Response to symptoms by Community Pharmacists

Andrew McLachlanFaculty of PharmacyUniversity of Sydney

Centre for Education and Research in Ageing, Concord Hospital

This session..

o Sentinel symptoms of concerno Frailty as a symptomo Multiple medicationso Risk assessment to inform managemento Importance of a comprehensive history

“ 90% of the diagnosis is in the history”

• Look and Listen• Careful review of precipitating factors

Mr NL– 78 year old man– Lives alone, supportive

nephew nearby– Mobilises with wheelchair– eGFR 60 ml/min/1.73 m2

– Assistance with shopping, cleaning and cooking

Mr NL

Presents with – decreased mobility (ataxia) and confusion

Symptoms not to ignore

Unexplained weight loss• common feature of many chronic underlying illnesses

(cancers, chronic infections, depression). Persistent fever (> 37.5 oC)• chronic underlying infection, cancer or some other

illnessUnexplained changes in bowel habits• bowel disease like inflammatory bowel disease or

cancer. • gastrointestinal disorders like ulcers, cancers and

infections.

Symptoms not to ignore

Confusion• behaviour change, disorientation, hallucinations• low blood sugar, side effects of drugs, possible head

injury or a psychiatric condition.Shortness of breath• lung or heart disease.Flashing lights• retinal detachmentHot, red or swollen joints• arthritis or joint infection.

Symptoms not to ignoreChest pain• crushing and radiating, suspect heart disease. • Sweating and difficulty breathing.Sudden unexplained headaches • fever, stiff neck, rash, mental confusion, seizure, vision

changes, weakness, numbness, or speaking difficulties.Sudden loss of function• weakness or numbness of the face, arm, or leg • loss of speech, blurring or loss of vision. • stroke or a transient ischaemic attack – urgent treatment

is needed.

Mr NL– 78 year old man– Lives alone, supportive

nephew nearby– Mobilises with wheelchair– Assistance with shopping,

cleaning and cooking

Mr NL

Admitted to Hospital with – decreased mobility (ataxia) and confusion

On examination– UTI– hyperkalaemia– hyponatremia

Mr NLMedical history from

carer and GP• Parkinson’s disease• ischemic heart disease• hypertension• schizophrenia • previous fall• previous episode of delirium • previous suspected TIA

• Gout• Vision impairment• MMSE: 25/30• eGFR 60 ml/min/1.73 m2

Medicines on AdmissionDrug generic name Product Dose (mg) FrequencyMirtazapine Avanza 45mg bdOlanzapine Zyprexa 10mg nOxazepam Alepam 7.5mg bdBenztropine Cogentin 1 mg bdLevodopa + carbidopa Sinemet 100 mg / 25 mg tdsAllopurinol Zyloprim 300mg dIsosorbide mononitrate Imdur 120mg mIndapamide Natrilix SR 1.5 mg mPerindopril Coversyl 4 mg bdAmoxycillin Amoxil 250 mg tdsTrimethoprim Triprim 300 mg dAspirin Cardiprin 100 mg dPotassium chloride Slow-K 600 mg 1 dLactulose Actilax 30mL prn nDocusate + senna Coloxyl + senna 2 bd prn

First rule of geriatric medicine

Old + sick = adverse drug reaction

Prof David Le Couteur, Concord Hospital

Jerry Avorn

Adverse drug reactions

Zang et al, Repeat adverse drug reactions causing hospitalization in older Australians: a population-based longitudinal study 1980–2003. Brit J Clin Pharmacol 2007

Oldest old

ADRs increaseRepeat admission increasing

Adverse effects in older patientsReduction in organ function

Altered pharmacokinetics

Altered pharmacodynamic

Reduced homeostatic function

Adverse effects

Multiple diseases

Multiple medications

Poor adherence

Medications which may worsen cognition or cause confusion

• anticholinergic agents• anticonvulsants (phenytoin,

carbamazepine)• antiparkinsonian agents

(levodopa, pergolide)• antipsychotics• opiods (esp pethidine)• benzodiazepines

• corticosteroids• some CV medicines

(digoxin, metoprolol, propranolol)

• NSAIDs (incl COX-2 selective agents)

• H2 blockers• some anti-infectives

(ciprofloxacin, aciclovir, cotrimoxazole)

Medicines on AdmissionDrug generic name Product Dose (mg) FrequencyMirtazapine Avanza 45mg bdOlanzapine Zyprexa 10mg nOxazepam Alepam 7.5mg bdBenztropine Cogentin 1 mg bdLevodopa + carbidopa Sinemet 100 mg / 25 mg tdsAllopurinol Zyloprim 300mg dIsosorbide mononitrate Imdur 120mg mIndapamide Natrilix SR 1.5 mg mPerindopril Coversyl 4 mg bdAmoxycillin Amoxil 250 mg tdsTrimethoprim Triprim 300 mg dAspirin Cardiprin 100 mg dPotassium chloride Slow-K 600 mg 1 dLactulose Actilax 30mL prn nDocusate + senna Coloxyl + senna 2 bd prn

First rule of geriatric medicine

Old + sick = adverse drug reaction

Second rule of geriatric medicine

Everything is complicated: multifactorial and multiple comorbities

Prof David Le Couteur, Concord Hospital

Variability in Drug Response

PharmacodynamicsPharmacokinetics

Renal diseaseAge

Environmental factors

Genetic differences

Drug interactions

Others diseases

Pharmacodynamic monitoring

Therapeutic drug monitoring

Dose individualisation

Hepatic disease

pregnancy Obesity

Frailty

Adherence

TDM

• integral role in pharmacotherapy• (in age care) valuable tool in

– optimising dose selection– medication safety– ADR identification and management

How old is old…..

• Chronological “age”• Functional “age”

• Old• Oldest old• Frail old

Frailty

Complex or phenotype………consisting of • Decreased mobility (walk time)• Reduced strength (eg grip strength) • poor nutritional status (weight loss)• Exhaustion • Declining physical activity

……………..increased number of medicines

Fried et al . Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56, M146-56

"It is not age that is at fault but rather our attitudes toward it"

Cicero, Essay on Old Age, 73 B.C.

Clinically Significant Drug Interactions

Three basic ingredients are neededo 2 drugso 1 patient

…..all of these can impact on the significance

Who is at risk from serious drug interactions?

o Older and very young peopleo multiple medicationso multiple prescriberso multiple disease states o chronic and serious illnesso changes in organ function

Medications on CRGH admission

Number of regular medications on admission

0

2

4

6

8

10

12

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Number of regular medications

Num

ber o

f pat

ient

s

n = 42

Clinical Significance of drug Interactions

o Patient characteristicso Nature of pharmacodynamic responseo Mechanism of drug interactiono Safety margin of the interacting drugso Size of the doseo Duration of therapyo Time course of drug interactiono Order and timing of administration

……my “current” working list

The short answer….

o The interactions that are likely to lead to significant misadventure in your patients

o This will differ from practice to practice

o We can focus on the drugs…..o But it’s the people we give them to that

determines the significance of a drug-drug interaction

Summary

o Know and recognise sentinel symptoms of concern

o Frailty is an important predictor of risko Multiple medications need to be managedo Risk assessment informs managemento Taking a comprehensive history is essential

Mr NLOn discharge (1 month)Ceased – Levodopa- no clear beneficial response – Benzotropine- contributing to confusion– Aspirin - risk without clear benefit– Indapamide - ceased and restartedDose reduction– oxazepam, olanzapine and mirtazipineUTI and electrolyte disturbance resolved