Guides to drug Prescription for the elderly & Pregnant women

Guides to drug Prescription for the elderly & Pregnant womenBy: Amr Mohammed Abdullah11110053Internal Medicine: Clinical pharmacology/Geriatric medicine

Prescribing drugs in the elderly:guide to general principles

Introduction Population aging is considered as the most serious problem in developed countries and is going to be a threat for developing countries. Aging is associated with various physiological changes and multiple diseases alter the pharmacological response to a drug. Moreover, elderly people are more sensitive to frequently used drugs like NSAIDs, benzodiazepines, opioids etc. All these factors alter the drug response resulting in adverse drug reactions (ADRs) and hospitalization, consuming 40% of health service expenditure in developed countries. Changes in metabolism have marginal clinical significance. They may increase the concentration and half-life of drugs undergoing Phase I metabolismA recent study[1] found that 4 medications/classes caused most of the problem: warfarin (33%), insulin (14%), oral antiplateletes (13%), and oral antihypoglycemics (11%).Beers Criteria for Potentially Inappropriate Medication Use in Older Adults[2] is a specialized reference concerning the safety of medications prescribed for persons 65 and older in all ambulatory and institutional settings in the United StatesThe goal of this reference is to decrease potentially inappropriate medications (PIMs).The Beers List suggests that the following medications should be used very cautiously in older adults: first generation antihistamines, muscle relaxants, benzodiazepines, digoxin > 0.125 mg, and tertiary tricyclic antidepressants.The STOPP/START Tool[3] is a medication review designed to identify where risks outweigh benefits and vice versa. The STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) criteria are focused on avoiding medications that are potentially inappropriate in older adults. The criteria are organized by organ system (eg, cardiovascular, central nervous). The START (Screening Tool to Alert doctors to the Right Treatment) criteria are focused on identifying undertreatment or prescribing omissions in elderly patients.

Factors causing ADR in elderly

Age related pharmacokinetics changes in the elderly

Commonly used drugs & their adverse effects in elderly

Principles of prescribing in elderlyImproving drug therapy in elderly patientsThe Good Palliative-Geriatric Practice Algorithm for drug discontinuation has been shown to be effective in reducing polypharmacy and improving mortality and morbidity in nursing home inpatients and community-dwelling older patients.Good Palliative-Geriatric Practice Algorithm: Improving drug therapy in elderly patients

ConclusionDrug therapy in older patients varies from that of adults due to:altered physiological functions.associated illness.age related disability.Loneliness.stress. The success of a drug therapy in elderly, depends on considering these factors in addition to correct: Diagnosis.treatment plan.Prescription.patient education.dose adherence. Care should be taken to avoid iatrogenic diseases in this population by avoiding inappropriate prescribing.ConclusionFor appropriate and rational prescription in elderly patients the following factors should be taken into account.age related pharmacokinetic and pharmacodynamic changes.socioeconomic, cultural and psychological factors.multiple diseases and altered presentation of illness.decreased vision, cognitive and hearing impairment.polypharmacy and increased susceptibility to ADRs.Above all adding quality life to years should be the major concern of a physician than mere addition of years to life.Prescribing in pregnant women:guide to general principles

Introduction Over 80 percent of women in the UK report taking medications during their pregnancy.Most will be unaware of the background risk of congenital malformations and that their own risk of having a baby with a congenital malformation may be increased by exposure during pregnancy to some medicines and chemicals. Alcohol, nicotine, drugs of abuse and certain disease states also increase the risk of congenital malformations, as do some genetic factors.Teratogenic effects

Drugs which are fetotoxic when taken in the 1st trimester

Drugs which are fetotoxic when taken in the 2nd & 3rd trimester

FDA pregnancy risk factors categories

Key pointsassess or reassess the need for medication in any woman planning a pregnancy, or who becomes pregnant.consider whether it is appropriate to try nondrug measures.review medical history & consider obstetric history and family history of malformations.balance risks of medication against benefit of treatment on mother and fetus.consider safety of medication (stage of pregnancy, route of administration, dose)Key pointsuse the lowest effective dose for the shortest possible time.monitor efficacy of medication throughout exposure.always assess risks and benefits on an individual patient basis.ensure the most up-to-date information is being used.patient counselling regarding drug exposure during pregnancy.The Home message All drugs should be prescribed at the lowest effective dose for the shortest possible time in pregnancy, and the risks and benefits assessed on an individual basis

Food and Drug AdministrationPregnancy CategoriesA. Controlled studies performed in pregnant women do not demonstrate a risk to the fetus during the first trimester of pregnancy with no evidence of risk in the second or third trimesters. The possibility of fetal harm appears highly unlikely.B. Either studies in reproducing animals do not demonstrate a fetal risk but there are no controlled studies in pregnant women, or animal reproduction studies have shown adverse effects (other than a decrease in fertility) that were not confirmed in controlled studies in pregnant women in the first trimester and there is no evidence of a risk in later trimesters.C. Either study in animals has demonstrated adverse effects on the fetus (teratogenic, embryocidal, or other effects) and there are no controlled studies in women, or studies in women and animals are not available. These drugs should be given only if the potential benefits of the drug justify the potential or unknown risk to the fetus.D. There is positive evidence of human fetal risk, but the benefits from administration in pregnant women may be acceptable despite the risk. For example, if the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective, administration may be indicated.X. Animals or human studies have demonstrated fetal abnormalities or there is evidence of risk to the fetus based on human experience, or both. The risk of the use of the drug in pregnant women clearly outweighs any possible benefit. The drug is therefore contraindicated in women who are or may become pregnant.References Drug Therapy for the Elderly [Wehling 2013]clinicians-handbook-of-prescription-drugswww.elsevier.es http://www.elsevier.es/en-revista-medicina-universitaria-304-articulo-use-of-medications-on-the-90367606www.japi.orghttp://japi.org/july_2008/u_525.htmlwww.onlinelibrary.wiley.comhttp://onlinelibrary.wiley.com/doi/10.1002/psb.578/pdf

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