Transcript 2013 Medication Issues and Laboratory Results - C. Tsang

MEDICATION AND
LABORATORY
MONITORING
GEM Conference 2013
September 17th, 2013
Clara Tsang RN (EC)
Agenda
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Background
Pharmacology Issues Among the Elderly
Clinical Management & Medication Issues
Diagnostic Testing
Case Study/Quiz
Our Role as GEM Nurses
High Risk Drugs to Avoid
Take Home Message
Background
Takes 1+ meds
4 out of 5 seniors (age 75+) take at least ONE
type of medicine
On average, seniors take 4.5 prescription, and 3.5
over the counter drugs at any point in time
1/3 have
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PADI in ED
31% of elderly patients in the emergency room
have at least 1 potential adverse drug interaction
(PADI)
10% adverse drug-related events lead to
ED visits for patients > 65
Pharmacology Issues
Among the Elderly
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Administration
Absorption
Distribution
Hepatic metabolism
Excretion
Pharmacokinetic/pharmacodynamic
Clinical Management &
Medication Issues
• Many types… for today’s discussion:
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Cardiovascular
Respiratory
Gastrointestinal
Hematological
Musculoskeletal
Endocrine
Neurologic
Skin
Renal/Urological
Clinical Management &
Medication Issues
• Cardiovascular: B/P, Cr, e’
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ACEI/ARB (K, Scr, coughing)
Antiarrhythmics (QTs, GI, TSH, Scr)
Anticoagulant/Antiplatelet (bleeding, plt, hb)
Beta Blocker(bradycardia, brochospasm, cold extremities/pain,
hypoglycemia),
CCB (constipation, peripheral edema)
Diuretic (e’, Scr, orthostatic, gout, hyperglycemia)
Vasodilator (headache, orthostatic)
Lipid lowering (muscle discomfort, CK, LFT)
Clinical Management &
Medication Issues
• Respiratory:
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OTC cough med (B/P)
Hydrocodone (CNS side effects)
Theophylline (arrhythmia, narrow therapeutic range)
Antibiotic (GI, QTs, C-Diff, ulcerative stomatitis)
• Gastrointestinal:
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PPI (pneumonia, C-Diff, mal-absorption)
Antacids (Mg, Ph, absorption)
H2 blocker (arrhythmia, AV block)
Laxative (e’)
Clinical Management &
Medication Issues
• Hematological:
– Anti-coagulants/platelets, Iron, B12 (INR, plt, Hb, ferritin, TIBC, Scr
(for pradaxa, xarelto, LMWH)
• Musculoskeletal:
– Analgesic (Tylenol/narcotics) (CNS, constipation, N/V)
– Anti-inflammatory (edema, B/P, bleeding, Scr)
• Endocrine:
– Antidiabetic (hypo, BUN/Scr)
– Thyroid (Ca)
– Corticosteroids (edema, B/P, GI bleeding, CNS, Blood sugar,
osteoporosis, glaucoma)
Clinical Management &
Medication Issues
• Neurologic
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Cholinesterase Inhibitor (GI, bladder/bowel incontinence)
Parkinson med (B/P, hallucination, sedation)
Anti-psychotic (QTs, EPS, sedation, diabetes, dyslipidemia)
Anti-depressant (CNS, hypoNa, anticholinergic side effects,
bleeding)
– Anti-convulsants (toxicity, CNS, LFT, Scr)
– Benzodiazepines (CNS, ataxia)
• Skin: Anti-pruritius (CNS, anticholinergic effect)
• Renal/Urological:
– Anti-spasmodic & Adrenergic antagonist (B/P, CNS)
Diagnostic Testing
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Risk of diagnostic tests: preparation, procedure, and tolerance
Alkaline phosphatase
BUN/Creatinine
CBC: Hb, HCT, MCV
D-dimer
Drug level (Dilantin, INR, Digoxin)
Electrolytes (Na, K, Ca, Mg)
ESR
HbA1C/serum glucose
Troponin
TSH
CASE STUDY #1: 80-Yr-Old Male
80 yrs male with glaucoma having angina visited ED, prescribed
Diltiazem 30mg qid, ASA 81 od in addition to his Timoptic eye drop. He
would have risk for…
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Bleeding episodes
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Fainting episodes and falls
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Rebound supraventricular tachycardia
D.
Blurred vision
The answer?
