Therapeutics Exam 3

Alarming medications in geriatric populations

anticholinergics

antipsychotics

Sulfonylureas

PPIs

Benzos

NSAIDs

Opioids

Orthostatic agents

side effects of these medications in older people include cognitive impairment, confusion, dry mouth, and constipation

first gen antihistamines

Alternative to first gen antihistamine

nasal steroids, second gen, or saline nasal spray (sleep hygiene if insomnia issue)

Preferred antidepressant in geriatrics

sertraline or escitalopram

preferred agent for geriatric neuropathic pain

gabapentin, pregabalin, topical agents

T/F paroxetine is a good option in geriatrics

False

T/F SSRIs are recommended in geriatrics

True

Exceptions for use of benzos in geriatric populations

seizures, withdrawal, severe anxiety

Preferred anxiety agent in geriatrics

buspirone and SSRIs

PPI guideline in geriatrics

limit use to 8 week (unless high risk)

when should an older patient be on a PPI

steroid or nsaid use, esophagitis, H2 failure

alternatives to PPIs

H2RAs, misoprostol

Digoxin doses in geriatrics (while should be avoided entirely) cannot exceed

0\.125mg/day

HTN medication that should be avoided in geriatrics

alpha blockers, central alpha agonists

T/F tamsulosin in okay in geriatrics

True

diabetes agents avoided in older patients

glyburide and glimepiride

T/F NSAIDs can be used in geriatrics

False

goal BP in geriatrics

Goal A1C in geriatrics w/o coexisting conditions

A1C guidelines in geriatrics with many chronic illnesses, cognitive impairment, or functional dependence

Therapy for geriatric with LDL>190

max statin

therapy for geriatric with LDL 75-189

moderate statin

Define CKD

kidney damage or GFR

Normal Proteinuria

Preferred way to measure CrCl

measured

G1 GFR

>90

G2 GFR

60-89

G5 GFR

CKD standings (G1-5) must also be with

kidney injury

renal protection is beneficial in what populations

Diabetic and non diabetic proteinuria renal disease

first line agents for renal protection

ACE or ARB

Second line agents for renal protection

Dapagliflozin and canagliflozin

biggest risk factors for initiation of CKD

diabetes and HBP

treatment threshold for anemia

Treatment threshold for serum ferritin

diagnosis of anemia

Hb

HB should be monitored in CKD patients receiving dialysis before diagnosis

q 3 months

HB should be monitored in patients receiving dialysis post diagnosis every ___

month

Daily dose of elemental iron

200mg

Iron drug interactions

levothyroxine, fluoroquinolone, antibiotics, antacids

iron must have what gi environment

Acidic

elemental iron in ferrous sulfate tablet

65mg

HD iron goal

1000mg total

HD iv iron regimen

100mg iron dextran x 10

when to hold IV iron

TSAT >50% or ferritin >800

Requires test dose

iron dextrose

antidote to iron overload

deroxamine

Increase RBC, HB, and HCT

ESAs

Goal of ESA therapy

increase hb to minimum amount

when to initiate ESA

9-10g/dL

when to monitor HB with ESAs

1-2 weeks ( 4 if stable )

Decrease ESA dose by 23-50% if Hb increases by _____ in 4 weeks

1g/dl

phos goal in CKD

2\.5-4.5

Calcium goal in CKD

8-10

Corrected serum Ca

measured + 0.8 ( 4- albumin )

when to consider aluminum hydroxide

patients with serum phos>7

First line Phos binders

calcium carbonate and calcium acetate

hydrochloride salt phos binder

sevelamer

admin 1hr before or 3hr after other drugs

sevelamer

binds at all pHs in gi

sucroferric oxyhydroxide

when to initiate Vitamin D therapy

when PTH is not controlled by phos management

Intiate inactive VD at what level

Available inactive vd

ergocalciferol and cholecalciferol

ADR of inactive VD therapy

hypercalcemia

must be activated by kidney

ergocalciferol and cholecalciferol

Active VD therapy

calcitriol, doxercalciferol, paricalcitol

Enhances the sensitivity of calcium sensing receptors on PT gland to extracellular ca

cinacalcet

Cinacalcet place in therapy

ESRD with increased PTH limited by hypercalcemia

Vitamins to give in dialysis

B, C, and folic acid

treatment for metabolic acidosis

citric acid/sodium citrate or sodium bicarb

biomarkers for alhzhimer’s

MRI, FDG-PET imaging and SPECT perfusion imaging

__________________ neurons are found to be deficient in AD patients Correlation with loss of cholinergic activity and plaque formation

Acetylcholine and cholinergic

5 A’s of dementia

aphasia, amnesia, agnosia, Apraxia, disturbed abstract thought

Most common test to assess cognitive function

MMSE

Non pharm treatment for dementia

body and brain exercising, diets

All these dementia drugs require titrations 2/2 side effects & tolerability and should be tapered if discontinuing

Acetylcholinesterase Inhibitors

CNS selective; reversible inhibitor for AChE

Donepezil

Dosing: 5mg qHS for 4-6 weeks, then increase to 10mg

Donepezil

Indication: mild to moderate AD; Parkinson’s Disease Dementia

Rivastigmine

MOA: CNS selective; pseudo-irreversible for AChE and BuChE

Rivastigmine

Patch dosage form available

Rivastigmine

reversible, selective, competitive for AChE & enhances acetylcholine effects on nicotinic receptors

galantamine

Initial: 4mg BID for 4 weeks, titrate to 8, max 12

galantamine

extended release formulation designed for the purpose of more convenient dosing

galantamine

cholinesterase inhibitor monitoring

Monitor weight Be mindful of NSAID use

GI side effects and anorexia can be very difficult to tolerate and may limit use.

Acetylcholinesterase Inhibitors

Dose dependent efficacy

Acetylcholinesterase Inhibitors

Moderate affinity, uncompetitive NMDA receptor antagonist, protecting against the effects of glutamate and calcium-mediated neurotoxicity

memantine

Monthly infused, Monoclonal antibody that targets Aβ, clearing the plaques

Aducanumab

When should dementia treatment be initiated?

at the time of diagnosis and the benefits, risks, expectations be discussed in detail with the family

When should memantine be added?

Once a pt progresses to the mod-severe stages memantine may be used as monotherapy or in conjunction with a ChEI

perferred antipsy in dementia

quetiapine

perferred ssri in dementia

citalopram

are NOT recommended in patients with dementia who have agitation or behavioral symptoms

carbamazepine and valproate

Apathy treatment in dementia

methylphenidate

Sedative options in dementia

low dose doxepin, ramelteon, mirtazepine

Only marker of liver damage

AST/ALT low

Acute treatment for ascites

Paracentesis

Albumin

Midodrine

Maintenance treatment for ascites

alcohol abstinence

sodium restriction

diuretics

Indicated in large volume paracentesis with __>__ 5 L removed

albumin