PTP 546Final Pharmacology Facts

Jayne Hansche Lobert, MS, RN, ACNS-BC, NP

Pharmacology Facts

• Older Adults– The average number of medications that an older

adult takes is seven– Polypharmacy dramatically increases the risk for

drug interactions and drug side effects– People over 65 years of age(16% of the population)

consumes 25% of the prescription drugs– People over 65 years of age(16% of the population)

consumes 33% of the nonprescription/ over the counter meds

Pharmacology Facts

• Increased risk for Falls with:– Sedative hypnotics– Anticonvulsants– Opioids– Diuretics/Laxatives– Antihypertensives

Pharmacology Facts

• Considerations for Children– Vaccination schedules– Dosage prescribed based on weight mg/kg

• Prescriber errors• Difficult for parents to calculate correct dosages

– Dosage forms such as liquids, capsules, etc. are highly relevant related to ability to administer• flavored medications

– Safe storage• Child resistant containers• Separate adult and pediatric medications

Pharmacology Facts

• Medication Errors in the Home– 36% of home errors are improper dosages– 28% of home errors are omission of doses– 21% of the errors are due to communication issues– 19% of the errors are due to a knowledge deficit– 10% of the errors are related to a lack of access to

valid information– Drugs associated with med errors• Warfarin 9%; Insulin 7%; Morphine 4%

Pharmacology Facts

• Adverse Drug Reactions: Inpatient Errors– Result in temporary or permanent harm or

disability; admission to a hospital, transfer to a higher level of care or prolonged stay; death

– ADR’s are responsible for more than 100,000 deaths per year

– 6% of individuals experience an ADR– 5-9% of the cost of hospitalizations can be linked

to ADR’s, 1-3 billion dollars/annually

Pharmacology Facts• Hospital Medication Errors: Causes

– Failed Communication• Poorly written orders & verbal orders• Drugs with similar sounding or similar looking names• Misuse of zeroes in decimal numbers• Use of the apothecary measures (ex: grains)• Misinterpreted abbreviations• Ambiguous or incomplete orders

– Poor Distribution Practices– Dose Miscalculations– Drug Packaging and Drug Delivery Systems– Incorrect Drug Administration– Lack of Patient Education

Health Literacy

• Facts– IOM: 90 million Americans have trouble comprehending

health information including prescription drug labels and instructions for administration

– Prescription drug information written at the 12th grade level; average American reads at the 7th grade level

– 700,000 ER visits per year caused by lack of clarity regarding prescription drugs

– 7,000 deaths annually related to med errors– One med error per hospitalized day– Costs: up to 3.5 billion

Pharmacology Facts

• Miscellaneous Data– If you have insurance you are 22% more likely to

have used a prescription drug– Women are more likely than men to use a

prescription drug– 48% of persons used at least one prescription drug

in the past month– Most frequently prescribed classes of meds:

analgesics, antihyperlipidemics and antidepressants

Final Thoughts

• APTA Evidence Based Guidelines– Medications Affecting Responses to Exercise or

Physical Activity• Beta Blockers• Calcium Channel Blockers• Digitalis• Bronchodilators• Diuretics• Vasodilators

Final Thoughts

• Top Ten Most Prescribed Drugs in 2010– Hydrocodone– Simvastatin– Lisinopril– Levothyroxine– Amlodipine– Omeprazole– Azithromycin– Metformin– Hydrochlorothiazide

Final Thoughts• Top Ten Best Selling($)Medications in 2010– Lipitor– Nexium– Plavix– Advair– Abilify– Seroquel– Singulair– Crestor– Actos– Epogen

Final Thoughts

• Most Frequently Prescribed Meds by Age– Age 0-11: bronchodilators– Age 12-19: CNS stimulants– Age 20-59: antidepressants– Age > 60: anticholesterol drugs

Final Thoughts

• Antihypertensive Drug Classes– Diuretics– Sympatholytic Drugs• Beta Blockers, Mixed Blockers & Centrally Acting

Adrenergics– Angiotensin Converting Enzyme (ACE)Inhibitors– Angiotensin Receptor Blockers (ARB)– Calcium Channel Blockers (CCB)

