Aging 3

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krug0043
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38716
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Aging 3
Updated:
2010-10-01 01:21:03
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pharmacotherapy test pharmaco therapy
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pharmacotherapy test 1 pharmaco therapy 3
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  1. Drug Induced Insomnia
    • Acetylcholinesterase inhibitors
    • Sympathomimetics
    • Centrally acting antihypertensives
    • Antiparkinson agents
    • Drug withdrawal
  2. Benzodiazepines – Dosing
    • Alprazolam: 0.25 mg
    • Estazolam: 0.5-1.0 mg
    • Lorazepam: 0.5-1 mg
    • Oxazepam: 10-15 mg
    • Temazepam: 7.5-15 mg
    • Triazolam: 0.0625-0.125 mg
  3. Nonbenzodiazepine BZD Receptor Agonists (NBRAs) - MOA and Initial Geriatric Dosing
    Selective for GABA A receptor (close to or complexed with BZD receptors)

    • Zolpidem: 5 or 6.25 mg
    • Zaleplon: 5 mg
    • Eszopiclone: 2 mg if trouble staying asleep. 1 mg if trouble getting to sleep.
  4. Zaleplon (Sonata®) - Dose
    200-1000 mg taken 30-60 minutes before bedtime
  5. Melatonin - MOA and Geriatric Dose
    Hormone produced and secreted by the pineal gland

    3 mg
  6. Ramelteon (Rozerem ™) - MOA and Dose
    •Melatonin receptor agonist


    •8mg taken within 30 minutes of sleep
  7. Geriatric pharmacotherapy for deppression - SSRIs
    Include A/Es
    • Citalopram - good one
    • escitalopram
    • fluoxitine
    • paroxetine - most sedating and anticholinergic
    • sertraline



    • •Gastrointestinal-
    • nausea, vomiting, diarrhea




    • •Neurologic -
    • insomnia, headache, fatigue




    Sexual dysfunction



    •SIADH-hyponatremia


    •Bone loss

    GI Bleeding
  8. Geriatric pharmacotherapy for deppression - SNRI Include A/Es
    • venlafaxine
    • duloxetine



    Adverse effects-

    • • Gastrointestinal-nausea,
    • constipation, somnolence, dry


    mouth, anorexia

    • • Neurologic-dizziness,
    • nervousness, somnolence

    • Dermatologic-sweating

    • Cardiovascular-hypertension

    Sexual dysfunction
  9. Geriatric pharmacotherapy for deppression - Dopamine/NE re-uptake inhibitor
    Include A/Es
    Bupropion

    Don't use if seizure disorder is concomitant

    Gastrointestinal-nausea, vomiting, dry mouth, constipation

    Neurologic -insomnia, dizziness, tremor, seizures (predisposing factors, dose related)
  10. eriatric pharmacotherapy for deppression - Central
    pre-synaptic α2-adrenergic antagonist

    Include A/Es
    Mirtazapine

    may be beneficial for depression with insomnia, appetite loss

    • •Neurologic-
    • somnolence

    • •Gastrointestinal-
    • dry mouth, constipation

    • •Metabolic-weight
    • gain
  11. Geriatric pharmacotherapy for deppression - SRI

    A/Es
    Trazodone

    Very sedating, but little anticholinergic effects

    • •Cardiovascular-orthostatic
    • hypotension, cardiac dysrhythmias


    • •Gastrointestinal:
    • constipation, diarrhea, loss of appetite, nausea, vomiting, dry mouth

    •Priapism
  12. Geriatric pharmacotherapy for deppression - TCAs

    Adverse effects
    • Nortriptyline: least likely TCA to cause orthostatic hypotension and one of the least anticholinergic and sedating TCAs, preferred when TCA is indicated
    • desipramine: may experience excitation or stimulation, in such cases, administer as asingel morning dose or divided dose.
  13. Drug therapy in Dementia
    • •Treatment
    • of concurrent medical problems

    • •Treatment
    • of cognitive disorder

    • •Treatment
    • of behavioral disturbances

    • •Treatment
    • goals-Slow decline of cognitive function, increase or maintain level of
    • function, manage behaviors, ease caregiver burden
  14. Possible Drug Therapys for Dementia
    • cholinesterase inhibitors: donepezil is approved for sever alzheimers
    • memantine:
  15. Pharmacologic management of Delirium
    • haloperidol
    • risperidone
    • quetiapine
    • olanzapine
    • lorazepam: if delirium is secondary to alcohol or benzodiazepine withdrawal. If delirium is secondary to alcohol, also use thiamine.
  16. Pharmacotherapy of UUI
    • · Anticholinergic/antispasmodics
    • #1





    • · Generally
    • considered equieffective (modest!)