CASE STUDY #2: 75-Yr-Old Female
75 yrs old female with hypertension visited ED due to dizziness and falls,
Ixs r/o infection, cardiac, CVA. Drug review found Niacin 1mg PO tid was
prescribed 2 weeks ago for high cholesterol. What specific education
should be included upon patient discharge?
A.
limiting fluid intake
B. measures to minimize orthostatic hypotension
C.
administration of the drug an hour after eating
D. slight modifications in diet that are required with drug therapy
The answer?
CASE STUDY #3: 78-Yr-Old Male
78 yrs old man with chronic asthma visited ED due to vomiting, stomach
cramps and confusion. He is on Theophylline 400 mg od and
hypertensive medications. What diagnostic study should be obtained?
A. Serum electrolytes
B. Digoxin level
C.
Theophylline level
D. Arterial blood gases
The answer?
QUIZ QUESTION #1
What anti-hypertensive drug classifications tend to reduce insulin
sensitivity?
A.
Diuretics & CCB
B.
Diuretics & Beta-blockers
C.
CCB and ACEI
D.
Alpha-blockers & ACEI
The answer?
QUIZ QUESTION #2
When a patient is on Metformin, what do we need to closely monitor
for?
A.
Significant increase of body weight
B.
Elevation of LDL cholesterol level
C.
Lactic acidosis
D.
Increase insulin requirement
The answer?
QUIZ QUESTION #3
An elderly man has BPH, which medication will likely aggravate this
condition?
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Glyburide
B.
Oral buspirone
C.
Inhaled ipratropium (Atrovent)
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Ophthalmic timolol (Timoptic)
The answer?
Our Role as GEM Nurses
How can we help?
INFORMATION
accurate list of meds with the contact information of providers
INSTRUCTION
Offer proactive education on indications, potential adverse efforts,
potential interaction with other meds/foods, proper medicine
administration, and advise to use one pharmacy for clear records
ORGANIZATION
Teach / offer suggestions for how to manage/store/dispose of medicines,
and to avoid sharing
HEALTH LITERACY
Drugs to Avoid
• Non-Steroidal Antiinflammatory Drugs
(NSAIDs)
• Certain Anti-cholinergic
Drugs
• Digoxin
• Certain over the counter
drugs (such as cold regime)
• Certain Diabetic Drugs
• Muscle Relaxants
• Certain anti-anxiety/antiinsomnia
• Demerol
• Anti-psychotics if not for
psychosis
• Estrogen replacement (HRT)
http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf
AGS Beers Criteria 2012
High Risk for Drug-Drug
Interactions
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Cardiac Med: Digoxin, CCB
Oral Anticoagulant
Theophyllin derivatives
Endocrine therapies:
Glyburide, Pioglitazone,
Simvastatin
• Opioid analgesics
• Immunosuppresants
• Psychiatric Med: Lithium,
SSRI, MAOI
• Anticonvulsants
• Antimicrobials: Macrolide,
Quinolone, Oral
Antifungals,
Antiretrovirals
• Anithistamine
http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf
AGS Beers Criteria 2012
Key Take Home Messages
1) Consider the possibility that a drug could exacerbate
an existing condition, or even lead to a new consider…
then evaluate all alternatives
2) Recognize a change of function as an early sign of ADR
3) Avoid using drugs to correct a drug-induced problem
Reference
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American Geriatrics Society 2012 Beers Criteria Update Expert Panel (2012) American
Geriatric Society Updated Beers Criteria for Potentially Inappropriate Medication Use in
Older Adults. JAGS 2012
Durso S. C, Bowker L. K., Price J. D. & Smith S. C. (2010) Oxford American Handbook of
Geriatric Medicine Oxford University Press
Fick D. M. & Semla T. P. (2012) 2012 American Geriatrics Society Beers Criteria: New
Year, New Criteria, New Perspective. JAGS 2012
Kazer M. D. & Grossman S. (2011) Gerontologyical Nurse Practitioner: Certification
Review. Springer Publishing Company
Vega C. P. (2013) PIM: The Real Drug Problem in Seniors Retrieved on Aug 20/2013
from www.medscap.com/viewarticle/802898
Woodfruff. K (2010) Preventing Polypharmacy in Older Adults. American Nursing Today
2010:5(10)
Wotten J.M.(2012) Pharmacotherapy Considerations in Elderly Adults South Med.
Journal 2012; 105(8);437-445.
Thank You
Questions?
GEM Conference 2013
September 17th, 2013
Clara Tsang RN (EC)