Yaşlı Hastalarda İlaç Seçimi
Özet
Yaşlılık dönemi, hücresel hasarların birikimiyle ortaya çıkan fizyolojik değişimleri ve beraberinde artan kronik hastalıkları getiren biyolojik bir süreçtir. Bu dönemde çoklu hastalıkların tedavisinde sıklıkla başvurulan polifarmasi, yani aynı anda birden fazla ilacın kullanılması, yaşlı hastalar için ciddi sağlık risklerini beraberinde getirmektedir. Yaşlanmaya bağlı olarak gelişen kas kütlesi azalması, yağ dokusundaki artış ve böbrek fonksiyonlarındaki gerileme gibi faktörler, ilaçların vücuttaki dağılım hacmini etkileyerek plazma konsantrasyonlarını yükseltmekte ve yarı ömürlerini uzatmaktadır. Bu farmakokinetik değişimlerin yanı sıra reçetesiz bitkisel takviyelerin kontrolsüz kullanımı, tehlikeli ilaç etkileşimlerine ve "reçeteleme kaskadı" adı verilen kısırdöngülere zemin hazırlamaktadır. Hekimlerin bu popülasyonda tedavi planlarken Beers Kriterleri gibi kalite ölçütlerini rehber edinmeleri, "önce zarar verme" ilkesiyle hareket ederek dozu düşük tutmaları ve rejimleri basitleştirmeleri hayati önem taşımaktadır.
Aging is a biological process characterized by cellular damage and an increased prevalence of chronic diseases, leading to a rise in drug consumption. Polypharmacy, the concurrent use of multiple medications, presents critical health risks for older adults due to age-related pharmacokinetic and pharmacodynamic alterations. Physiological shifts, such as decreased muscle mass, increased body fat, and declining renal function, prolong drug half-lives and elevate plasma concentrations. Furthermore, the unmonitored use of over-the-counter herbal supplements exacerbates the risk of drug-drug interactions and triggers adverse effects, often leading to a detrimental "prescribing cascade". To optimize geriatric care, clinicians must prioritize the principle of primum non nocere by leveraging structured quality indexes like the Beers Criteria. Consequently, implementing low-dose strategies, continuously re-evaluating regimens, and simplifying dosing schedules remain imperative to mitigate adverse drug events and enhance patient compliance during transitions of care.
Referanslar
Cho S, Lau SW, Tandon V, Kumi K, Pfuma E, Abernethy DR. Geriatric drug evaluation: where are we now and where should we be in the future? Arch Intern Med. 2011;171(10):937-40.
Rowe JW, Andres R, Tobin JD, Norris AH, Shock NW. The effect of age on creatinine clearance in men: a cross-sectional and longitudinal study. J Gerontol. 1976;31(2):155-63.
Reidenberg MM, Levy M, Warner H, Coutinho CB, Schwartz MA, Yu G, et al. Relationship between diazepam dose, plasma level, age, and central nervous system depression. Clin Pharmacol Ther. 1978;23(4):371-4.
Herings RM, Stricker BH, de Boer A, Bakker A, Sturmans F. Benzodiazepines and the risk of falling leading to femur fractures. Dosage more important than elimination half-life. Arch Intern Med. 1995;155(16):1801-7.
Scott JC, Stanski DR. Decreased fentanyl and alfentanil dose requirements with age. A simultaneous pharmacokinetic and pharmacodynamic evaluation. J Pharmacol Exp Ther. 1987;240(1):159-66.
Saraf AA, Petersen AW, Simmons SF, Schnelle JF, Bell SP, Kripalani S, et al. Medications associated with geriatric syndromes and their prevalence in older hospitalized adults discharged to skilled nursing facilities. J Hosp Med. 2016;11(10):694-700.
Qato DM, Wilder J, Schumm LP, Gillet V, Alexander GC. Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011. JAMA Intern Med. 2016;176(4):473-82.
Nahin RL, Pecha M, Welmerink DB, Sink K, DeKosky ST, Fitzpatrick AL. Concomitant use of prescription drugs and dietary supplements in ambulatory elderly people. J Am Geriatr Soc. 2009;57(7):1197-205.
Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med. 1993;328(4):246-52.
Parvez MK, Rishi V. Herb-Drug Interactions and Hepatotoxicity. Curr Drug Metab. 2019;20(4):275-82.
Wold RS, Lopez ST, Yau CL, Butler LM, Pareo-Tubbeh SL, Waters DL, et al. Increasing trends in elderly persons' use of nonvitamin, nonmineral dietary supplements and concurrent use of medications. J Am Diet Assoc. 2005;105(1):54-63.
Morris CA, Avorn J. Internet marketing of herbal products. Jama. 2003;290(11):1505-9.
Spinewine A, Schmader KE, Barber N, Hughes C, Lapane KL, Swine C, et al. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet. 2007;370(9582):173-84.
Wolfstadt JI, Gurwitz JH, Field TS, Lee M, Kalkar S, Wu W, et al. The effect of computerized physician order entry with clinical decision support on the rates of adverse drug events: a systematic review. J Gen Intern Med. 2008;23(4):451-8.
Field TS, Gurwitz JH, Avorn J, McCormick D, Jain S, Eckler M, et al. Risk factors for adverse drug events among nursing home residents. Arch Intern Med. 2001;161(13):1629-34.
Wimmer BC, Cross AJ, Jokanovic N, Wiese MD, George J, Johnell K, et al. Clinical Outcomes Associated with Medication Regimen Complexity in Older People: A Systematic Review. J Am Geriatr Soc. 2017;65(4):747-53.
