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8 - Respiratory Disorders |
207
Table 8-2. Therapy at Each State of COPD
Patient Group
Recommended First
Choice Alternative Choice
Other Possible
Treatments
A (few symptoms,
low risk of
exacerbation)
Short-acting
anticholinergic prn
or
short-acting β
2
agonist
prn
Long-acting anticholinergic
or
long-acting β
2
agonist
or
short-acting β
2
agonist and
short-acting anticholinergic
Theophylline
B (more significant
symptoms but
low risk of
exacerbation)
Long-acting
anticholinergic
or
long-acting β
2
agonist
Long-acting anticholinergic
and long-acting β
2
agonist
Short-acting β
2
agonist
and/or
short-acting
anticholinergic
Theophylline
C (few symptoms
but high risk for
exacerbations)
Inhaled corticosteroid +
long-acting β
2
agonist
or
long-acting
anticholinergic
Long-acting anticholinergic
and long-acting β
2
agonist
or
long-acting anticholinergic
and phosphodiesterase-4
inhibitor
or
long-acting β
2
agonist and
phosphodiesterase-4
inhibitor
Short-acting β
2
agonist
and/or
short-acting
anticholinergic
Theophylline
D (many symptoms
and high risk for
exacerbations)
Inhaled corticosteroid +
long-acting β
2
agonist
and/or
long-acting
anticholinergic
Inhaled corticosteroid +
long-acting β
2
agonist and
long-acting anticholinergic
or
inhaled corticosteroid +
long-acting β
2
agonist
and phosphodiesterase-4
inhibitor
or
long-acting anticholinergic
and long-acting β
2
agonist
or
long-acting anticholinergic
and phosphodiesterase-4
inhibitor
Short-acting β
2
agonist
and/or
short-acting
anticholinergic
Theophylline
prn, as needed.
Source: Reprinted with permission from the Global Strategy for Diagnosis, Management and Prevention of
COPD 2014, © Global Initiative for Chronic Obstructive Lung Disease (GOLD), all rights reserved. Available from
http://www.goldcopd.org.
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| Fundamentals of Geriatric Pharmacotherapy
Review of Evidence Base
Supporting Treatment
Recommendations for Elderly
Patients
A systematic search of the medical literature
evaluated the inclusion of older adults in clinical
trials in COPD.
4
After reviewing two decades’
worth of information, the authors concluded
that although older adults were not specifi-
cally excluded from the trials, they were under-
represented. The average age of the subjects
recruited was 58–69 years, and very few
subjects over the age of 80 years participated
in the trials. In addition, subjects with comorbidi-
ties such as asthma, other respiratory disorders,
and cardiovascular diseases were excluded
from these trials. Approximately 40% of clinical
trials excluded subjects with electrocardiogram
abnormalities and cardiovascular disease, such
as recent myocardial infarction, unstable angina,
arrhythmias, and heart failure. This is discon-
certing, given the potential for cardiovascular
side effects associated with therapy for COPD
(e.g., QT interval prolongation, tachycardia and
other arrhythmias, worsening of myocardial isch-
emia and congestive heart failure, electrolyte
disturbances).
Another systematic search of the medical
literature evaluated the inclusion of older adults in
clinical trials in asthma.
5
The average age of the
subjects in these clinical trials ranged from 25 to
49 years, with some trials excluding older adults.
Of the articles reviewed, approximately 17% had
no specific exclusions or contained information
on exclusions. Existing clinical trials need to be
interpreted with caution, because exclusion of
patients of advanced age and multiple medical
comorbidities was common. The asthma treat-
ment algorithms emphasize long-term pharma-
cologic treatment, with careful attention placed
on self-management.
Inhaled beta agonists can cause both
pulmonary and extrapulmonary adverse effects.
In a meta-analysis of randomized placebo-
controlled trials of beta agonists in 6,623 patients
(mean age 52.2 years) with obstructive airway
disease, cardiac adverse events were classified
as mild, including minor changes in heart rate
and clinically unimportant changes in the level of
serum potassium. There was an increase in the
risk for adverse cardiovascular events (relative
risk 2.5), largely caused by an increase in the
risk of sinus tachycardia. The likelihood of major
cardiovascular events did not reach statistical
significance.
6
In absolute terms, approximately
one additional event occurred in the beta-
agonist group for every 200 patients treated
over a 6-month period.
