pemakaian antibiotik polifarmasi pada geritari

7/22/2019 pemakaian antibiotik polifarmasi pada geritari

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Aznan Lelo

Dep. Farmakologi & Terapeutik,Fakultas Kedokteran

Universitas Sumatera Utara

1 Juni 2013 FK UNBRAH Padan


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Objectives

Geriatrics

Antibiotics

Priscribing cascade Polypharmacy

Drug interaction

Antibiotic - drugsAntibioticantibiotic


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Geriatrics as an increasing

segment of the population

1 in 8 is > 64yo in 1994

1 in 5 projected to be > 64yo in 2030

Geriatric criteria based on WHO :

Middle age : 45-59 Years

Elderly : 60-74 Years

Old : 75-90 Years

Very old : > 90 Years


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getting older

co-morbid

- Cardiovascular (CHD, CHF)- Degenerative (OA)

- Metabolic (DM), dll

polypharmacy

- ACE-inhibitor- NSAID

- OAD, etc

drug interaction

side effects . . .

Problem in

prescribing medicines

for geriatrics


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Medications in the Elderly

General 2/3 of elderly take Rx or OTC meds

Avg of 5 Rx and 2 OTC/pt (more in NH)

30% of all RX written for pts > 65 yrs old Biochemistry of medications in the elderly

Longer duration of activity

More frequent adverse drug effects Increase likelihood of drug toxicity

Lower doses needed to obtain

therapeutic levels


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ADEs: Aging or Age-related?

Hutchinson et al J Chronic Dis 1986;39:533-42

0

2

4

6

8

10

18-24 25-34 35-44 45-54 55-64 65-74 >75

%

Patientswi

thADEs

AGE


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ADRs and Age

Incidence of ADR increases with age ADR are 7 times more common in the

elderly

Account for 16% of hospital admission and50% of medication related deaths

Elderly receive more medicines Incidence of ADR increases the more

prescribed medicines taken (exponentially?)

Grymonpre et al (1988)study > 50 yrsADR rates5% for 1 or 2 medicines

Increased to 20% when >5 medicines


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Most frequent drug class causing

ADR in elderly

Drug Class N %

Cardiovascular active agents 28 34

Analgesics (opioid mainly) 15 18Antibiotics 12 15

Hypoglycemic agents 8 10

Psychotropic agents 6 7Anticoagulants 4 5

Others 10 12

JAMA 2006; 296:1858

66, JAGS 2004;52:1349

54, NEJM 2003;348:1556

64


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Common Conditions Could

Really Be Adverse Drug Effects

Constipation Calcium Channel Blockers; Iron

Incontinence -blockers

Memory loss Antihistamines

Syncope Tricyclics, -blockers

Falls Benzodiazepines

Weight loss Fluoxetine


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Factors contributing to adverse drug

reactions in elderly patients

Many elderly people receive 12 medications per day


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Prescribing in Geriatrics

Benefits

Risks


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Respondsensitivity

Watercomp,

Unbounddrug

PlasmaProtein

ToxicityDrug

accum.

Unchangeddrug

Biotrans-formation

T-1/2

Clearance

Elderly have unique pharmacokinetics


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Long t-1/2 associated to drug accumulation

give once dailyof short half-life

0

100

200

300

400

500

600

700

800

0 2 4 6 8 10 12 14 16 18 20 22 24

young

elderly

time (hour)

Kinetic profile of drug in

young and elderly subjects


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Have I taken them

before?

I have got them, but

how to consume the

drugs

Where are my

medicines ?

3 x 1 1 x 3Therapeutic effect Adverse effect

Avoid the dangerous drug . . . . .. . . . . . . . . . . choose the safest one


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Drug Use in Community Dwelling

Elderly*

*1996: N=27,285,988

Moxey, Health Care Financing Review 2003

Percentage (%)


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Antibiotics

One of the most commonly used

group of drugs

May account for up to 50% of ahospitals drug expenditure

Studies worldwide has shown a high

incidence of inappropriate use


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diarrhea

anti-

microbialagents

fever

anxiety

cough

insomnia

etc,etc,etc

etc

crying dyspnea

anti-

microbialagents

anti-

microbialagents

anti-

microbialagents

anti-

microbialagents

anti-

microbialagentscipropenem


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ANTIBIOTIKA bukan ANTIPIRETIKA

ANTI-TUSIVA

ANTI-DIARE

ANTI-ANXIETY

ANTIBIOTIKA hanyadiberikan bila terbukti atau

disangka kuat ada proses INFEKSI(kuman,

jamur, virus, protozoa)

ANTIBIOTIKA TUNGGAL lebih baik

daripada ANTIBIOTIKA KOMBINASI

Waspadaterhadap interaksiANTIBIOTIKA

dengan OBAT LAIN


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Infections in Elderly

Risk factors of elderly

Common infections of elderly

RTI: Pneumonia, Influenza, TB

Skin and Soft tissue infections Shingles

Leg Ulcers

GIT: C. Difficile

UTI: ESBLs


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Infections in the elderly:

characteristics

Increased susceptibility to infections

High morbidity and mortality

Atypical clinical presentation Presumtion diagnostic rather than etiologic

diagnostic

Side effects of antibiotic treatment High cost of treatment

TT Yoshikawa. Clin Inf Dis. 2000; 30:931-933


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Antibioticsadverse effects

Antibiotics Adverse effectsMacrolides nausea, vomitus, allergy, hepatitis, ototoxicity

