Geriatric

Pharmacotherapy
Geriatric
Pharmacotherapy and
Polypharmacy
BROCKLEHURST'S TEXTBOOK OF GERIATRIC MEDICINE AND
GERONTOLOGY , SEVENTH EDITION
Background

Obat adalah hal yang sering menjadi problem lansia.

Banyak kemajuan dicapai dalam farmakoepidemiologi dan farmakologi
klinik

Lansia penurunan:
 Sistem gastrointestinal
 mekanisme homeostatis
 sistem kardiovaskular dan sistem saraf pusat,
 penurunan kemampuan metabolisme dan eskresi obat,
 perubahan komposisi jaringan dan volume distribusi obat serta
perubahan sensitivitas reseptor obat
Background

 Obat digunakan untuk

 Mengurangi gejala
 Meningkatkan kualitas hidup
 Mengobati penyakit
 Memperpanjang hidup
 MEDICATION-RELATED PROBLEMS
IN ELDERLY PATIENTS
Adverse Drug Reactions
Epidemiology (IGD)
 Terbanyak terjadi di IGD.
 Budnitz: 5,9 % kasus IGD lansia (USA)
 Yee :12,6 % Kasus IGD
 Pirmohamed 6,5 % kasus IGD (England)
 Kebanyakan bisa dihindari
Adverse Drug Reactions
Epidemiology (Outpatients)
 27,6 % preventable
 Hanlon : 37,6 % preventable
 Gurwitz: 51,6% preventable
ADRs Risk

 Polypharmacy
 Pemakaian obat
 CNS
 Anti infeksi
 Antikoagulan
ADRs Risk

 Age related alteration, farmakodinamik & farmakokinetik

 Fragmented medical care
 Adherence
 Suboptimal medication monitoring
 Suboptimal prescribing
 Polypharmasi
 Inappropriate use
Polypharmacy

 Penggunaan obat lebih dari yang diindikasikan

 > 9 obat ---- obat yang tidak perlu
Inappropriate prescribing

 Pemberian obat tanpa standar dasar ilmiah

 Lebih banyak resiko dari manfaat
Adherence

 Kecil efeknya thd ADRs

 75 lansia patuh pada pengobatan
 Yg non adherence biasanya underuse
Epidemiologi ADWE

 Cardiovascular
 CNS
 Gastrointestinal
Obat pencetus ADWE

 Antihipertensi (ACEI)
 Antiparkinson (levodopa/carbidopa)
 Benzodiazepine
 Antidepresan
ADWE risk

 Multiple diagnosis
 Multiple medications
 Dirawat di rumah sakit
 Lama pemberian obat
Epidemiologi Therapeutic
Failure
 Congestive heart failure
 Chronic Obstructive Pulmonary Disease
Faktor resiko TF

 Low prescribed dose

 Drug-drug interaction
 Drug resistance / nonresponse
 Inadequate therapeutic monitoring
 nonadherence
 underprescribing
Non-adherence

 Tidak mengambil resep obat

 Tidak memakan obat
 Melewati jadwal obat
 Mengurangi dosis
Underpsrescribing pencetus TF

 NSAID tanpa gastroprotective

 DM tanpa ACEI
 Osteoporosis tanpa Calcium
MEASURES TO REDUCE MEDICATION-
RELATED PROBLEMS IN ELDERLY
PATIENTS
 Health systems design
 Health services approaches
 Patient/caregiver education
PRINCIPLES OF GERIATRIC
PHARMACOTHERAPY
PRINCIPLES OF GERIATRIC
PHARMACOTHERAPY
1. Consider whether medication therapy is necessary.
2. Know the pharmacology of the medication in relation
to age.
3. Know the adverse effect profile of the medication in
relation to the patient’s other medication(s) and
disease(s).
4. Choose initial dose, and adjust it carefully (doses will
often need to be smaller in elderly people).
5. Select the least costly alternative.
PRINCIPLES OF GERIATRIC
PHARMACOTHERAPY
7. Monitor for adverse drug reactions, an important cause
of geriatric illness.
8. Slowly taper medications to prevent/minimize adverse
drug withdrawal events (if possible).
9. Regularly review the need for chronic medications and
discontinue unnecessary ones.
10. Assess whether there is omission of needed medication
for the established diagnosis/condition.
11. Review adherence, simplify the medication regimen, if
possible, and consider use of aids
Medications Associated With Adverse
Drug Withdrawal Events in the Elderly
Gastrointestinal

 Stopp diphenoxilate, loperamide, codein pada diare yg tidak

diketahui causanya  tertunda diagnosis, menyebabkan
konstipasi dengan diare overflow, menunda penyembuhan
gastroenteritis
Kardiovaskular

 Stopp
 Digoksin pada ggn fungsi ginjal  penurunan GFR  Efek
toksik
 Loop diuretik sbg monoterapi hipertensi  Penggunaan obat lain
lebh aman dan efektif
 Thiazide bila ada gout
 Betablocker kombinasi verapamil  risiko symptomatic heart
block
 Aspirin bila ada riwayat ulkus peptikum, bleeding.
 Klopidogrel dg riwayat bleeding
 Dipyridamole sbg monoterapi prevensi sekunder kardiovaskuler
 bukti efikasi kurang
kardiovaskuler

 Start
 Aspirin pada fibrilasi atrium kronik  mencegah stroke
iskemik
 Klopidogrel pada stroke iskhemik
 Antihipertensi pada sistole konsisten pada >= 160 mmHg
 ACEi pada CHF atau sesudah IMA  mengurangi beban
kerja jantung, mengurangi remodeling pasca IMA