7
The Salmeterol and
Fluticasone Propionate and Survival in Chronic
Obstructive Pulmonary Disease trial, commonly
referred to as the TORCH trial (n = 6184, 1,542
patients in the salmeterol arm, mean age 65
years) found that cardiovascular causes contrib-
uted to mortality in 3% of patients, with no signifi-
cant difference between the salmeterol and
placebo groups.
8
The Salmeterol Multi-Center
Research Trial (SMART), designed to test the
safety of salmeterol, had about 26,000 partici-
pants but was stopped early because of safety
concerns. As a result of the study, the Food and
Drug Administration (FDA) issued a public health
advisory for long-acting beta-2 agonists (LABA).
It warned that these medications can cause
a “small but significant risk in asthma-related
deaths.” The FDA also required the addition of a
boxed warning to LABAs.
There has been considerable debate over
the use of beta agonists in the management of
moderate and severe COPD. Supporters of beta
agonists believe that clinical trials clearly show
short-acting beta-2 agonists and LABAs improve
dyspnea, quality of life, and reduce respiratory
exacerbations in patients with COPD.
9
Also,
proponents argue that anticholinergics have
equal or superior efficacy to beta agonists in
improving lung function parameters without
creating tolerance over time as seen with regular
use of beta agonists.
9
In elderly asthmatic
patients, LABA should be used only in combina-
tion with ICS due to these safety concerns and
the potential for cardiac comorbidities. It would
be prudent to carefully assess the cardiac risk
factors before instituting a LABA in a patient with
COPD.
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In patients with moderate to severe COPD,
ICS should be used to reduce exacerbations. A
meta-analysis of 12 randomized controlled trials
assessing ICS demonstrated one fewer exac-
erbation for every 12 patients with moderate-
to-severe disease who were treated for 18
months.
10
However, ICS are associated with a
variety of adverse effects; the most common are
the local effects in the upper airways, such as
thrush and dysphonia. These complications can
be minimized through the use of spacers and
rinsing the mouth after inhalation of the drug.
Due to the increased risk of osteoporosis and
osteopenia in older adults, treatment with ICS
has been evaluated to examine if these agents
pose any increased risk of reduced bone mineral
density. In the TORCH trial, patients treated
with fluticasone alone or in combination with
salmeterol reported a nonsignificant increase
in the incidence of fractures compared with
placebo (5.4%, 6.3%, and 5.1% respectively).
8
In a subset of TORCH, in which participants (n =
658) were specifically assessed for changes in
bone mineral density, the prevalence of osteopo-
rosis was significant. Specifically, about 70% of
all patients had osteopenia or osteoporosis, indi-
cating that abnormal bone health is a common
problem in COPD. Higher doses of ICS, such as
those used in the management of asthma, have
been associated with increased bone turnover,
but data on bone mineral density and fracture at
these doses are not available.
11
Those patients
requiring oral corticosteroids for management of
their respiratory disease should be on adequate
doses of calcium and vitamin D, at a minimum.
Bisphosphonates are the drugs of choice for
the treatment and prevention of glucocorticoid-
induced osteoporosis and should be considered
if the patient will require continuous glucocor-
ticoid therapy, unless there is a documented
contraindication.
Cataracts and glaucoma have also been
associated with ICS. The TORCH study performed
slit-lamp examinations in a safety subset of 658
subjects using high-dose ICS (fluticasone 500
mcg, twice daily). Only 29% of patients did not
have cataracts at baseline examination. There
were no differences in the development of new
cataracts compared with the placebo group.
Thus, the relationship of ICS to cataract forma-
tion is not totally clear.
12
In a systematic review
of the literature, an expert panel found grade C
evidence that ICS are associated with cataracts
in young asthma patients; however, the risk may
be elevated in older patients.
13
This same expert
panel found the risk of glaucoma with ICS use to
be small, probably dose dependent, and found
insufficient evidence to conclude whether any
specific ICS formulation had an increased risk.
13
Common Problems Encountered
When Treating Elderly Patients
with Chronic Obstructive
Pulmonary Disease
Elderly patients may use inhaler devices improp-
erly due to poor eyesight, poor hand strength,
arthritis, and coordination difficulties. Older
adults are underrepresented in studies evalu-
ating different inhaler types, and results are
often extrapolated from predominately younger
adults with asthma, not COPD. However, most
patients, regardless of their age, should be
able to acquire and maintain adequate tech-
nique when given appropriate instruction, with
the exception of those patients with significant
cognitive impairment.
