1985 65 1987 12% 12% 25% 1999 1%( 13%) 1997 30% 8% 65 61% 3 5 3 (over- the-counter medication) 1993 70% 1996 1995 56 1996 62.8% 2.79 75.8 83.4% 3.64 85 75.5% (heterogeneity / diversity) Title: Prescription Principles in the Elderly Authors: Ying-Hsiang Huang, Feng-Hwa Lu; Department of Family Medicine, National Cheng Kung University Hospital Key Words: elderly, prescription, adverse drug reaction, inappropriate medication, pharmacokinetics, pharmacodynamics 2003 7 3 385
Geriatric Medicine (individualized) (pharmacokinetics) (pharmacodynamics) (albumin) 1 (alpha 1 -acid glycoprotein, AAG) ( warfarin naposin phenytoin tobutamide ) (free fraction) ( propranolol lidocaine imipramine quinidine) (absorption) (distribution) AAG AAG (lean body mass) (total body water) ( digoxin ) ( diazepam chlorpromazine) (passive diffusion) (Bioavailability) (half life) (maximal effect) (active transport) B 1 B 12 (metabolism) (first-pass effect) (smooth endoplasmic reticulum) propranolol morphine digoxin penicillin diazepam cytochrome P 450 386 Formosan J Med 2003 Vol.7 No.3
(elimination) metoclopramide (extrapyramidal symptoms). (inducibility) (polypharmacy) (hepatic extraction ratio) (reservoir) (adverse drug reaction ADR) (drug-drug interaction) (compliance /. adherence) ( ) allopurinol aminoglycosides cephalosporin digoxin chlorpropamide ( ) (receptor) ( ) - receptors - adrenergic agonists antagonists dopamine dopamine-blocker 2003 7 3 387
Geriatric Medicine 13. 14. 15. 1. ( ) 7. (Ccr 50 ml/min) 2. 8. 85 3. 9. 9 4. (adverse drug reaction) 10. 5. (nonadherence / noncompliance) 11. 6. 6 ( ) 12. (body-mass index) ( Am J Hosp Pharm 1990; 47: 533-43.,Consult Pharm 1997; 12:1103-11.) 1. ( ) 2. 3. 4. 1. 5. 2. 6. 7. 3. 8. 4. 9. 5. 10. 11. 6. 12. 388 Formosan J Med 2003 Vol.7 No.3
(NSAIDs) 1992 52.6% Hanlon 45.6% 30.8% (Medication Appropriateness Index MAI) Benzodiazepine 30 1988 1989 13.5% (potentially inappropriate medication) 12-40% 30% 1991 Beers (adverse drug reactions (Explicit) (Implicit) (Explicit) 1997 ADRs) (Inappropriate Practices in 1999 Prescribing for Elderly People) Beers 1997 4.2 1992 27% Beers. ( ). ( ). 15 ( ) (adverse drug reactions ADRs) (WHO) (Implicit) 2003 7 3 389
Geriatric Medicine ( ) (Iron supplements) 325mg (Digoxin) hydroxyzine, cyproheptadine, chlorpheniramine, diphenhydramine Benzodiazepine lorazepam(ativan), oxazepam(serenal), alprozolam(xanax), zolpidem (Stilnox) ( Am Fam Physician 2002;66:1917-24., CMAJ 1997;156:385-91., Arch Intern Med 1991;151: 1825-32., 1997;157:1531-6.) ( ) Propoxyphene Aspirin Acetaminophen Indomethacin Pentazocine Reserpine, Reserpine/Hydrochlorthiazide Trimethobenzamide Phenothiazine Disopyramide Ia Meperidine Dipyridamole (Ergot Mesylates), Cyclospasmol Ticlopidine Aspirin Aspirin (Muscle relaxant) (Antispasmodic agents*) (Gastrointestinal antispasmodic agents**) 390 Formosan J Med 2003 Vol.7 No.3
( ) Meprobamate Amitriptyline Doxepine Diphenhydramine Flurazepam, Chlordiazepoide, Diazepam Phenylbutazone Chlorpropamide Methyldopa, Methyldopa/Hydrochlorthiazide Phenobarbital Barbiturates Benzodiazepine phenobarbital * methocarbamol, carisoprodol, chlorzoxazone, metaxalone, cyclobenzaprine, oxybutynin ** belladonna alkaloids, dicyclomine, hyoscyamine, propantheline, clidinium ( Am Fam Physician 2002;66:1917-24., CMAJ 1997;156:385-91., Arch Intern Med 1991;151:1825-32., 1997;157:1531-6.) (FDA) ADRs Benzodiazepine ADRs ADRs ADRs ADRs 1988 (Committee on Safety of Medicines) 1964-1985 ( ) ADRs ( ) 2003 7 3 391