Interaction with cytochrome P450 3A4 (inhibition)

Aminoglycoside nephrotoxicity; irreversible hearing loss

neuromuscular blocking; respiratory depression;

Metronidazole Metallic taste, dark urine

Fluoroquinolones CNS more common in elderly,

QTc prolongation

Doxycycline diarrhea, photosensitivity; rash; hepatitis; and,particularly in elderly patients esophageal

ulcerations or strictures

Beta-lactams allergy


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Prescribing Cascade

Rochon PA, Gurwitz JH. BMJ.315:1096-9,1997.

obat 1

Drug 1

efek samping obatdiinterprestasikan sebagai

suatu kondisi klinis baru

Adverse drug effect

misinterpreted as

new medical condition

efek samping obat

Adverse drug effect

obat 2

Drug 2


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HYPER-

TENSIONACE-I

Antibiotic

COUGH

Subsequent

therapy

New

symptomTherapy

Initial

condition

Atropin

Diarrhea

Laxantia

Constipation


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loperamide etc

fever

CTM antivomitus

allergy diarrhea etcnausea

Anti-biotic

Prescribing Cascade

Rp

Rp Rp Rp Rp

diarrheacough

Iatrogenic diseases

Iatrogenic COST


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A Vicious Cycle...

Elderly

Patient

Multiple

Medical

Problems

Multiple

Medications

Risk of

Adverse Effects

New Drug

Added

Failure to

RecognizeMultiple

Medications


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Polypharmacy

Polypharmacy means "many drugs.

The use of more medication than isclinically indicated or warranted.

4 or more drugs

7 or more drugs


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Many elderly patients

visit several doctors, each of whom may

prescribe different medicationsuse over-the-countermedication regularly

including jamu

containing steroid

get medications frommore than one pharmacy,

or from friends

Polypharmacy in the Elderly


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Polypharmacy leads to:

More adverse drug reactions

Drug-drug interactions

Duplication of drug therapy

Decreased adherence to drugregimens

Suggested contribute to at least 10-15% hospital admissions


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Polypharmacy leads to patient

outcomes

Poor quality of life High rate of symptomatology

(Unnecessary) drug expense


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Potential Drug Interactions


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Antibiotic - Drug Interactions

Antimicrobial Interacting Drug Concern

Aminoglycosides NSAID Nephrotoxicity

Diuretics (ethacrynic acid, furosemide),

quinine

Ototoxicity

Doxycycline Antacids, Ferrous sulfate, Cimetidine Decreased doxycycline

absorptionAnticonvulsants (barbiturates,

phenytoin, carbamazepine)

enhanced hepatic metabolism

Digoxin Digoxin toxicity

OCP Pregnancy

Trimethoprim andsulfamethoxazole

Warfarin Increased anticoagulation

Phenytoin Phenytoiin toxicity

Methotrexate Bone marrow suppression

Glipizide Hypoglycemia


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Antibiotic - Drug Interactions


Fluoroquinolones Antacids, Ferrous sulphate,

Zinc, Sucralfate

Decreased quinolon

absorption

Type IA,C, II antiarrhythmics Arrhytmia

Warfarin Bleeding

Ciprofloxacin Theophylline Theophyline toxicity,

Beta-lactams

(acidic drugs)

PPI (omeprazole, etc) Beta-lactam absorption may

be impaired

Probenecid, disulfiram Beta-lactam levels increased

Allopurinol decreases ampicillin effectsMacrolides Warfarin Bleeding

Clarithromycin Omeprazole increase concentration of bothdrugs


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Antibiotic - Antibiotic interactions


Aminoglycosides

Amphotericin B

NephrotoxicityCeftazidime

Vancomycin

Erythromycin

OtotoxicityAzythromycin

Vancomycin

Beta-lactamas Synergic

antibiotics


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Antibiotic Combination Therapy

infection is caused by multiplemicroorganisms, e.g.: anaerobe (Bacteroides fragilis) and gram

negative bacilli (E. coli) metronidazole andthird generation cephalosporins or fluoroquinolon

Gram negative bacilli and gram positive coccusaminoglycoside and beta-lactams

Nosocomial infections Serious infections in which a combination issynergistic


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Antibiotic combination

Trimethoprimc and sulfixazole co-

trimoxazole

Amoxicillin and clavulanic acid co-

amoxiclav

Ampicillin and sulbactam

OAT combination


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Elderly have unique pharmacokinetics

Elderly receive more medicines

Incidence of ADR increases with age Antibiotic is one of the most commonly

used agents combined with other drugs

Antibiotics may induce a prescribing cascade

Polypharmacy antibiotics in geriatrics may

be dangerous

pemakaian antibiotik polifarmasi pada geritari

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