14,15
Spacer devices may
be used with metered-dose inhalers (MDIs)
when patients have difficulty with hand-breath
coordination. Spacers improve drug delivery
and reduce systemic absorption. Common prob-
lems encountered by older adults include diffi-
culty connecting the MDI to the spacer, difficulty
activating the device, and unnecessary repeti-
tive firing into the spacer. Up to 85% of patients
who were prescribed spacer devices did not use
them.
16,17
Dry-powder inhalers (DPIs) have been
developed to overcome difficulties encountered
with MDIs and have been viewed as more patient
friendly by patients and healthcare providers. In
general, DPIs require a higher peak inspiratory
flow (PIF) than MDIs for effective drug delivery,
because a minimum inspiratory flow is required
to disaggregate and disperse the drug powder
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| Fundamentals of Geriatric Pharmacotherapy
in the inhaled airstream.
18
In a study specifi-
cally designed to assess the use of DPIs in
elderly patients with mild and moderate COPD,
a large percentage of participants were unable
to generate adequate PIFs for optimum use of
some popular DPI devices. An analysis showed
that both age and COPD disease severity were
independent variables influencing PIF.
19
KEY POINT:
Dry-powder inhalers
require a higher peak inspiratory ow than
MDIs for eective drug delivery. Many
elderly patients with mild and moderate
COPD are unable to generate adequate
peak inspiratory ows for optimum use
of some popular dry-powder inhalers.
Another common issue encountered in the
elderly is cognitive impairment and ability to use
inhalers correctly. Not surprisingly, elderly people
with significant cognitive impairment were
unable to learn to use a standard MDI. Patients
with mild-to-moderate dementia may be able to
use either an inhaler with a spacer device or an
inspiration-triggered inhaler. However, only those
patients who had no cognitive impairment were
able to demonstrate perfect inhaler technique.
15
Subsequent studies have shown that patients
with a Mini-Mental State Examination (MMSE)
test score of less than 23 out of 30 or the inability
to copy intersecting pentagons are unlikely to
master MDI technique. Executive domains are
important determinants of an adequate inhaler
self-administration technique with or without
overt cognitive impairment on the MMSE.
19,20
A
majority of this research has been conducted in
a frail elderly population during hospitalizations
for rehabilitation, and additional research has
been called for in a community-based sample.
In addition to cognitive impairment, patients
having difficulties with exhalation, hand-breath
coordination, and breath-holding are likely to
have difficulty with any inhaler; therefore, frailty
may be a central issue.
21
A patient’s cognitive
function should be assessed prior to initiating
therapy with an inhaler to establish a baseline
and aid in the selection of an inhaler device.
It is not known whether patients with mild-to-
moderate dementia can retain inhaler skills as
their cognitive function declines. Therefore,
planned regular review of technique should take
place to test competence and changes made to
therapy as necessary.
15
Furthermore, supervi-
sion of inhaler use is recommended for patients
with cognitive impairment.
It is a myth that nebulizers are more effec-
tive than correctly administered inhalers. An
evidence-based review of effectiveness reported
that nebulizers, DPIs, and MDIs have comparable
effectiveness when used properly.
22
The appro-
priate use of nebulizers does contain complexi-
ties, such as the need to disassemble, wash,
dry, and reassemble the nebulizer between
treatments. Nebulizer compressors require peri-
odic maintenance, such as filter replacement.
23
Subjectively, older adults often seem to prefer
nebulizers. Perhaps this is due to the sensa-
tion of the taste and sight of the mist; however,
no objective evidence has been published to
support this notion, and patient compliance with
home nebulizer therapy in COPD patients aver-
aged 57% in one study.
24
Appropriate candi-
dates for nebulizer therapy are those patients
with very poor hand-breath coordination, such
as those with Parkinson disease or severe
osteoarthritis of the hands.
Older adults with COPD are at risk for
adverse effects from benzodiazepines. Benzo-
diazepines can impair respiratory drive in indi-
viduals with COPD yet are commonly prescribed
to treat insomnia, anxiety, and breathlessness.
In a study of 111,445 older adults with COPD,
almost one third received a new prescription for
a benzodiazepine, with higher rates in those with
more severe COPD.
