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7/22/2019 pemakaian antibiotik polifarmasi pada geritari
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Aznan Lelo
Dep. Farmakologi & Terapeutik,Fakultas Kedokteran
Universitas Sumatera Utara
1 Juni 2013 FK UNBRAH Padan
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Objectives
Geriatrics
Antibiotics
Priscribing cascade Polypharmacy
Drug interaction
Antibiotic - drugsAntibioticantibiotic
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Geriatrics as an increasing
segment of the population
1 in 8 is > 64yo in 1994
1 in 5 projected to be > 64yo in 2030
Geriatric criteria based on WHO :
Middle age : 45-59 Years
Elderly : 60-74 Years
Old : 75-90 Years
Very old : > 90 Years
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getting older
co-morbid
- Cardiovascular (CHD, CHF)- Degenerative (OA)
- Metabolic (DM), dll
polypharmacy
- ACE-inhibitor- NSAID
- OAD, etc
drug interaction
side effects . . .
Problem in
prescribing medicines
for geriatrics
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Medications in the Elderly
General 2/3 of elderly take Rx or OTC meds
Avg of 5 Rx and 2 OTC/pt (more in NH)
30% of all RX written for pts > 65 yrs old Biochemistry of medications in the elderly
Longer duration of activity
More frequent adverse drug effects Increase likelihood of drug toxicity
Lower doses needed to obtain
therapeutic levels
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ADEs: Aging or Age-related?
Hutchinson et al J Chronic Dis 1986;39:533-42
0
2
4
6
8
10
18-24 25-34 35-44 45-54 55-64 65-74 >75
%
Patientswi
thADEs
AGE
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ADRs and Age
Incidence of ADR increases with age ADR are 7 times more common in the
elderly
Account for 16% of hospital admission and50% of medication related deaths
Elderly receive more medicines Incidence of ADR increases the more
prescribed medicines taken (exponentially?)
Grymonpre et al (1988)study > 50 yrsADR rates5% for 1 or 2 medicines
Increased to 20% when >5 medicines
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Most frequent drug class causing
ADR in elderly
Drug Class N %
Cardiovascular active agents 28 34
Analgesics (opioid mainly) 15 18Antibiotics 12 15
Hypoglycemic agents 8 10
Psychotropic agents 6 7Anticoagulants 4 5
Others 10 12
JAMA 2006; 296:1858
66, JAGS 2004;52:1349
54, NEJM 2003;348:1556
64
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Common Conditions Could
Really Be Adverse Drug Effects
Constipation Calcium Channel Blockers; Iron
Incontinence -blockers
Memory loss Antihistamines
Syncope Tricyclics, -blockers
Falls Benzodiazepines
Weight loss Fluoxetine
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Factors contributing to adverse drug
reactions in elderly patients
Many elderly people receive 12 medications per day
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Prescribing in Geriatrics
Benefits
Risks
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Respondsensitivity
Watercomp,
Unbounddrug
PlasmaProtein
ToxicityDrug
accum.
Unchangeddrug
Biotrans-formation
T-1/2
Clearance
Elderly have unique pharmacokinetics
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Long t-1/2 associated to drug accumulation
give once dailyof short half-life
0
100
200
300
400
500
600
700
800
0 2 4 6 8 10 12 14 16 18 20 22 24
young
elderly
time (hour)
Kinetic profile of drug in
young and elderly subjects
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Have I taken them
before?
I have got them, but
how to consume the
drugs
Where are my
medicines ?
3 x 1 1 x 3Therapeutic effect Adverse effect
Avoid the dangerous drug . . . . .. . . . . . . . . . . choose the safest one
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Drug Use in Community Dwelling
Elderly*
*1996: N=27,285,988
Moxey, Health Care Financing Review 2003
Percentage (%)
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Antibiotics
One of the most commonly used
group of drugs
May account for up to 50% of ahospitals drug expenditure
Studies worldwide has shown a high
incidence of inappropriate use
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diarrhea
anti-
microbialagents
fever
anxiety
cough
insomnia
etc,etc,etc
etc
crying dyspnea
anti-
microbialagents
anti-
microbialagents
anti-
microbialagents
anti-
microbialagents
anti-
microbialagentscipropenem
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ANTIBIOTIKA bukan ANTIPIRETIKA
ANTI-TUSIVA
ANTI-DIARE
ANTI-ANXIETY
ANTIBIOTIKA hanyadiberikan bila terbukti atau
disangka kuat ada proses INFEKSI(kuman,
jamur, virus, protozoa)
ANTIBIOTIKA TUNGGAL lebih baik
daripada ANTIBIOTIKA KOMBINASI
Waspadaterhadap interaksiANTIBIOTIKA
dengan OBAT LAIN
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Infections in Elderly
Risk factors of elderly
Common infections of elderly
RTI: Pneumonia, Influenza, TB
Skin and Soft tissue infections Shingles
Leg Ulcers
GIT: C. Difficile
UTI: ESBLs
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Infections in the elderly:
characteristics
Increased susceptibility to infections
High morbidity and mortality
Atypical clinical presentation Presumtion diagnostic rather than etiologic
diagnostic
Side effects of antibiotic treatment High cost of treatment
TT Yoshikawa. Clin Inf Dis. 2000; 30:931-933
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Antibioticsadverse effects
Antibiotics Adverse effectsMacrolides nausea, vomitus, allergy, hepatitis, ototoxicity
Interaction with cytochrome P450 3A4 (inhibition)
Aminoglycoside nephrotoxicity; irreversible hearing loss
neuromuscular blocking; respiratory depression;
Metronidazole Metallic taste, dark urine
Fluoroquinolones CNS more common in elderly,
QTc prolongation
Doxycycline diarrhea, photosensitivity; rash; hepatitis; and,particularly in elderly patients esophageal
ulcerations or strictures
Beta-lactams allergy
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Prescribing Cascade
Rochon PA, Gurwitz JH. BMJ.315:1096-9,1997.
