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PRINSIP TERAPI PADA PASIEN GERIATRI - Dr. Fita Rahmawati, SP - FRS
PRINSIP TERAPI PADA PASIEN GERIATRI - Dr. Fita Rahmawati, SP - FRS
PASIEN GERIATRI
17,2 21,7
13,2 13,1 14,3
10,3
People w ith no People w ith People w ith one People w ith no People w ith People w ith one
chronic disease three or more or more serious chnoic disease three or more or more serious
chronic chronic chronic chronic
diseases diseases diseases diseases
64,9
51,9
45,2 46,4
37,9 38,0
34,9
28,6
18,9 21,3 18,8
16,7
12,2 12,9 12 12,8
8,1
3,9
6,9 6,8
3,9 6,4 8,7 4,1
Perubahan fisiologi
Peningkatan PH asam lambung
Penurunan motilitas gastrointestinal
Reduksi luas permukaan total absorpsi
Reduksi aliran darah jaringan
Reduksi ukuran hati
Reduksi aliran darah hati
Reduksi filtrasi glomerulus
Table Effect of ageing on drug disposition (Cussack, 2001)
Gastric pH
Gastrointestinal motility changes
Blood flow in the
Active membran transport elderly
process
as well as
changes in the hepatic drug metabolism during the first
pass of the drug through the liver
DISTRIBUTION
Factors influence the distribution:
Body composition
(changes in the elderly, lead to decreased Volume of
distribution)
12% 5%
CELL SOLID
53% 30% BONE MINERAL
FAT
H2O
70 YEARS OLD Brocklehurst & Allen, 1987
Biochemical changes in old age
Available
drug
Protein
bound
drug
DRUG IN CIRCULATION
An example of typical concentration-vs-time data from
which pharmacokinetik parameters can be estimated
DRUG METABOLISM
In the Elderly
Blood flow
Liver function Drug metabolism
Congestive Heart in the Liver
failure (+)
Renal elimination of most drugs is closely
correlated with the endogenous creatinine
clearance. CLcr (in mg/dl) as a function of age and
serum creatinine concentration, it may be
calculated from the Cockroft and Gault equation
(Turnheim, 2004):
BENEFIT
RISK
PROBEM PENGGUNAAN OBAT
PADA GERIATRI
Consider…
…the use of well-known drugs
about which enough is known
regarding the risk/benefit
balance for elderly patients.
…recourse to non
pharmacuetical treatments
(diet advice, smoking
cessation, physical activity).
Polytherapy: possible causes
Presence of pluripathologies.
Expectations of the patient
and medical prescription.
“Fragmentation of cures”.
Recourse to self-medication.
Adverse reactions treated as
pathologies.
Fragmentation of cures
(Viktil K et al. The Janus face of polypharmacy: overuse vs underuse of medication.
Norsk Epidemiol, 2008)
Known drugs
Over the
counter
medicines
Herbal
products Particular
foods
Alcohol
The prescription ‘snowball’
opiates)
falls and fractures benzodiazepins, anti-hypertension
drugs
urinary incontinence eg. diuretics
Polytherapy and interactions between drugs
benzodiazepine
AUC, Cmax strengthens the effects of BDZ
Calcium channel
blockers Immune-
Haematic levels
(headaches, hypotension,
supressants
Adverse
tachycardia )
effects
statins nefrotoxicity,
AUC (16 times) cefalea, liver disease
myopathy
Antidepressants
arrythmia,
antihistamines tricyclics
Levels of liver Levels of liver
disease disease
Prolonged QT
Berikut Pharmacist ’s guide terkait dengan
penurunan polifarmasi (Terie, 2004):
Determine all medications being taken
Identify the indication for all medications
Identify any potential for adverse effects for
each medication
Recommend eliminating all medications with
no therapeutic benefit, goal, or indication
Recommend substituting medications with
a lesser side-effect profile, when possible
When possible, select agents with an
infrequent dosing schedule
Avoid utilizing another medication to threat a
side effect of another agents
Berikut Pharmacist ’s guide terkait dengan
penurunan polifarmasi (Terie, 2004):
Gastrointestinal Cardiovascolar
disturbances Disturbances
Constipation Cardiac arrhythmia
Avoid: Avoid:
anticolinergics, antidepressants
antidepressants tricyclics
tricyclics
Ulcers Urinary Disturbances
Avoid: FANS, Incontinence
aspirin, K+ Avoid: -blockers
integrators
Respiratory Disturbances
Endocrine Disturbances Athsma o COPD
Diabetes Avoid: -blockers
Avoid:
corticosteroids, -
blockers
Inappropriate drugs: what to do?
time 7 8 9 11 12 13 16 19 20 21 22 23 24
drug
Pantoprazol 1
cpr
Gliclazide 1 1 1
cpr cpr cpr
Furosemide 1 1
cpr cpr
Ramipril 1
cpr
References