25
Benzodiazepines should
be used as a second-line treatment for patients
with COPD, and the lowest possible dose should
be prescribed for the shortest period of time.
Older adults are more likely to develop
adverse reactions to pharmacotherapy while
receiving asthma therapy (see Table 8-1); there-
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fore, it is prudent to provide more intense moni-
toring.
26
Most elderly patients will require contin-
uous treatment programs to control their disease.
In part, this may be because bronchodilator
response to inhaled beta agonists declines with
age.
27
Even in mild disease, older adults should
receive regular preventive treatment with ICS,
given the poor perception of bronchoconstriction
by older asthmatic patients.
28
If symptoms persist
despite ICS, the addition of a LABA should be
considered. Due to concerns about the safety
of beta-2 agonists in older adults, LABA should
only be used concomitantly with ICS, and these
patients should have regular cardiac assess-
ments, including periodic electrolyte monitoring
to rule out hypokalemia.
A critical component of self-management
is the provision of a written asthma plan that
instructs patients on how to deal with changes
in asthma symptoms. In a study that investigated
the risk factors associated with hospitalization
for asthma, 40% of elderly people with asthma
reported that they did not know everything they
needed to know to manage flare-ups, adjust their
medications, or avoid asthma triggers.
5
Most did
not have a peak-flow meter, and of those who
did, 29% did not know what to do in case of an
abnormal reading. It is imperative that written
asthma plans and adequate peak-flow coun-
seling are provided to older adults with asthma.
If cognitive impairment is present, caregivers
should be educated on the steps needed to
adjust therapy and when to seek help.
Adverse effects from beta agonists may
occur more frequently in elderly patients, espe-
cially in those with pre-existing cardiac disease.
Levalbuterol, the R-isomer of albuterol, has been
touted as producing fewer adverse effects and
superior bronchodilation when compared to
albuterol. Studies in asthma and COPD have
shown mixed results. If an elderly patient has
minimal response to albuterol or significant
adverse effects, levalbuterol may be considered
as an alternative. However, current evidence
does not support routine use of levalbuterol as
the beta agonist of choice in the elderly.
Inhaled anticholinergic medications may
increase intraocular pressure and have other
adverse ocular effects. This is important in the
elderly population because of the high preva-
lence of glaucoma, macular degeneration, and
other ophthalmologic problems. Several case
reports have correlated the use of a loose-fitting
mask while administering ipratropium bromide
to anisocoria, due to unilateral mydriasis.
29
Prolonged pupillary dilation can occur if the
drug is sprayed directly into the eye, and this
is especially worrisome regarding tiotropium
because of its prolonged duration of action.
Avoiding contact with the eyes seems to be the
best strategy; studies of ipratropium given at
four times the recommended dose in patients
with normal angle glaucoma had no effect on
intraocular pressure, pupil dilation, or accom-
modation.
30
Inhaled anticholinergic medication is poorly
absorbed, making systemic side effects unlikely.
The most common adverse effect with inhaled
anticholinergic medications is dry mouth, but
this rarely leads to discontinuation. Inhaled
anticholinergic agents have a relatively low inci-
dence of cardiovascular or respiratory adverse
effects, although supraventricular tachycardias,
increased cardiovascular risk, and paradoxical
bronchoconstriction have been reported.
6
This
notion was challenged recently in a system-
atic review and meta-analysis of patients using
ipratropium or tiotropium, which showed an
increased risk for cardiovascular events.
31
The
analysis included 17 trials that lasted from 6
weeks to 5 years, with nearly 15,000 patients.
Patients treated with inhaled anticholinergics
were more likely to reach the primary endpoint
of cardiovascular death, myocardial infarc-
tion, and stroke (1.8% versus 1.2%). When the
studies were analyzed based on length, the
risk remained elevated in the long-term studies,
and short-term studies did not reach statistical
significance. These findings remind the clinician
to carefully monitor COPD patients receiving
long-term inhaled anticholinergic therapy.
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| Fundamentals of Geriatric Pharmacotherapy
Theophylline is generally avoided in the
elderly due to its narrow therapeutic index and
potential to cause major systemic side effects
and drug interactions (see Table 8-1). If theoph-
ylline must be used in elderly patients, serum
concentrations should be monitored and a
lower therapeutic range of 8–12 mg/L should be
targeted.
