NR 566 Week 7 Review from prof
NR566
NR 566 Week 7 Review from prof
Chapter 48: Women as Patients
▪ Prescribing during childbearing years-
... [Show More] need constant awareness of possible pregnancy
▪ Lactation also requires careful prescribing.
▪ Women are at risk for violence; all women should be screened.
▪ Women live longer than men.
▪ There are gender differences in pharmacokinetics, including volume of distribution
▪ Gender differences in drug metabolism women clear many drugs faster than men.
▪ Gender differences in pharmacodynamics. Drug examples include: opioid analgesics, warfarin/aspirin psychotropic drugs & antiretroviral drugs
▪ Puberty
▪ Female adolescent athletes at risk for female athlete triad
▪ Disordered eating and overexercise leads to suppression of hypothalamic-pituitary- ovarian axis.
▪ Reduced estrogen levels leads to amenorrhea and decreased bone mineralization.
▪ Treatment: calcium, vitamin D, oral contraceptives
▪ “Normal” adolescent diet low in calcium, vitamin D, and iron may need replacement
▪ ***Depo-Provera may cause bone mineral density loss don’t use longer than 2 years.
▪ Pregnancy issues to be aware
▪ Pharmacokinetic changes in pregnancy:
▪ Drug absorption from lungs and skin increases.
▪ Increased plasma volumes affect volume of distribution.
▪ Drug clearance increases.
▪ Iron deficiency anemia is a concern in pregnancy iron supplement needed
▪ Teratogen risk from many drugs, alcohol and tobacco use
▪ Caffeine use should be limited.
▪ Smoking/tobacco use affects oxygen availability to fetus.
▪ Low birth weight, preterm, abruptio placenta
▪ Herb use in pregnancy not well-studied.
▪ HIV/AIDs in Pregnancy
▪ 27% of new HIV infections occur in women.
▪ Infected pregnant women can pass the virus to their babies during pregnancy, delivery, or breastfeeding.
▪ Zidovudine greatly reduces transmission risk from 25% to 2% if started early in pregnancy.
▪ All pregnant women should be offered HIV testing.
▪ Menopause
▪ Reproductive, musculoskeletal, cardiovascular and cognitive changes seen in menopause
▪ Hormone replacement therapy
▪ Herbal or complementary and alternative medicine therapy
▪ Exercise is critical.
▪ Older Women
▪ Caucasian women have life expectancy of 80.5 years.
▪ African-American women 76.1 years
▪ Cardiovascular disease causes greatest morbidity and mortality.
▪ Breast cancer
▪ Smoking increases risk of disease.
▪ Factors That Influence Outcomes
▪ Number of drugs taken
▪ Duration of therapy
▪ Fear that medications cause disease
▪ Nutritional status
▪ Safety of medications during breastfeeding
▪ Ethnic, cultural, and religious differences
▪ Dysmenorrhea
▪ Affects 30% to 40% of women of all ages
▪ Primary dysmenorrhea due to myometrial activity induced by prostaglandins.
▪ NSAIDs are first-line therapy start 2 to 3 days before menses.
▪ Oral contraceptives also effective
▪ Nonpharmacological interventions massage, yoga, exercise, heating pad
▪ Premenstrual Syndrome (also called PMS)
▪ Symptoms include: Irritability, depression, angry outbursts, anxiety, confusion, social withdrawal, and mood swings, fatigue, insomnia, dizziness, headaches, breast tenderness, weight gain, bloating, water retention, muscle and joint pain
▪ Ibuprofen days 17 to 28 of cycle may help.
▪ Reduce salt, sugar, caffeine, chocolate, red meat, dairy and alcohol.
▪ Vitamin B6 100 mg/day may be helpful.
▪ Calcium carbonate 1,200 to 1,600 mg/day may help.
▪ Premenstrual Dysphoric Disorder (also called PMDD)
▪ Diagnostic criteria (must have 5 or more)
▪ Markedly depressed mood, heightened anxiety/tension/edginess/nervousness, affective liability, persistent and marked anger and irritability, decreased interest, lack of energy, hypersomnia or insomnia
▪ Symptoms are cyclical and improve during menstruation.
