Pharm III Week 10 (Geriatric Pharm, Polypharmacy & OTC)

Philosophical Principles: Geriatric Prescribing

The essence of aging: progressive decline of ability to maintain homeostasis

All drugs disturb homeostasis

Geriatric Population and Drugs

• Over 200,000 adults over age 60 are hospitalized each year due to ADRs

• ~25% of older Americans were unnecessarily exposed to potentially hazardous prescribing

• Direct correlation exists between the age of the patient and the number of prescriptions they take daily

- >90% of older adults take at least one prescription daily, most take at least 2

- In LTC, patients average 7 different medications

PK/PD in the Elderly

Altered Drug Sensitivity

Increase in the incidence of drug toxicity

Increase in ADRs (and present differently)

Physiological Alterations with Aging: Absorption

Decreased absorption rate

- Decreased GI motility

- Higher pH/Use of antacids

Total drug absorption (bioavailability) largely remains unchanged for most drugs!

- Time to Peak Concentration (Tmax) is often delayed**

Time to Peak Concentration (Tmax) is often _________ in older adults

Time to Peak Concentration (Tmax) is often delayed

Physiological Alterations with Aging: Distribution

protein? Vd of hydrophilic vs hydrophobic?

Decreased albumin production

Decreased Vd of hydrophylic drugs (ie. Digoxin, Lithium)

Increased Vd of hydrophobic drugs (ie. Diazepam, amiodarone)

Decreased albumin production - Protein-sensitive drugs?

phenytoin, warfarin, aspirin, naproxen

Decreased Vd of hydrophylic drugs (ie. Digoxin, Lithium)

decline in?

fat free mass

Increased Vd of hydrophobic drugs (ie. Diazepam, amiodarone)

increase in _____ with aging?

Increase in body fat with aging

Physiological Alterations with Aging: Metabolism

Slower metabolism

Decreased liver function needed to breakdown drugs

- Examples: caffeine, benzodiazepines, lidocaine, theophylline

Long-acting benzodiazepines: sets up patients for falls/hip fractures

safest benzos for older adults?

LOT: Lorazepam, Oxazepam, Temazepam

Changes to Cytochrome P450 System

Affects ~90% of commonly prescribed medications.

Some drugs induce enzymes (increasing metabolism)

Some drugs inhibit enzymes (decreasing metabolism)

Physiological Alterations with Aging: Elimination

Geriatric patients have impaired excretion (renal and GI)

Decreased kidney size, blood flow, GFR, decrease CrCl

MOST DRUGS GIVEN TO GERIATRIC PATIENTS CARRY SOME RISK

Physiological Alterations with Aging that may Affect Pharmacokinetics

SUMMARY

Most troubling categories: Altering Cognition

*don't need to memorize but good reference*

Identifying A Problem

- Symptoms often mistaken as?

Symptoms often mistaken as signs of aging (ie. Confusion, poor/blurred vision, dry mouth/eyes, constipation)

Re-evaluate patient's drugs regimen as they age

- Some meds safe for a 30 year old may produce unexpected results in elderly

How to Avoid Polypharmacy Problems

• Know the Beers Criteria!

• Prescribe with an exit strategy

• Carefully weigh the risks versus benefits

• Make only one change at a time, if possible

• Start low, go slow - but go until you get there

How to Avoid Problems with Polypharmacy

• Discuss the benefits of the medication and the consequences of non-adherence

• Inform the patient about potential reactions

• Periodically review the list of meds - especially when starting new ones

• Simplify medication lists and schedules

• SUSPECT A MEDICATION AS THE CAUSE OF ANY MAJOR MEDICAL OR COGNITIVE CHANGE

Polypharmacy - appropriate vs problematic

Multiple prescribers, multiple pharmacies

Appropriate polypharmacy: Multiple medications are clinically indicated, optimized, and evidence-based, improving quality of life and life expectancy

Problematic or Inappropriate Polypharmacy: Unmanageable, unnecessary, or harmful medication use increasing the risk of ADRs, DDIs, and Hospitalizations

Prescribing Cascade

- ADRs are misinterpreted as a new medical condition for which another drug is then prescribed