32
T
Etiology, Epidemiology, and
Clinical Presentation Specic to
Geriatrics
TB, caused by Mycobacterium tuberculosis,
has been declining in recent years in the United
States due to increased awareness and selec-
tive prevention therapy, including treatment of
latent infection. The elderly have the highest
case reports among all age groups.
33
Disease in
the elderly mostly occurs in community-dwelling
individuals; however, patients who reside in
nursing homes and long-term care facilities
(LTCFs) are at a 2–3 times higher risk for TB.
34,35
Furthermore, the rate of tuberculin reactivity is
associated with the length of stay in a nursing
home, and in nursing homes with known recent
infectious cases.
34,35
Elderly patients are at higher risk for TB
infection due to higher rates of exposure and
infection that occurred early in the 20th century.
The increasing likelihood of latent infection
combined with immunosenescence increases
the likelihood of reactivation. Reactivation of a
primary infection in the elderly accounts for 90%
of TB, of which a component is from use of newer
biologic immunomodulating drugs.
34,35
Despite
improvements, prevention and control of TB in
the elderly population remains a challenge.
The tuberculin skin test (TST) is used to
diagnose M. tuberculosis infection. It contains a
5-tuberculin unit dose of purified protein deriva-
tives (PPD) injected intradermally to form a weal.
Interpretation of TST results 48–72 hours after
administration should be stratified according to
risk groups. Patients who do not have signs or
symptoms of TB but have a positive TST may
have latent TB infection (LTBI). Elderly patients
may not be able to mount an immune response
to provide a positive result to the TST. Therefore,
a two-step TST is recommended. If the patient’s
first TST is negative, a second TST should be
given 1–3 weeks later. A positive TST, regardless
of whether it was the first or a two-step, warrants
a chest radiograph and further investigation to
determine treatment modality.
Although relatively uncommon, a false-posi-
tive TST can occur, especially in patients who
have recently received the Bacillus Calmette-
Guérin (BCG) vaccine or those infected with
atypical mycobacteria. BCG is not used in the
United States. However, foreign-born individuals
may have received the BCG vaccine. Cell-medi-
ated immunity to PPD declines over time in indi-
viduals who have received the BCG vaccine.
34,35
Older patients with a positive TST result should
be treated for LTBI or M. tuberculosis infection,
regardless of whether a history of BCG vaccine
is noted in the patient’s chart, especially in indi-
viduals that came from endemic areas of TB or
have been exposed to TB.
34,35
LTBI may not be detected in the elderly
population because of an inability to mount an
immune response to the PPD. A false-negative
TST occurs in patients with febrile illness, human
immunodeficiency virus (HIV), and other viral
disease and in patients taking corticosteroids
or other immunosuppressive drugs.
34,35
The rate
of false-negative in the elderly is more common
than in the general population.
33
In the elderly,
lack of a reaction to TST cannot conclusively rule
out TB disease or infection.
Summary of Standard Treatment in
the General Adult Population
The American Thoracic Society, Centers for
Disease Control and Prevention, and Infectious
Diseases Society of America have developed
treatment recommendations for TB.
33
Control of
TB is focused on breaking the chain of transmis-
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sion. This can be achieved in the United States
by (1) rapid detection of TB, (2) screening of
high-risk groups, (3) effective treatment of LTBI
and active TB, and (4) prevention of TB transmis-
sion into the community.
33
The standard treatment
for LTBI is isoniazid for 9 months; alternatively,
it is a combination of isoniazid and rifapentine
given weekly for 12 weeks. Directly Observed
Therapy (DOT) can be used. In patients who are
intolerant or resistant of isoniazid, daily rifampin
can be used for 4 months. For the treatment of
active TB, all appropriate specimens should be
obtained before empiric therapy is started. DOT
and therapy that covers multidrug-resistant TB
based on local resistance patterns is recom-
mended.
33
Baseline and monthly monitoring of
liver function tests (LFTs) are recommended for
individuals with HIV and chronic liver disease.
Review of Evidence Base
Supporting Treatment
Recommendations for Elderly
Patients
Recommendations for TB treatment do not
differ between adults and the elderly popula-
tion, according to guidelines. Studies have not
focused on the elderly specifically; however,
comorbidities and social issues may require
adjustments to be made in standard treat-
ment plans. The majority of TB cases in elderly
patients in Western societies are probably treat-
ment-sensitive; most infections in the elderly
are due to reactivation of disease that was
acquired prior to the availability of antitubercu-
lous therapy early in the 20th century.