    • · Major issue
    • is tolerability (none are bladder-specific)




    · Oxybutynin IR > 7.5 mg/d least tolerated




    • · What are
    • first-line vs. second-line vs. third-line agents?




    • · Don’t be
    • afraid to change drugs (and don’t use two or more concurrently in low doses!)
  17. Pharmacotherapy of SUI
    • · Estrogens –
    • modest role, use only topical (PV) agents





    • · Alpha-agonists
    • (pseudoephedrine, phenylephrine) – lots of
    • contraindications/precautions





    • · Duloxetine – best clinical data but many drug-drug
    • interactions (2D6/1A2), avoid in liver disease and CrCl < 30 mL/min, can ­ BP, hepatotoxic, ­ suicide risk even in pts. without depression,
    • withdrawal syndrome




    • · Usually need
    • combo therapy
  18. Pharmacotherapy of Overflow UUI
    · Bethanecol trial if atonic bladder (#1)





    • · Alpha-blocker
    • trial if atonic bladder (#2) (add if
    • some response to bethanecol)





    • · Remove the
    • obstruction, if present (drug therapy of prostate cancer/BPH)
  19. PK of BPH
    • 1. 5a-reductase inhibitors
    • (finasteride, dutasteride)

    • 2. Alpha1
    • adrenergic blockers (prazosin, terazosin, doxazosin, tamsulosin, alfuzosin, silodosin)
  20. Iron Therapy
    Ferrous sulfate 325 mg PO QD (or less*)

    •Percentage absorbed decreases with larger doses

    • •Administer 1 hour before or 2 hours after food (with
    • food if GI distress)

    –About 3 – 6 months to replace iron stores

    –Many drug-drug interactions (e.g., quinolones, acid suppressants, tetracyclines, calcium, levodopa
  21. ACD-Treatment
    •Erythropoietic agents (erythropoietin, darbepoetin)

    • –generally ineffective, Higher doses may be
    • effective

    • •Transfusion
    • therapy: reserve for
    • patients with cardiac history, severe cardiovascular symptoms or Hgb: 7-8 g/dL

    • •1
    • unit PRBCs = ­ Hgb 1 g/dL; effect lasts for
    • about 1 month
  22. Drug Causes of OP
    • Vitamin D toxicity
    • Chronic systemic glucocorticoid use
    • Excessive thyroxine
    • Certain anticonvulsant agents
    • Hormonal agents
    • Depot medroxyprogesterone acetate (Depo-Provera)
    • Gonadotropin releasing hormone (GnRH) agonists/analogs
    • Aromatase inhibitors
    • Chronic heparin therapy
    • Chemotherapy
    • HIV medications
    • Long term proton-pump inhibitor use: shown a link fractures not osteop.
    • SSRI
  23. Modifiable Risk factors for osteoporosis
    • Smoking
    • Alcohol use
    • Low calcium intake
    • High caffeine intake
    • Lowbody wt.
    • Low physical activity
  24. Non-modifiable Risk factors for osteoporosis
    • Small, thin frame
    • Low BMD, low peak BMD
    • Caucasian or Asian
    • Female
    • Post-menopause
    • Advancing age (50)
    • Previous fracture
    • Family history of fragility fracture
  25. Conditions that increase fracture risk
    • Dietary disorders
    • neurological disorders
    • renal disease
    • rheumatoid arthritis
    • endocrine disorders
    • gi disease
    • liver disease
  26. WHO T-score Class
    Severe (established osteopororosis: T-score -2.5 and fractures.

  27. PT of Osteoporosis
    • Calcium and Vitamin D
    • Bisphosphonates
    • SERMs
    • Calcitonin
    • Forteo
    • Prolia
  28. Osteoporosis Treatment Algorithm
    •Bisphosphonates: first line for treatment unless contraindicated

    –Most patients prefer weekly dosing

    –Alendronate preferred due to generic availability

    –IV reserved for patients who cannot tolerate oral or with adherence issues (Zoledronic acid is least expensive and most convenient)

    •Second line:

    • –Raloxifene
    • – good for patients with breast cancer risk

    • –Teriparatide
    • – may be first line in patients with T-score less than -3.5

    –Desunomab?

    •Third line:

    • –Calcitonin
    • –Estrogen

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