obat 1
Drug 1
efek samping obatdiinterprestasikan sebagai
suatu kondisi klinis baru
Adverse drug effect
misinterpreted as
new medical condition
efek samping obat
Adverse drug effect
obat 2
Drug 2
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HYPER-
TENSIONACE-I
Antibiotic
COUGH
Subsequent
therapy
New
symptomTherapy
Initial
condition
Atropin
Diarrhea
Laxantia
Constipation
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loperamide etc
fever
CTM antivomitus
allergy diarrhea etcnausea
Anti-biotic
Prescribing Cascade
Rp
Rp Rp Rp Rp
diarrheacough
Iatrogenic diseases
Iatrogenic COST
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A Vicious Cycle...
Elderly
Patient
Multiple
Medical
Problems
Multiple
Medications
Risk of
Adverse Effects
New Drug
Added
Failure to
RecognizeMultiple
Medications
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Polypharmacy
Polypharmacy means "many drugs.
The use of more medication than isclinically indicated or warranted.
4 or more drugs
7 or more drugs
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Many elderly patients
visit several doctors, each of whom may
prescribe different medicationsuse over-the-countermedication regularly
including jamu
containing steroid
get medications frommore than one pharmacy,
or from friends
Polypharmacy in the Elderly
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Polypharmacy in the Elderly
Polypharmacy leads to:
More adverse drug reactions
Drug-drug interactions
Duplication of drug therapy
Decreased adherence to drugregimens
Suggested contribute to at least 10-15% hospital admissions
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Polypharmacy in the Elderly
Polypharmacy leads to patient
outcomes
Poor quality of life High rate of symptomatology
(Unnecessary) drug expense
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Potential Drug Interactions
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Antibiotic - Drug Interactions
Antimicrobial Interacting Drug Concern
Aminoglycosides NSAID Nephrotoxicity
Diuretics (ethacrynic acid, furosemide),
quinine
Ototoxicity
Doxycycline Antacids, Ferrous sulfate, Cimetidine Decreased doxycycline
absorptionAnticonvulsants (barbiturates,
phenytoin, carbamazepine)
enhanced hepatic metabolism
Digoxin Digoxin toxicity
OCP Pregnancy
Trimethoprim andsulfamethoxazole
Warfarin Increased anticoagulation
Phenytoin Phenytoiin toxicity
Methotrexate Bone marrow suppression
Glipizide Hypoglycemia
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Antibiotic - Drug Interactions
Antimicrobial Interacting Drug Concern
Fluoroquinolones Antacids, Ferrous sulphate,
Zinc, Sucralfate
Decreased quinolon
absorption
Type IA,C, II antiarrhythmics Arrhytmia
Warfarin Bleeding
Ciprofloxacin Theophylline Theophyline toxicity,
Beta-lactams
(acidic drugs)
PPI (omeprazole, etc) Beta-lactam absorption may
be impaired
Probenecid, disulfiram Beta-lactam levels increased
Allopurinol decreases ampicillin effectsMacrolides Warfarin Bleeding
Clarithromycin Omeprazole increase concentration of bothdrugs
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Antibiotic - Antibiotic interactions
Antimicrobial Interacting Drug Concern
Aminoglycosides
Amphotericin B
NephrotoxicityCeftazidime
Vancomycin
Erythromycin
OtotoxicityAzythromycin
Vancomycin
Beta-lactamas Synergic
antibiotics
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Antibiotic Combination Therapy
infection is caused by multiplemicroorganisms, e.g.: anaerobe (Bacteroides fragilis) and gram
negative bacilli (E. coli) metronidazole andthird generation cephalosporins or fluoroquinolon
Gram negative bacilli and gram positive coccusaminoglycoside and beta-lactams
Nosocomial infections Serious infections in which a combination issynergistic
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Antibiotic combination
Trimethoprimc and sulfixazole co-
trimoxazole
Amoxicillin and clavulanic acid co-
amoxiclav
Ampicillin and sulbactam
OAT combination
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Elderly have unique pharmacokinetics
Elderly receive more medicines
Incidence of ADR increases with age Antibiotic is one of the most commonly
used agents combined with other drugs
Antibiotics may induce a prescribing cascade
Polypharmacy antibiotics in geriatrics may
be dangerous