34,35
The
most challenging component in treating elderly
patients is selecting the highest effective treat-
ment regimen while diminishing the probability of
major adverse reactions. Table 8-3 reviews the
common agents used in TB.
Common Problems Encountered
When Treating Elderly Patients
with Tuberculosis
Despite elderly individuals having the highest
rate of infection, some view TB as a problem
of the young. This, in part, is due to the emer-
gence and focus on HIV-associated TB that
predominately occurs in younger individuals.
37
Also, healthcare professionals may not always
identify a possible TB infection, because symp-
toms may be less pronounced, nonspecific, or
confused with other pulmonary, heart, or malig-
nant disease; radiological findings may be
atypical; and the frequency of false-negative
TST occurs more often in the elderly population.
These factors contribute to a possible delay in
diagnosis, which can result in a higher rate of
mortality and the spread of TB.
37
Anti-tumor necrosis factor (TNF)-alpha
treatment has been identified as a risk factor
for reactivation of TB in older adults. These
biologic immunomodulating drugs are growing
in usage for adults of all ages. Studies have been
published using an active-surveillance database
and the FDA’s Adverse Event Reporting System,
which indicate that treatment with infliximab or
etanercept is associated with a fivefold overall
increased risk of TB.
38-42
Based on these find-
ings, it is recommended to screen all patients
for LTBI or active disease before starting anti-
TNF-alpha treatment.
Some LTCFs are reluctant to admit residents
with a diagnosis of TB because of the difficulty
treating elderly patients successfully and fear
of increasing the risk of transmission to other
residents. The need for respiratory precautions,
resident isolation, equipment dedicated to the
patient with TB, and segregated laundry require-
ments increases the burden on both the facility
and staff. For elderly patients newly admitted
to a LTCF or nursing home, screening with two-
step TST and treatment for LTBI per established
guidelines is recommended.
34,35
Hepatic toxicity with isoniazid has a higher
incidence in individuals over 35, and this was a
main reason for restricting treatment for LTBI in
the elderly in the past when alternative agents
were considered first-line for older patients.
42
Intolerance to INH has been documented in
older individuals, and the risk for INH-hepatitis is
the highest in individuals ≥50 years (2.3% risk).
In patients at high risk for hepatotoxicity—those
with HIV and chronic liver disease—it is recom-
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| Fundamentals of Geriatric Pharmacotherapy
mended to perform baseline and monthly LFT.
Currently, INH is considered first-line therapy
in older adults, but symptomatic monitoring of
INH-induced hepatitis may not be optimal in
elderly individuals with impaired communication
or cognition skills or chronic comorbidities.
34,35
Therefore, it may also be appropriate to monitor
LFTs in these patients.
All agents used in treatment of TB have
significant toxicities and drug interactions of
importance in older adults. Elderly patients, in
particular those with diabetes, uremia, malnu-
trition, or history of alcohol abuse are at higher
Table 8-3. First-Line Agents Used for the Treatment of LTBI or Active TB
Class: Medication
Examples
General Adult Treatment
Principles Geriatric Considerations
Isonicotinic acids:
Isoniazid
First-line treatment as
monotherapy for LTBI or in
combination for active TB.
Monitor liver function and counsel patient on
alcohol consumption.
Supplement with pyridoxine 25–50 mg/day to
prevent peripheral neuropathy.
Monitor for drug interactions.
May increase concentration of phenytoin,
carbamazepine, warfarin, diazepam;
corticosteroids may decrease levels of
isoniazid.
a
Rifamycins:
Rifampin
Rifabutin
Rifapentine
First-line treatment as
monotherapy for LTBI or in
combination for active TB.
May turn urine reddish/orange.
Monitor liver function and counsel patient on
alcohol consumption.
Monitor for drug interactions. Rifampin may
decrease concentrations of methadone,
digitalis glycosides, cyclosporine, warfarin,
oral hypoglycemic drugs, corticosteroids,
theophylline, phenytoin, ketoconazole, protease
inhibitors, and non-nucleoside reverse
transcriptase inhibitors.