▪ Selective serotonin reuptake inhibitor are first-line therapy.
▪ Spironolactone, oral contraceptives, and NSAIDs may also be helpful.
▪ Endometriosis: presence of functioning endometrial tissue outside the uterus
▪ Cyclical changes and inflammation cause pain.
▪ Can lead to fibrosis, scarring, adhesions, infertility
▪ Drug treatment
▪ Gonadotropin-releasing hormone agonists for 3 months
▪ Danazol for 6 months
▪ NSAIDs decrease pain.
▪ Oral contraceptives
▪ Diet changes: Remove xenoestrogen exposure.
▪ Calcium, magnesium, and omega-3 supplements
▪ Infertility absence of conception after 1 year of unprotected intercourse
▪ Incidence increases with age
▪ Refer for fertility evaluation.
▪ Polycystic Ovarian Syndrome (also called PCOS)
▪ Endocrine disorder
▪ High estrogen, testosterone, and luteinizing hormone
▪ Decreased follicle-stimulating hormone
▪ Ovaries double in size with multiple follicular cysts
▪ Impaired glucose tolerance and hyperinsulinemia
▪ High risk of developing type 2 diabetes mellitus
▪ Treatment: oral contraceptives, metformin or insulin
▪ Screening: mammograms; papanicolaou screening; colon cancer screening; bone mineral density screening
▪ Gay and Lesbian Issues
▪ Lesbian health is not the same as women’s health.
▪ Lesbians can get sexually transmitted infections.
▪ Lesbians need cervical cancer screenings.
Chapter 49: Men as Patients
▪ There is gender-related health disparity for men across the lifespan.
▪ Men are less likely to receive annual exams & health screenings.
▪ The leading causes of death in men are heart disease, cancer, and unintentional accidents.
▪ The concept of masculinity begins with socialization at a young age.
▪ Masculinity directly affects health care and health-care choices.
▪ Hypogonadism affects an estimated 13 million men in the United States.
▪ Refers to the failure of the testes to produce androgen, sperm, or both.
▪ Primary hypogonadism (testicular failure) characterized by low testosterone and elevated gonadotropins.
▪ Secondary hypogonadism (hypothalamic-pituitary failure) characterized by low testosterone and low or normal gonadotropins.
▪ Congenital Hypogonadism- insufficient amounts of testosterone are produced by the gonads.
▪ During puberty, delayed, arrested, or absent testicular growth and delayed secondary sexual characteristic development (voice does not deepen, no muscle mass increase, penis and testes do not develop and mature)
▪ Symptoms of hypogonadism in adulthood include:
▪ Depression
▪ Development of male breasts
▪ Erectile dysfunction
▪ Failure of facial and body hair to grow
▪ Increase in body fat, loss of energy
▪ Inhibited sexual desire
▪ Loss of muscle mass
▪ Onset of osteoporosis
▪ Shrinking and softening of the testicles
▪ Older Men
▪ Testosterone production decreases with age.
▪ Spermatogenesis is maintained into the 80s.
▪ Testosterone replacement improves muscle strength and body composition in frail elderly men.
▪ Testosterone Replacement Therapy (TRT) restores levels to normal range, improving effects of hypogonadism.
▪ Effects of TRT
▪ Stimulates erythropoiesis
▪ Increased bone mass in eugonadal men
▪ Long-term benefit of TRT on bone mineral density is not known.
▪ May improve cognitive functioning
▪ Improves insulin sensitivity
▪ No association between TRT and cardiac events
▪ Has variable effects on mood, energy, and sense of well-being
▪ Muscle mass and strength
▪ May reverse age-dependent body composition changes and associated morbidity
▪ Associated with a greater improvement in grip strength than a placebo
▪ Sexual desire, function, and performance
▪ May benefit men with erectile dysfunction (ED) caused by hypogonadism
▪ Enhances libido
▪ Testosterone: Clinical Use and Dosing
▪ Depot esters 200 mg intramuscular every 2 weeks
▪ Dosages adjusted to aim for mid-normal (400 to 600 ng/dL) testosterone levels after 1 week or at the low end (250 to 350 ng/dL) just before the next injection is due at 2 weeks.
