Response to symptoms by Community Pharmacists
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Transcript of Response to symptoms by Community Pharmacists
Response to symptoms by Community Pharmacists
Andrew McLachlanFaculty of PharmacyUniversity of Sydney
Centre for Education and Research in Ageing, Concord Hospital
This session..
o Sentinel symptoms of concerno Frailty as a symptomo Multiple medicationso Risk assessment to inform managemento Importance of a comprehensive history
“ 90% of the diagnosis is in the history”
• Look and Listen• Careful review of precipitating factors
Mr NL– 78 year old man– Lives alone, supportive
nephew nearby– Mobilises with wheelchair– eGFR 60 ml/min/1.73 m2
– Assistance with shopping, cleaning and cooking
Mr NL
Presents with – decreased mobility (ataxia) and confusion
Symptoms not to ignore
Unexplained weight loss• common feature of many chronic underlying illnesses
(cancers, chronic infections, depression). Persistent fever (> 37.5 oC)• chronic underlying infection, cancer or some other
illnessUnexplained changes in bowel habits• bowel disease like inflammatory bowel disease or
cancer. • gastrointestinal disorders like ulcers, cancers and
infections.
Symptoms not to ignore
Confusion• behaviour change, disorientation, hallucinations• low blood sugar, side effects of drugs, possible head
injury or a psychiatric condition.Shortness of breath• lung or heart disease.Flashing lights• retinal detachmentHot, red or swollen joints• arthritis or joint infection.
Symptoms not to ignoreChest pain• crushing and radiating, suspect heart disease. • Sweating and difficulty breathing.Sudden unexplained headaches • fever, stiff neck, rash, mental confusion, seizure, vision
changes, weakness, numbness, or speaking difficulties.Sudden loss of function• weakness or numbness of the face, arm, or leg • loss of speech, blurring or loss of vision. • stroke or a transient ischaemic attack – urgent treatment
is needed.
Mr NL– 78 year old man– Lives alone, supportive
nephew nearby– Mobilises with wheelchair– Assistance with shopping,
cleaning and cooking
Mr NL
Admitted to Hospital with – decreased mobility (ataxia) and confusion
On examination– UTI– hyperkalaemia– hyponatremia
Mr NLMedical history from
carer and GP• Parkinson’s disease• ischemic heart disease• hypertension• schizophrenia • previous fall• previous episode of delirium • previous suspected TIA
• Gout• Vision impairment• MMSE: 25/30• eGFR 60 ml/min/1.73 m2
Medicines on AdmissionDrug generic name Product Dose (mg) FrequencyMirtazapine Avanza 45mg bdOlanzapine Zyprexa 10mg nOxazepam Alepam 7.5mg bdBenztropine Cogentin 1 mg bdLevodopa + carbidopa Sinemet 100 mg / 25 mg tdsAllopurinol Zyloprim 300mg dIsosorbide mononitrate Imdur 120mg mIndapamide Natrilix SR 1.5 mg mPerindopril Coversyl 4 mg bdAmoxycillin Amoxil 250 mg tdsTrimethoprim Triprim 300 mg dAspirin Cardiprin 100 mg dPotassium chloride Slow-K 600 mg 1 dLactulose Actilax 30mL prn nDocusate + senna Coloxyl + senna 2 bd prn
First rule of geriatric medicine
Old + sick = adverse drug reaction
Prof David Le Couteur, Concord Hospital
Jerry Avorn
Adverse drug reactions
Zang et al, Repeat adverse drug reactions causing hospitalization in older Australians: a population-based longitudinal study 1980–2003. Brit J Clin Pharmacol 2007
Oldest old
ADRs increaseRepeat admission increasing
Adverse effects in older patientsReduction in organ function
Altered pharmacokinetics
Altered pharmacodynamic
Reduced homeostatic function
Adverse effects
Multiple diseases
Multiple medications
Poor adherence
Medications which may worsen cognition or cause confusion
• anticholinergic agents• anticonvulsants (phenytoin,
carbamazepine)• antiparkinsonian agents
(levodopa, pergolide)• antipsychotics• opiods (esp pethidine)• benzodiazepines
• corticosteroids• some CV medicines
(digoxin, metoprolol, propranolol)
• NSAIDs (incl COX-2 selective agents)
• H2 blockers• some anti-infectives
(ciprofloxacin, aciclovir, cotrimoxazole)
Medicines on AdmissionDrug generic name Product Dose (mg) FrequencyMirtazapine Avanza 45mg bdOlanzapine Zyprexa 10mg nOxazepam Alepam 7.5mg bdBenztropine Cogentin 1 mg bdLevodopa + carbidopa Sinemet 100 mg / 25 mg tdsAllopurinol Zyloprim 300mg dIsosorbide mononitrate Imdur 120mg mIndapamide Natrilix SR 1.5 mg mPerindopril Coversyl 4 mg bdAmoxycillin Amoxil 250 mg tdsTrimethoprim Triprim 300 mg dAspirin Cardiprin 100 mg dPotassium chloride Slow-K 600 mg 1 dLactulose Actilax 30mL prn nDocusate + senna Coloxyl + senna 2 bd prn
First rule of geriatric medicine
Old + sick = adverse drug reaction
Second rule of geriatric medicine
Everything is complicated: multifactorial and multiple comorbities
Prof David Le Couteur, Concord Hospital
Variability in Drug Response
PharmacodynamicsPharmacokinetics
Renal diseaseAge
Environmental factors
Genetic differences
Drug interactions
Others diseases
Pharmacodynamic monitoring
Therapeutic drug monitoring
Dose individualisation
Hepatic disease
pregnancy Obesity
Frailty
Adherence
TDM
• integral role in pharmacotherapy• (in age care) valuable tool in
– optimising dose selection– medication safety– ADR identification and management
How old is old…..
• Chronological “age”• Functional “age”
• Old• Oldest old• Frail old
Frailty
Complex or phenotype………consisting of • Decreased mobility (walk time)• Reduced strength (eg grip strength) • poor nutritional status (weight loss)• Exhaustion • Declining physical activity
……………..increased number of medicines
Fried et al . Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56, M146-56
"It is not age that is at fault but rather our attitudes toward it"
Cicero, Essay on Old Age, 73 B.C.
Clinically Significant Drug Interactions
Three basic ingredients are neededo 2 drugso 1 patient
…..all of these can impact on the significance
Who is at risk from serious drug interactions?
o Older and very young peopleo multiple medicationso multiple prescriberso multiple disease states o chronic and serious illnesso changes in organ function
Medications on CRGH admission
Number of regular medications on admission
0
2
4
6
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12
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Number of regular medications
Num
ber o
f pat
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n = 42
Clinical Significance of drug Interactions
o Patient characteristicso Nature of pharmacodynamic responseo Mechanism of drug interactiono Safety margin of the interacting drugso Size of the doseo Duration of therapyo Time course of drug interactiono Order and timing of administration
……my “current” working list
The short answer….
o The interactions that are likely to lead to significant misadventure in your patients
o This will differ from practice to practice
o We can focus on the drugs…..o But it’s the people we give them to that
determines the significance of a drug-drug interaction
Summary
o Know and recognise sentinel symptoms of concern
o Frailty is an important predictor of risko Multiple medications need to be managedo Risk assessment informs managemento Taking a comprehensive history is essential
Mr NLOn discharge (1 month)Ceased – Levodopa- no clear beneficial response – Benzotropine- contributing to confusion– Aspirin - risk without clear benefit– Indapamide - ceased and restartedDose reduction– oxazepam, olanzapine and mirtazipineUTI and electrolyte disturbance resolved