geriatric Case discussion 1

A DRUG CAN NOT ONLY CURE THE DISEASE BUT ALSO CAN AGGREVATE THE CONDITION WITHOUT #PharmDoctor

1. CASE DISCUSSION SESSION-1 # PharmD Dr. S P Srinivas Nayak , PharmD , Rph , MSc, Dip.D Assistant Professor, PIPR, Parul University, Vadodara, Gujarat

2. CASE ON ELDERLY An 80-year-old woman presented to an out-patient clinic with a history of severe giddiness and a few episodes of blackouts . She was K/C/O angina and hypertension . She had been on Tab. Hydrochlorthiazide 2 mg od , and Tab. isosorbide mononitrate 60 mg SR Od for a few years. Her GP had recently added nifedipine SR 20 mg twice daily for poorly controlled hypertension . On examination her blood pressure was 120/70 mmHg while supine and 90/60 mmHg on standing up.

3. QUESTION What is the underlying problem in this patient?

4. Points to remember about Thiazides Thiazides cause electrolyte disturbances, which include hypokalaemia, hyponatraemia , metabolic alkalosis, hypomagnesaemia and hypercalcaemia . They may cause impotence; hence thiazides are not the preferred antihypertensives in young males. Others: Skin rashes, photosensitivity, gastrointestinal disturbances like nausea, vomiting, diarrhoea, etc.

5. ADVERSE EFFECTS OF NITRATES Has rapid firstpass metabolism Adverse effects are due to extensive vasodilatation. They are headache, postural hypotension, tachycardia, palpitation, weakness, flushing and rarely syncope. To avoid these symptoms, the tablet may be spit out as soon as the pain is relieved. Overdosage may cause methaemoglobinaemia . Tolerance to nitrates occurs on prolonged use.

6. Points to remember about Nifedipine All calcium channel blockers are well absorbed through GI tract but undergo varying degree of firstpass metabolism. All are highly bound to plasma proteins, metabolized in liver and excreted in urine Postural hypotension, Palpitation Reflex tachycardia, Oedema, Flushing, Fatigue Dizziness, Sedation.

7. ANSWER This patient obviously has significant postural hypotension . All her drugs have the potential to produce postural hypotension, and when used together they may produce symptomatic postural hypotension.

8. It is important to recognise that some drugs such as nifedipine and nitrates have impaired first-pass metabolism in the elderly and that their clinical effects are enhanced. In addition, orthostatic circulatory responses are also impaired in the elderly. The need for antihypertensive drugs should be carefully assessed in all elderly patients, and, if therapy is indicated, the smallest dose of drug should be commenced and increased gradually. Patients should also be told to avoid sudden changes of posture.

9. PHYSIOOGICAL Changes in elderly reduced gastric acid secretion • decreased gastro-intestinal motility • reduced total surface area of absorption • reduced splanchnic blood flow • reduced liver size • reduced liver blood flow • reduced glomerular filtration • reduced renal tubular filtration.

10. Drugs that cause hypotension Antihypertensive drugs, drugs with α receptor blocking effects (e.g. tricyclic antidepressants, phenothiazines and some butyrophenones ), drugs which decrease sympathetic outflow from the central nervous system (e.g. barbiturates, benzodiazepines , antihistamines and morphine) and antiparkinsonian drugs (e.g. levodopa and bromocriptine )

11. Elderly population is more sensitive to Benzodiazepines Warfarin Digoxin Risk for Parkinsonism Stroke Osteoporosis Arthritis HTN CVS-MI Urinary incontinence, CONSTIPATION, LEG ULCERS

12. CASE-2 An 80-year-old woman with a previous history of hypothyroidism presented with a history of abdominal pain and vomiting. She had not moved her bowels for the previous 7 days. Two weeks earlier her general practitioner had prescribed a combination of paracetamol and codeine to control pain in her osteoarthritic hips. WHAT IS THE CAUSE OF HER PROBLEM?

13. ANSWER This patient developed severe constipation after taking a codeine-containing analgesic. Ageing is associated with decreased gastro-intestinal motility. Hypothyroidism, which is common in the elderly, is also associated with reduced gastrointestinal motility . Whenever possible, drugs that are known to reduce gastro-intestinal motility should be avoided in the elderly.

14. CASE-3 A 70-year-old man was found by his general practitioner to have hypertension and was commenced on lisinopril 5 mg once a day . He had a previous history of peripheral vascular disease for which he had required angioplasty. Two weeks after commencing antihypertensive treatment, he presented with lack of appetite, nausea and decreased urine output . WHAT MAY BE THE REASON FOT HIS PROBLEM?

15. ANSWER The patient is probably developing renal failure . With a previous history of peripheral vascular disease, he is likely to have bilateral renal artery stenosis. ACE inhibitors can cause renal failure in the presence of bilateral renal stenosis by reducing blood supply to the kidneys .

16. THANK YOU.. A DRUG CAN NOT ONLY CURE THE DISEASE BUT ALSO CAN AGGREVATE THE CONDITION WITHOUT # PharmDoctor --- MED EASY