▪ Dosage for the transdermal or the buccal TRT results in the systemic absorption of 2.5 to 10 mg daily.
▪ A testosterone value in the mid-normal range (400 to 600 ng/dL) is the goal.
▪ Risks and Contraindications of Testosterone Replacement Therapy
▪ Erythrocytosis
▪ Check hemoglobin (Hgb)/hematocrit (Hct) levels.
▪ Hgb greater than 17.5 gm/dL or Hct greater than 54% suggests overtreatment or occasionally abuse.
▪ Prostate cancer risk
▪ Digital rectal examination and prostate-specific antigen (PSA) should be monitored throughout therapy.
▪ Decreased sperm production and infertility
▪ Evaluate efficacy at 3 to 6 months of therapy.
▪ Evaluate testosterone level at 3 to 6 months from starting therapy (goal is mid-normal range)
▪ Evaluate Hct/Hbg at 3 and 6 months, then annually.
▪ Evaluate bone mineral density at 1 to 2 years.
▪ Evaluate PSA levels and digital rectal exam before beginning therapy and at 3 and 6 months.
▪ Erectile Dysfunction
▪ Treatment includes phosphodiesterase type 5 (PDE-5) inhibitors, or TRT.
▪ PDE-5 inhibitors: sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis)
▪ Potential for fatal hypotension if PDE-5 inhibitors are taken concurrently with nitrates (nitroglycerine).
▪ Do not prescribe to patients with acute myocardial infarction, stroke, or arrhythmia in past 6 months.
▪ Rare reports of vision and hearing problems
▪ Patient education is critical.
▪ Hair Loss
▪ Rational drug selection
▪ Topical minoxidil applied twice daily to scalp; if discontinued, hair will shed in 3 to 4 months.
▪ Systemic finasteride
▪ Type II 5-alpha reductase–specific inhibitor
▪ Daily treatment with full treatment effect after 6 to 12 months of use.
▪ Do not prescribe to patients with hepatic dysfunction, elevated PSA.
▪ Pregnancy category X
▪ Avoid exposure to semen if planning pregnancy.
▪ Ethnic and Racial Issues
▪ African-American men have shorter life spans and more health risks.
▪ Socialization, structural barriers, and practitioner bias can adversely affect health behaviors and health outcomes for minorities.
▪ Men Who Have Sex With Men
▪ HIV infection and sexually transmitted infections
▪ Men who have sex with men are not using protection high rates of syphilis
▪ Anal cancer: incidence is 17 times higher in gay and bisexual men than it is in heterosexual men.
▪ Tobacco abuse: 33% of gay men smoke
Chapter 50: Children as Patients
▪ History
▪ Federal Food and Drug Act of 1906 passed d/t children dying from tainted food products
▪ The 1938 Amendment to the Federal Food and Drug Act passed after more than 100 children died after taking sulfanilamide
▪ 1962: Harris-Kefauver Amendment mandated preclinical animal trials before testing drugs in children
▪ FDA Modernization Act of 1997
▪ The U.S. Food and Drug Administration can make a request for pediatric data on drugs that may be used in children.
▪ Provides a 6 month extension of the patent of medications that are studied in children
▪ Best Pharmaceuticals for Children Act (BPCA) reinstated pediatric exclusivity
▪ Also mandates a list of requested studies (list updated annually)
▪ BPCA 2007 extended the patent for on-patent drugs studied in children
▪ Expert panel developed a priority list of needs in pediatric therapeutics
▪ In 2012, made permanent
▪ Pediatric Research Equity Act requires pediatric studies of drug applications for
▪ New active ingredients, new indications, new dosage forms, new dosing regimens, new routes of administration
▪ Review of Developmental Pharmacology developmental changes affect drug absorption, binding, renal elimination, metabolism
▪ Gastrointestinal Absorption: gastric pH does not reach adult values until age 20 to 30 months.
