Pitfalls in Prescribing for older people.ppt

Pitfalls in Prescribing for older people Christopher Patterson McMaster University, Hamilton, Ontario Canada Objectives Pharmacokinetic changes with age Pharmacodynamic changes Polypharmacy and interactions Underprescribing Medication errors Pharmacokinetics and aging Absorption Distribution Metabolism Excretion And…therapeutic effect at receptor level Absorption Changes in gastric pH (higher with aging) Changes in GI transit time (increased with aging) Changes in intestinal absorptive area (reduced) BUT Very little change in absorption of drugs Absorption Type of preparation often more important e.g. absorption of phenytoin: liquidtabletcapsule Interactions important e.g. calcium and levothyroxine Distribution Chronic illness associated with lower levels of serum albumin Highly protein bound drugs may be affected by acute displacement eg. Warfarin and sulphonyureas Acid 1 alpha glycoprotein elevated in acute illness may affect binding e.g.amitriptyline Changes in body composition with aging Water soluble vs. fat soluble drugs H2O soluble-hydrophilic Atenolol Hydrochlorthiazide Sotalol Theophylline Triazolam Aminoglycosides Fat soluble-lipophylic Amiodarone Diazepam Haloperidol Phenytoin: zero order kinetics saturation of protein binding sites Metabolism Mostly in liver Phase 1 Oxidation, reduction, hydrolysis Most affected by aging Phase 2 Acetylation, glucuronidation, sulfation, glycine Mostly unaffected by aging Metabolism Changes in hepatic metabolism with age Serum t ? (hours) and agePhase 1 metabolism Serum t ? unchanged:phase 2 metabolism Glucuronidation Oxazepam Temazepam Lorazepam Oxidation Metoprolol Acetylation Hydralazine Elimination Elimination represents clearance of drug from the body May be predominantly renal (water soluble drugs and metabolytes) Biliary (e.g. some metabolytes of digoxin) Other Renal function and aging Drugs predominantly eliminated via renal route Digoxin Aminoglycoside antibiotic