- Adds unnecessary burden to the patient's already complicated regimen

Prescribing Cascade Examples

• Ibuprofen → Hypertension → Antihypertensive

• Metoclopramide → Parkinsonism → Levodopa/Carbidopa

• Amlodipine → Edema → Furosemide **

• Lithium → Tremor → Propranolol

• Donepezil → Urinary Incontinence → Oxybutynin

• Narcotic → Constipation → Sennosides/Docusate

• Sennosides → Diarrhea → Loperamide

• Lisinopril → Cough → Dextromethorphan

• Furosemide → Hypokalemia → Potassium Supplement

Non-Adherence to Medication

Approximately 125,000 deaths annually are attributed to non-adherence

- 2x the number killed each year in automobile accidents

30% of hospital admissions for people over the age of 65 are directly related to non-adherence

Non-Adherence Examples

Not filling a prescription initially or not refilling

Taking prescription incorrectly

Stopping a medication without prescriber advice

Taking someone else's medication

Consequences of Nonadherence

Increased risk of morbidity and mortality

Reduced quality of life

Increased healthcare costs

Increased burden on caregivers

Adherence: Identifying Barriers

Patient Barriers: Remembering, beliefs/attitude, knowledge, physical limitations

Therapy Barriers

• Efficacy and side effects

• Complex drug regimen or frequent medication changes

Socioeconomic Barriers

• Financial (Average 2026 Medicare Part D deductible $615)

• Cultural/language/dietary

Adherence Tools

Role of a Physician Assistant: Transition of Care and Best Practices

Transitions of Care

- Medication Reconciliation

- Patient and family education

Best Practices

- Early engagement

- Interdisciplinary participation

- Documentation

- Follow up (make sure they picked up and know how to use)

Rational Geriatric Prescribing

• Individualized and simple

• Avoid potentially inappropriate medications

• Monitor for adverse drug reactions

• Consider non-pharmacologic interventions

• Reasonable therapeutic goals

• Consider cost and patient preferences

• Involve caregivers

Initiating a New Drug

Initiating a new drug in the elderly should be done cautiously

Avoid rx before a dx is made

Review medications before adding a new medication

Start 1 med at a time, start low and go slow

Know the actions, ADRs, & toxicity of the meds

Attempt to maximize dose before switching to another agent

The Deprescribing Process: Comprehensive Audit

Review all prescription, OTC medications, supplements, and herbal products.

The Deprescribing Process: Efficacy vs. Risk Assessment

Evaluate the current clinical response and ongoing necessity of each drug.

The Deprescribing Process: Structured Action Plan

Formulate an intentional plan to discontinue, taper, or substitute alternatives.

The Deprescribing Process: Close Monitoring

Watch vigilantly for withdrawal symptoms, rebound effects, or new adverse events; adjust as needed.

The Deprescribing Process: Patient & Caregiver Alignment

Factor in the patient's individual goals, quality-of-life preferences, and caregiver support

Prescribing Tools

American Geriatrics Society Beers Criteria

Medication Appropriateness Index (MAI)

www.GlobalRPh.com (HELPFUL RESOURCE!)

Medication Appropriate Index (MAI)

use to develop critical thinking for prescribing

- Is there an indication for the medication?

- Is the medication effective for the condition?

- Is the dosage correct?

- Is the duration of therapy acceptable?

- Are the directions correct and practical?

- Are there clinically significant drug-drug interactions?

- Are there clinically significant drug-disease/condition treatment?

- Are there unnecessary duplications with other medications?

- Is this medication the least expensive alternative?

Prescription Writing Guideline - Prescription Requirements in PA

- Patient's name and address

- Prescriber's name and address or other identifier (NPI)

- Prescriber's DEA# (for CDS)

- Date written

- Drug name and quantity

- Directions

- WET signature (manually signed for hardcopy prescriptions)

DOB, phone # (pt and yours), spell out names!

Prescription Writing Guideline

Prescription expiration - Non Controlled

expiration date: 1 Year from Date Written

max refills: up to 1 Year Supply

key rules: refills expire after 12 months regardless of remaining count

Prescription Writing Guideline

Prescription expiration - Schedule III - V

expiration date: 6 Months from Date Written

max refills: max 5 Refills

key rules: total supply cannot exceed 6 months from date written

Prescription Writing Guideline

Prescription expiration - Schedule II

expiration date: 6 Months from Date Written

max refills: NONE

key rules: sequential prescribing permitted (Do Not Fill Until)

Prescribing Law (FYI)

Prescribing and Dispensing Drugs, Pharmaceutical Aids and Devices

Prescribing, Administering and Dispensing Controlled Substances

Dispense As Written (DAW) Codes

Codes in Pharmacy used to on insurance claims to explain whether a generic or brand name drug is being dispensed and why

Most Common:

• DAW 0: No Product selection indicated. Substitution allowed. • DAW 1: Substitution not allowed prescriber. Brand medically necessary.