▪ Oral bioavailability of acid labile compounds is increased (e.g., Beta-lactams)
▪ Oral bioavailability of weak organic acids is decreased (e.g., Phenobarbital and phenytoin)
▪ Basic drugs have increased absorption (e.g., diazepam and theophylline)
▪ Distribution
▪ Newborns and infants have higher percentage of water.
▪ Blood-brain barrier is incomplete and permeable in the newborn.
▪ Infants under 6 months have decreased plasma proteins available for drug binding.
▪ Metabolism: Drugs are metabolized by both metabolic and enzymatic reactions
▪ Phase I Enzymes: Cytochrome (CYP) P450
▪ Family of drug-metabolizing enzymes account for majority of drug metabolism in humans
▪ The enzymes may be slowed (inhibited) or increased (induced).
▪ Concurrent therapy with an inhibitor or inducer may alter the metabolism of a medication.
▪ CYP 1A2: developmental variation
▪ Reaches adult levels at 4 months & exceeds adult levels at 1 to 2 years
▪ Higher drug dosages may be needed from age 1 year until puberty.
▪ Reaches adult levels at puberty: Monitor levels as child goes through puberty.
▪ Diseases such as cystic fibrosis (CF) can affect CYP 1A2 activity: CF patients do not metabolize some drugs predictably.
▪ Foods may also interact with drug metabolism.
▪ CYP 3A4: Used to metabolize more than 20 commonly used pediatric medications (Carbamezapine, prednisone, oral contraceptives, macrolides, NSAIDs, antihistamines, etc.)
▪ Developmental variation
▪ Low activity at birth
▪ 30% to 40% of adult level by age 1 month
▪ Full adult level at age 6 months
▪ Exceeds adult level at 1 to 4 years of age
▪ Decreases to adult level after puberty
▪ Implications for practice
▪ Monitor when on more than one drug metabolized by CYP 3A4 enzyme & during developmental changes.
▪ Phase II Enzymes: Responsible for synthesis of water-soluble compounds
▪ Most reach adult activity by age 3 to 4 years
▪ Less information available on Phase II activity in children
▪ Ethnic variations: Koreans do not reach adult activity levels of thiopurine methyltransferase (TPMT) until 7 to 9 years.
▪ Common medications: Acetaminophen, morphine, propofol, caffeine
▪ Implications for practice: Monitor therapeutic effectiveness based on developmental age & understand ethnic variations in metabolism may be present.
▪ Patients with low levels of TPMT activity are at greater risk of hepatic toxicity from some chemotherapy drugs (thiopurines).
▪ Patients with low or undetectable levels of TPMT activity experience severe myelosuppression when treated with “standard” doses of thiopurines.
▪ Patients with high levels of TPMT activity are likely to have reduced clinical responses.
▪ Elimination: renal blood flow and glomerular filtration rate reaches adult levels at age 9 months.
▪ Adjust dosages of medications to account for decreased renal function.
▪ Breastfed Infants: Excretion of drugs in breast milk
▪ Factors that influence infant exposure to maternal drugs
▪ Maternal phenylketonuria
▪ Time of feeding in relation to dosing
▪ Infant phenylketonuria
▪ Susceptibility to drugs effects
▪ Milk to plasma ration (M:P)
▪ Pediatric Medication Administration
▪ Infants: Teach parents about medications & Teach how to administer medications.
▪ Toddlers and preschoolers exert Independence; use higher concentrations so lower volume.