Miscellaneous:
Pyrazinamide
Ethambutol
Used in combination for active
TB.
Monitor liver function and counsel patient on
alcohol consumption.
Monitor uric acid levels.
Counsel patient to report any visual disturbances
if taking ethambutol.
Adjust dose for renal impairment.
a
Not a complete list of drug interactions; it is important to screen all medications for drug interactions
carefully.
risk for peripheral neuropathy from INH. To prevent
peripheral neuropathy, pyridoxine 25–50 mg/day
may be given. INH has also been shown to
increase serum concentrations of some benzo-
diazepines and anticonvulsants. See Table 8-3.
Use of rifampin with pyrazinamide for the
treatment of LTBI is strongly discouraged due
to the potential for severe hepatotoxicity (see
Table 8-3).
36
A complete medication review for
potential drug interactions should be completed
prior to initiating therapy and concomitant use of
known hepatotoxic agents should be avoided.
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8 - Respiratory Disorders |
215
C 1: A
Setting:
Skilled nursing facility.
Subjective:
MD is an 82-year-old woman who has been a long-time resident of the skilled nursing facility.
Recently, the nursing staff has noted that she is having increasing shortness of breath and
nighttime awakenings, which they attribute to a worsening of her asthma.
Past Medical History:
Late-onset asthma, osteoarthritis, hypertension, recently diagnosed glaucoma, and depression.
Medications:
Fluticasone 250 mcg/salmeterol 50 mcg inhaler 1 inhalation BID, albuterol 0.083% solution
3 mL via nebulizer four times a day prn, acetaminophen 500 mg four times a day, furosemide
20 mg daily
, metoprolol 50 mg BID, sertraline 50 mg daily. There is an order for timolol 0.5%
ophthalmic solution 1 gtt BID, initiated 2 weeks ago.
Allergies:
NKDA.
Social History:
Negative for tobacco and alcohol use.
Family History:
Mother died of old age, father died of a myocardial infarction at age 81.
Objective:
Ht 5´2˝, Wt 101 lb, BP 130/82, P 62 BPM, RR 20
Physical Examination:
Bilateral wheezing, use of accessory muscles on inhalation, remainder of examination is within
normal limits.
Assessment:
MD is experiencing shortness of breath caused by bronchoconstriction induced by ophthalmic
and systemic beta blockade.
Plan:
1.
Recommend the discontinuation of the timolol ophthalmic solution and substitution of
latanoprost eye drops.
2.
Recommend the discontinuation of metoprolol and substitution of amlodipine 5 mg daily.
3.
Reinforce proper inhaler technique with the patient and nursing staff.
Rationale:
1. The use of ophthalmic beta blockers has been shown to exacerbate reactive airway
disease because of systemic absorption. Patients already taking systemic beta blockers
are at an increased risk for bronchoconstriction, and addition of the topical agent is likely
tipping MD into bronchoconstriction. The use of ophthalmic beta blockers should be
avoided in patients with a history of asthma. If they must be used, nasolacrimal pressure
should be applied for 1 minute after the instillation of the drops to minimize systemic
absorption.
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216
| Fundamentals of Geriatric Pharmacotherapy
2. MD has no compelling indications for the use of a beta blocker (e.g., post myocardial
infarction) and has a relative contraindication (i.e., asthma). Amlodipine will not cause
bronchoconstriction. The dose should be titrated to achieve blood pressure goal.
3.
Proper inhaler technique is difficult to achieve for many elderly patients, and periodic
assessment of a patient’s technique is useful to ensure optimal medication management.
Because nursing staff are involved in drug administration in LTCFs, they are helpful in
evaluating and reinforcing proper technique on a day-to-day basis.
Case Summary:
Older adults are at increased risk for adverse drug reactions and drug-induced disease. A
careful assessment should be conducted before prescribing any new medications to ensure
that the proposed therapy will not exacerbate other chronic conditions. It is imperative that
clinicians consider any symptom in an elderly patient a medication adverse event until proven
otherwise. Using this mindset, the clinician will not overlook the possibility that the patient
may be suffering from a medication adverse event as opposed to worsening of the underlying
asthma. Patient education is critical for effective management of asthma and other respiratory
disorders. Experts have stated that management of respiratory disorders is 10% medication
and 90% education. Patients need to be assessed for their ability to comprehend self-
management plans and the complexities of using inhaler devices.
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