• DAW 2: Substitution allowed. Patient Requested Brand.

Improper DAW Code Use

General Considerations for OTC Medications

• In general, OTC medications are for SYMPTOM RELIEF

• Know your scope of practice and legal requirements

• Assess Patient Appropriateness

• Provide patient education

• Cost!

• Use pharmacists!

Pharmaceutical Brand vs. Generic

Save Money! Use Generics!

Generics must submit an Abbreviated New Drug Application (ANDA) : Must show pharmaceutically equivalent (same active ingredient, dosage form, strength, and route of administration)

Only major differences between brand or generic are inactive ingredients

Pain Relief - Oral

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

4As: Antipyretic, Anti-inflammatory, Antiplatelet, Analgesic

ie. Aspirin, Ibuprofen, Naproxen, Diclofenac (topical)

Renal Elimination

Pain Relief - Oral

Acetaminophen (Tylenol)

Antipyretic and Analgesic

Maximum 3000 mg daily

Hepatic Elimination

Pain Relief - Topicals

Limited systemic absorption, generally safe for most patients

Lidocaine (Aspercreme)

- Many formulations (cream, lotion, patch, spray, roll on)

Counterirritants: Menthol +/- Methyl Salicylate (Biofreeze/IcyHot/SalonPas)

Diclofenac 1% Gel (Voltaren)

Allergy - Oral

1 st Generation Antihistamines

Diphenhydramine

Chlorpheniramine

Diphenhydramine - Drug of choice for ? Considerations?

Drug of choice for allergic reactions

Drowsiness

Avoid in elderly (beers criteria) -- anticholinergic

2nd Generation Antihistamines

Loratadine, Cetirizine, Fexofenadine, Levocetirizine

2nd Generation Antihistamines Use and ADRs

All are "Non-drowsy" although more people report drowsiness with cetirizine vs loratadine

Good for seasonal allergy symptoms, will help dry up a post nasal drip

Intranasal Corticosteroids

Fluticasone, Mometasone, Triamcinolone

Intranasal Corticosteroids - First Line for? Counseling Point?

Allergic Rhinitis: Highly effective for nasal congestion, sneezing ans post nasal drip

Counseling Point: Requires consistent daily use for full efficacy. Proper administration technique is important.

Topical Corticosteroid Options

Hydrocortisone 1% Cream - *Preferred*

Diphenhydramine 2% Cream (Benadryl)

- Available but clinically less effective vs oral formulation

Calamine Lotion

Cough and Cold - Golden Rule

Avoid Multi-Symptom products with 3+ ingredients unless every single agent is indicated (or strictly to reduce pill burden)

Common Core Ingredients of Cough and Cold OTC Medications

Analgesic/Antipyretic?

Expectorant?

Decongestant?

Cough Suppressant?

Night Time/PM Sedation?

Analgesic/Antipyretic: Acetaminophen (watch total daily limit)

Expectorant: Guaifenesin (thins mucus)

Decongestant: Phenylephrine (poor agent)

Cough Suppressant: Dextromethorphan (DM)

Night Time/PM Sedation: Doxylamine or Chlorpheniramine

Safety Warning for cough/cold meds

High risk of therapeutic duplications, specifically APAP

Cough and Cold - Cough Management

Dry Cough = Dextromethorphan (Delsym)

Productive/Wet = Guaifenesin (Mucinex/Robitussin)

Cough drops: Menthol, Lemon, Honey, Pectin*

Congestion Management

Phenylephrine (Sudafed PE) - STAY AWAY

Pseudoephedrine (Sudafed) - Federally Regulated

• Daily purchase limit 3.6 grams

• Monthly purchase limit 9 grams (rolling 30 days)

• not good in HTN!

Oxymetazoline (Afrin) - No more than 3 consecutive days

OTC Resources

Orange Book

Approved drug products with therapeutic equivalence evaluations

https://www.fda.gov/drugs/drug-approvals-and-databases/orange-book-data-files

DailyMed

Searchable database for up to date FDA labeling. Lists all active and inactive ingredients for specific products. https://dailymed.nlm.nih.gov/dailymed/