option
with no alternatives (benefits outweigh the risks).
 Antipsychotics are most commonly used in geriatrics for the treatment of dementia and
certain behavioral problems (anxiety) but this is unsafe as antipsychotics increase the
risk of stroke and mortality in geriatric patients with dementia.
11- benzodiazepines:
what are the indications for the use of benzodiazepines in geriatrics?
May be used as hypnotics/for anxiety/for depression and can also be used as a pre-operative
sedative agent (IV anesthetic agents).
 benzodiazepines are divided into sub-types depending on their duration of action:
A- short and intermediate acting benzodiazepines: should be avoided in geriatrics
regardless of the indication.
B- long acting benzodiazepines: preferred ones to be used in geriatrics (approved).
- most benzodiazepines are metabolized by the liver, and this causes a problem as we know
that geriatrics have lower rates and efficiency of metabolism.
Page | 5
SHEET L.13 SLIDE 5 (IV drug preparation guidelines)
March 28, 2017
- benzodiazepines may cause cognitive impairment which increases the risk of falling and
fractures.
- if benzodiazepines are to be used in geriatrics, we prefer the long acting ones for certain
indications only, which are:
1234-
seizures
ethanol withdrawal symptoms
severe generalized anxiety disorder
pre-operative anesthetic agent
12- Oral hypoglycemic agents:
(glyburide/chlorpropamide): long duration sulfonylureas: they should be monitored because
they increase the risk of hypoglycemia.
-
side note: Beers criteria divided the drugs depending on which systems in the body they
work on.
13- GIT drugs: metoclopramide: in JUH it is widely used as an antiemetic agent, the
problem is that it works on dopamine receptors and may cause the extrapyramidal
symptoms "tardive dyskinesia" (abnormal movements of your face and body that you
can't control).
14- Proton pump inhibitors: are used by most of the geriatrics (has been recently added in
the criteria). Problems are:
a. Risk of clostridium difficile infections
b. Risk of bone loss (increases the risk of osteoporosis)
c. Risk of fractures
All these side effects happen only when the patient is using a very high dose of the drug for
more than one year (but we talk about the risks that are associated with the use of PPI's if they
were used for 8 weeks or more as the side effects start to appear after 8 weeks of use).

What are the indications for the use of PPI's in geriatrics?
As a prophylaxis in patients using NSAID's chronically and for high risk of NSAID's induced peptic
ulcers (risk of bleeding is high).
 When PPI's can be used for long periods of time?
1. In the chronic use of NSAID's (not all patients but those with high risk of NSAID's induced
ulcers and bleeding).
2. Erosive esophagitis
3. Barrett's esophagitis
4. Pathological hypersecretory conditions: increase the production of acids.
Page | 6
SHEET L.13 SLIDE 5 (IV drug preparation guidelines)
March 28, 2017
5. Demonstrated need for maintenance treatment (i.e. due to failure of drug
discontinuation trial or H2 blocker).
In Jordan, the use of PPI's is not approved for any other conditions or polypharmacy (patients
who use many drugs for HTN, neurons and osteoporosis).
15- meperidine: pain medication: preferred to be avoided but it is used in JUH. The problem
is that it accumulates in the body in CKD patients and produces a toxic metabolite which
causes seizures (decreases seizure threshold) unless it is used for less than 24 hours with
a dose of less than 600 mg with a normal kidney function (considered in this case
normal).
- alternative to be used is morphine which does not have the same side effects but doctors are
afraid to use it.
** as we said, meperidine can cause neurotoxic effects which can be avoided if the drug is used
less than 2 days (in hospitals it is used as PRN).
16- NSAID's: most side effects are: increase the risk of bleeding and peptic ulcers. All these
-
side effects can be avoided with the short period use of NSAID's and are increased by
the long duration of use.
paracetamol can be used as an alternative for NSAID's but it does not have an antiinflammatory effect, it only has an analgesic effect, so in the inflammatory conditions
paracetamol cannot be used. NSAID's are given with PPI's to decrease the risk of
developing peptic ulcers.
Skeletal muscle relaxants: orphenadrine: works as a skeletal muscle relaxant but has an
anticholinergic effect so it increases the risk of fractures and falling. In this case, we only
use analgesics without the use of skeletal muscle relaxants.
Page | 7
SHEET L.13 SLIDE 5 (IV drug preparation guidelines)
March 28, 2017
Sahar Alazzam
Eman Alamayreh
Danya Aljabrah
Sahar Alazzam
Page | 8