Final Thoughts

• Drugs used to treat Angina– Nitrates• Fast Acting: Nitroglycerin (Nitro Stat)• Long Acting: Nitroglycerin (Nitro Dur, NitroBid);

Isosorbide Dinitrate (Isordil)– Beta Blockers• Propanolol (Inderal)

– Calcium Channel Blockers• Continuous Release: Nifedipine (Procardia XL)

Final Thoughts

• Treatment of Heart Failure– To decrease cardiac workload• ACE inhibitors• Beta Blockers• Diuretics• Nitrates

– To increase contractility• Cardioglycosides

Final Thoughts• Diuretics: Implications for Physical Therapy:

– Monitor BP for changes-increased risk of orthostasis– Monitor EKG for exercise induced changes– Decreased blood volume may cause a baro-reflex increase in

cardiac output and peripheral vascular resistance; this causes an excessive demand on myocardium especially in patients with cardiac disease – demand ischemia.

– Stay close to the bathroom/urinal• Cardioglycosides: Implications for Physical Therapy

– Monitor for signs of dig toxicity – these side effects are due to a medical cause, not functional impairment. Notify MD if you suspect dig. toxicity.

Final Thoughts• Beta Blockers: Implications for Physical Therapy

– Decreased resting and exercise heart rate and blood pressure they may increase a patient’s capacity to exercise or participate with functional mobility as they delay the onset of angina.

– Make sure if using an exercise test results to calculate exercise intensity that you know if it was done with or without Beta-Blockers.

– Cannot use traditional formulas to calculate exercise intensity based on HR - use RPE to determine intensity.

– Patients need to make sure to wean off these meds not just stop taking them.

Final Thoughts• ACE Inhibitors: Implications for Physical Therapy:

– Hypotension (not usually orthostatic)– Decreased resting and exercise blood pressure– Check Electrolytes (e.g. Sodium & Potassium)

• Nitrates: Implications for Physical Therapy– If the patient is in an acute period of ischemia causing angina

probably not the best time for exercise. – If the patient is using long term nitrates (e.g. slow release skin

patch) concerns occur for hot pack, ultrasound, and e-stim in this area.

– Monitor Vitals and be aware that these patients are very sensitive to position changes – increased risk of orthostasis and syncope.

Final Thoughts

• Drugs used to treat excessive clot formation– Anticoagulants• Heparin• Low Molecular Weight Heparin (Lovenox)• Warfarin (Coumadin)

– Antithrombotics• Aspirin• Clopidogrel (Plavix)

– Thrombolytics• Streptokinase (Streptase)

Final Thoughts

• Anticoagulants: Implications for Physical Therapy– Monitor for unusual bleeding – urine, stool,

nosebleeds, bruising etc.– Mointor for back or joint pain; this may be abdominal

or intra-joint hemorrhage.– Check Lab Values for Therapeutic Ranges: Heparin

(PTT) and Coumadin (PT/INR)– LMWH –patients are therapeutic immediately

therefore no need to monitor lab values for therapeutic ranges

Final Thoughts

• Agents used to treat hyperlipidemia– HMG-CoA Reductase Inhibitors (Statins)• Simvastatin (Zocor)• Lovastatin (Mevacor)

– Fibric Acid Agents• Gemfibrozil (Lopid)• Fenofibrate (Tricor)

– Cholesterol Absorption Inhibitor• Ezetimbe (Zetia)

Final Thoughts

• Expectorants & Mucolytics– Ex: expectorant: Guaifenesin (Robitussin)– Ex: mucolytic: Acetylcysteine (Mucomyst)

• Antihistamines– Ex: Cetrizine (Zyrtec); Diphenhydramine

(Benadryl), Loratadine (Claritin)

Final Thoughts• Meds used to treat/prevent of diseases of airway obstruction

(Asthma, Bronchitis, Emphysema)– Beta Adernergic Agonists– Xanthine Derivatives– Anticholinergics– Cromones Mast Cell Stabilizers– Glucocorticoids– Leukotriene Inhibitors

• Implications for PT:– To maximize the effect, inhaled medications need to be coordinated

with a deep breath. Also, patients should have their inhalers nearby during exercise as exercise can trigger bronchospasm in some patients.