Geriatric Medicine (Potassium supplements) antispasmodic agents ( Buscopan) 15 1. Disopyramide 2. β-blocker( ) Corticosteroids( ) 3. Amphetamine 4. β- (β-blocker) (Sedative/Hypnotics) 5. β- (β-blocker) 6. (NSAIDs) Aspirin ( 325mg) 7. / Metoclopramide, chlorprothixene, Thorazine, Clozapine 8. β- (β-blocker) 9. NSAIDs, Aspirin, Dipyridamole, Ticlopidine 10. Anticholinergic antihistamine/antidepressants, Gastrointestinal 11. 12. Tricyclic antidepressants, Narcotics, Anticholinergics 13. / benzodiazepine ( Flurazepam, Diazepam) β- 14. Tricyclic antidepressants 15. Decongestants, β-agonists, Theophylline, SSRIs ( Am Fam Physician 2002;66:1917-24., CMAJ 1997;156:385-91., Arch Intern Med 1991;151: 1825-32., 1997;157:1531-6.) 392 Formosan J Med 2003 Vol.7 No.3
7. (one disease one drug and once a day) 8. start low and go slow 9. cisapride Macrolide ( 1. Erythromycin) (Torsade de pointes) ( ) (NSAIDs) 2. 10. 3. 11. 12. 4. - 5. (prescribing cascade) 13. 6. 14. 2003 7 3 393
Geriatric Medicine (medication calendar / diary) 15. 16. 17. ( ) 1. Williams CM: Using medications appropriately in older adults. Am Fam Physician 2002; 66: 1917-24. 18. 2. Rathore SS, Mehta SS, Boyko WL Jr, et al: Prescription medication use in older Americans: a national report card on prescribing. Fam Med 19. 1998; 30: 733-9. 3. Carlson JE: Perils of polypharmacy: 10 steps to prudent prescribing. Geriatrics 1996; 51: 20. 26-30, 35. 4. 1995;11:164-9 5. : 踪 NSC87-2314-B006-108. 6. : 1999 7. Applied therapeuticals: the clinical use of drugs. 7 th Edition, 2001. 8. Scharf S, Christophidis N: Pharmacokinetics and pharmacodynamics in the elderly. Austr J Hosp Pharmacy 1991; 21: 198-202. 9. Hepler CD, Strand LM: Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990; 47: 533-43. 10. Fouts M, Hanlon J, Pieper C, et al: Identification of elderly nursing facility residents at high risk for drug-related problems. 394 Formosan J Med 2003 Vol.7 No.3
Consult Pharm 1997;12:1103-11. elderly. An update. Arch Intern Med 11. Tamblyn RM, McLeod PJ, Abrahamowicz M, 1997:157:1531-6. et al: Questionable prescribing for elderly 18. Roberts MS, Stokes JA: Explicit patients in Quebec. CMAJ 1994;150:1801-9. evidence-based prescribing criteria - an 12. Chu LW, Pei CK: Risk factors for early emergency hospital readmission in elderly medical patients. Gerontology 1994;45:220-6. 13. Lindley CM, Tully MP, Paramsothy V, et al: Inappropriate medication is a major cause of adverse drug reactions in elderly patients. Age Aging 1992;21:294-300. important step in achieving quality therapeutics in nursing home. Age Aging 2003;32:6-7. 19. Giron MS, Wang HX, Bernsten C, et al: The appropriateness of drug use in an older nondemented and demented population. J Am Geriatr Soc 2001;49:277-83. 20. McLeod PJ, Huang AR, Tamblyn RM, et al: 14. Defining inappropriate practices in prescribing 2001,123p. for elderly people: a national consensus panel. 15. Hanlon JT, Schmader KE, Samsa GP, et al: A CMAJ 1997;156:385-91. method for assessing drug therapy 21. Castleden CM, Pickles H: Suspected adverse appropriateness. J Clin Epidemiol drug reactions in elderly patients reported to 1992;45:1045-51. the Committee on Safety of Medicines. Br J 16. Beers MH, Ouslander JG, Rollingher I, et al: Explicit criteria for determining inappropriate Clin Pharmacol 1988;26:347-53. 22. Hazzard WR, Blass JP, Ettinger WH, et al: medication use in nursing home residents. Arch Principles of geriatric medicine and Intern Med 1991;151:1825-32. 17. Beers MH: Explicit criteria for determining gerontology. 4 th ed. New York: McGraw-Hill, 1999;303-31. potentially inappropriate medication use by the 2003 7 3 395