▪ School-age children: Industrious; Liquid vs. pills
▪ Adolescents: Independent, Interdependent
▪ State laws regarding consent to treat: Confidentiality laws
▪ Factors That Influence Outcomes
▪ Length of treatment
▪ Complexity of regimen
▪ Medication interval
▪ Palatability
▪ Cost
▪ Family issues
▪ Improving Adherence
▪ Medication concentration
▪ Written and oral instructions
▪ Calendars (Sticker charts)
▪ Telephone reminders
▪ Contracts
Chapter 51: Geriatric Patients
• Fastest growing segment in US population is people > 65 years of age, population > 85 growing even faster
• By 2030 approximately 1/5 will be > 65 years of age
• Elderly account for 1/3 of prescription drug use, while only 13% of the population
• Polypharmacy common in older adult population
• Emergency visits due to adverse drug reactions more common in older adults than younger adults
• Functional status changes often make medication management difficult
• Physical Changes Associated with Aging
• Mental Changes: Increased susceptibility to delirium and cognitive side effects of drugs
• Sensory Changes
• Sight: 1/3 of older adults have visual impairment
• Hearing: 1/3 of older adults have hearing impairment
• Smell and Taste: Diminished smell and taste may impair nutrition; compounded by medications
• Peripheral Sensation: contributes to fall risk; compounded by medication
• Pharmacokinetic changes
• Absorption: Not dramatically different in older adult compared to younger adult
• Distribution: increased fat stores, decreased TBW and serum albumin
• Metabolism: decreased hepatic blood flow, decreased CYP 450 system function
• Excretion: decreased renal mass and GFR and tubular secretion; serum creatinine is an unreliable marker of renal function.
• Pharmacodynamic Changes
• Reduced homeostatic mechanisms
• Altered receptor sensitivity
• Increased sensitivity to drugs
• Pharmacotherapeutics: High risk for adverse drug reactions
• Non-adherence: Intentional and unintentional
• Unsafe practices
• High prevalence of use of OTC and herbal therapies
• Polypharmacy
• Risk of Drug-Drug Interactions
• Prevalence of co-morbidities
• Using one drug to treat side effects of another
• General Principles for Prescribing for Older Adults
• Before prescribing collect a “complete” drug history—revisit at least every 6 months
• Avoid a drug if benefit is only marginal
• Evaluate drug list for duplications
• Review drug list for ADRs and query patient
• Prescribe non-pharmacologic treatments whenever possible
• Ensure patient symptom not part of normal aging
• Risk predictions
• Start low, go slow
• Self-Management Practices
• Maintain a medication list including allergies and ADRs.
• Brown bag to each visit
• Drug information sheet
• Use of pill box
• Reconcile medications with all care transitions
• Functional Assessment
• Ability to manage ADLs and cognitive status are strong indicators of ability to manage medications.
• Social support important to assess
• ADL Assessment: Katz ADLs, Lawton IADLs
• Assess vision and hearing
• Assess cognitive status: GDS for depression, MMSE or Mini-Cog
• Medication management assessments: MMAA, MAT
• Improving Adherence
• Assess potential causes of unintentional non-adherence
• Ensure functional status allows for appropriate medication use
• Home assessment of frail older adults
• Collaborate with pharmacist to check for drug-drug/drug-food interactions or duplications.
• Inappropriate prescribing
• Beer’s criteria
• Start/Stopp Tools
• Criteria:
• Avoid drugs with narrow therapeutic range
• Have slow elimination rates
• Drugs that totally depend on kidney excretion
• Have high drug-drug interactions
• Have high ADR profiles
• Transitions of Care
• Transitions are a period of vulnerability for older adults
• Medication reconciliation is a critical activity at each care transition
• Care settings provide unique challenges for prescriber
• Private Homes with and without home care
• Independent living
• Assisted Living
• Skilled Nursing Facilities
• Long term Care
• Private Homes and Independent Living: Prescribing Considerations
• Social support
• Communication with caregiver
• Caregiving limitations
• Home care for homebound patients
• Skilled
• Unskilled
• Reasonable caregiver expectations
• Assisted Living: Prescribing Considerations
• Home-like, not medical environment
• Variable regulatory standards
• Variable nursing support
• Medication administration issues
• Cognitive impairment common
• Caregiver knowledge limited
• Written medication orders for OTC, prescription and herbal products required
• Skilled Nursing Facilities: Prescribing Considerations
• Oversight by pharmacist and RN in facility
• All medications must be linked with diagnosis
• Queries by pharmacists common
• Quality improvement opportunities related to medication use abound.
• Summary
• The elderly take more medications than any other age group.
• Pharmacokinetics and pharmacodynamics are altered.
• Adverse drug reactions are common.
• Risks go up with the number of drugs used.
• Nonprescription and herbal therapies are common.
• With care and common sense there will be less ADRs.
• Have monitoring systems in your clinical practice. [Show Less]