Final Thoughts

• Sedative Hypnotic Agents– Benzodiazipines– Barbiturates– Newer agents

• Treatment of Anxiety– Short Term: Benzodiazepines– Long Term: Buspar

Final Thoughts

• Treatment of Depression– MAO’s

• Ex: Isocarboxazid (Marplan) ; Tranylcypromine (Parnate)– Tricyclic Anti Depressant (TCA)

• Ex: Amitriptyline (Elavil); Imipramine (Tofranil)– SSRI’s

• Ex: Sertraline (Zoloft); Citalopram (Celexa)Paroxetine (Paxil); Fluoxetine (Prozac

– SNRI’s• Ex: Duloxetine (Cymbalta); Venlafaxine (Effexor); Bupropion (Wellbutrin)

• Manic Depressive Bipolar Disorder– Lithium

Final Thoughts

• Treatment of Psychoses– Traditional: Phenothiazines• Ex: Chloropromazine (Clozaril;Thorazine)

– Newer Agents:• Ex: Risperidone (Risperdal);Quetiapine (Seroquel);

Aripiprazole (Abilify); Olanzapine (Zyprexa); Haloperidol (Haldol)

Final Thoughts

• Treatment of Seizures– Barbiturates

• Ex: Phenobarbital (Phenobarb)– Benzodiazepines

• Ex: Diazepam (Valium)– Carboxylic Acids

• Ex: Valproic Acid (Depakote)– Hydantoins

• Ex: Phenytoin (Dilantin)– Iminostilbenes

• Ex: Carbamazepine (Tegretol)

Final Thoughts• Anticonvulsants: Implications for Physical Therapy

– Be informed of a patient’s past medical history including epilepsy or seizures and aware of any current seizure precautions.

– Be prepared for potential seizure activity and know how to recognize and intervene during episodes of seizure.

– Remember that seizure activity can be exacerbated by environmental stimuli such as bright lights and sounds. Therefore, if possible, attempt to offer treatment in a relatively quiet setting.

– The primary goal for this drug class is establishing dosing within a therapeutic window; high enough level to control seizures while attempting to minimize side effects. It is vital for PTs to assist in observations of seizure effects or frequency. The PT must provide feedback to the appropriate team members so recommendations for effective dosing can be made.

Final Thoughts

• Treatment of Seizures– Second Generation Agents• Ex: Lamotrigine (Lamictal)• Ex: Levetiracetam (Keppra)• Ex: Topiramate (Topamax)• Ex: Gapapentin (Neurontin)

Final Thoughts• Treatment of Parkinsons Disease

– Levodopa• Ex: Levodopa/Carbidopa (Sinemet)

• Implications for Physical Therapy– Levodopa-Carbidopa is associated with an earlier onset of motor dysfunction; therefore, it

may be preferred to delay use in younger patients.– There is a diminished response to Levodopa, often when used continually for 3-4 year periods.– There is a potential for an On/Off Phenomenonspontaneous worsening of Parkinson’s

Disease “classic” symptoms, possibly related to diminishing plasma levels.– Drug Holiday: Implemented when patients have become resistant to the benefits of Levodopa

or those with a sudden increase in adverse side effects. The patient is gradually tapered off from all medications for short periods (2 days to 3 weeks). Team must prepare for dramatic deduction in mobility.

– Peak effects of Levodopa usually appear within 1 hour after the medication has been administered. Ideally, scheduling therapy after breakfast provides both drug effectiveness and decreased fatigue.

– End of Dose Akinesia: The effectiveness of the drug simply seems to wear off prior to the next dose.

Final Thoughts• Muscle Relaxants: Implications for PT

– Remember to schedule session as appropriate around med administration times, as peak drug effect will improve session dramatically. For instance, reduced muscle tone will allow more effective prolonged stretching. Also, for a patient to be more alert, attempt to schedule when sedation is at a minimum.

– Be aware that a functional deficit may be produced initially in patients who previously use increased tone for support with mobility. It is a PT goal to assist patients accommodate to the new patterns.