Lu WH, Wen YW, Chen LK, Hsiao FY. Effect of polypharmacy, potentially inappropriate medications and anticholinergic burden on clinical outcomes: a retrospective cohort study. Cmaj. 2015;187(4):E130-e7.
Rawle MJ, Cooper R, Kuh D, Richards M. Associations Between Polypharmacy and Cognitive and Physical Capability: A British Birth Cohort Study. J Am Geriatr Soc. 2018;66(5):916-23.
Weng MC, Tsai CF, Sheu KL, Lee YT, Lee HC, Tzeng SL, et al. The impact of number of drugs prescribed on the risk of potentially inappropriate medication among outpatient older adults with chronic diseases. Qjm. 2013;106(11):1009-15.
Rochon PA, Gurwitz JH. Optimising drug treatment for elderly people: the prescribing cascade. Bmj. 1997;315(7115):1096-9.
Mitchell SL, Teno JM, Kiely DK, Shaffer ML, Jones RN, Prigerson HG, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529-38.
Higashi T, Shekelle PG, Solomon DH, Knight EL, Roth C, Chang JT, et al. The quality of pharmacologic care for vulnerable older patients. Ann Intern Med. 2004;140(9):714-20.
Steinman MA, Landefeld CS, Rosenthal GE, Berthenthal D, Sen S, Kaboli PJ. Polypharmacy and prescribing quality in older people. J Am Geriatr Soc. 2006;54(10):1516-23.
O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213-8.
Rochon PA, Anderson GM, Tu JV, Gurwitz JH, Clark JP, Shear NH, et al. Age- and gender-related use of low-dose drug therapy: the need to manufacture low-dose therapy and evaluate the minimum effective dose. J Am Geriatr Soc. 1999;47(8):954-9.
Mallet L, Spinewine A, Huang A. The challenge of managing drug interactions in elderly people. Lancet. 2007;370(9582):185-91.
Onder G, Pedone C, Landi F, Cesari M, Della Vedova C, Bernabei R, et al. Adverse drug reactions as cause of hospital admissions: results from the Italian Group of Pharmacoepidemiology in the Elderly (GIFA). J Am Geriatr Soc. 2002;50(12):1962-8.
Alhawassi TM, Krass I, Bajorek BV, Pont LG. A systematic review of the prevalence and risk factors for adverse drug reactions in the elderly in the acute care setting. Clin Interv Aging. 2014;9:2079-86.
Beijer HJ, de Blaey CJ. Hospitalisations caused by adverse drug reactions (ADR): a meta-analysis of observational studies. Pharm World Sci. 2002;24(2):46-54.
Budnitz DS, Pollock DA, Weidenbach KN, Mendelsohn AB, Schroeder TJ, Annest JL. National surveillance of emergency department visits for outpatient adverse drug events. Jama. 2006;296(15):1858-66.
Oscanoa TJ, Lizaraso F, Carvajal A. Hospital admissions due to adverse drug reactions in the elderly. A meta-analysis. Eur J Clin Pharmacol. 2017;73(6):759-70.
Rochon PA, Gurwitz JH. The prescribing cascade revisited. Lancet. 2017;389(10081):1778-80.
Avorn J, Bohn RL, Mogun H, Gurwitz JH, Monane M, Everitt D, et al. Neuroleptic drug exposure and treatment of parkinsonism in the elderly: a case-control study. Am J Med. 1995;99(1):48-54.
Stephen PJ, Williamson J. Drug-induced parkinsonism in the elderly. Lancet. 1984;2(8411):1082-3.
Avorn J, Gurwitz JH, Bohn RL, Mogun H, Monane M, Walker A. Increased incidence of levodopa therapy following metoclopramide use. Jama. 1995;274(22):1780-2.
Holbrook AM, Pereira JA, Labiris R, McDonald H, Douketis JD, Crowther M, et al. Systematic overview of warfarin and its drug and food interactions. Arch Intern Med. 2005;165(10):1095-106.
Juurlink DN, Mamdani M, Kopp A, Laupacis A, Redelmeier DA. Drug-drug interactions among elderly patients hospitalized for drug toxicity. Jama. 2003;289(13):1652-8.
Garg AX, Papaioannou A, Ferko N, Campbell G, Clarke JA, Ray JG. Estimating the prevalence of renal insufficiency in seniors requiring long-term care. Kidney Int. 2004;65(2):649-53.
Gurwitz JH, Field TS, Judge J, Rochon P, Harrold LR, Cadoret C, et al. The incidence of adverse drug events in two large academic long-term care facilities. Am J Med. 2005;118(3):251-8.
Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. Jama. 1998;280(15):1311-6.
Forster AJ, Clark HD, Menard A, Dupuis N, Chernish R, Chandok N, et al. Adverse events among medical patients after discharge from hospital. Cmaj. 2004;170(3):345-9.
Cramer JA. Enhancing patient compliance in the elderly. Role of packaging aids and monitoring. Drugs Aging. 1998;12(1):7-15.
Green JL, Hawley JN, Rask KJ. Is the number of prescribing physicians an independent risk factor for adverse drug events in an elderly outpatient population? Am J Geriatr Pharmacother. 2007;5(1):31-9.
Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. Jama. 2005;294(6):716-24.
Holmes HM, Hayley DC, Alexander GC, Sachs GA. Reconsidering medication appropriateness for patients late in life. Arch Intern Med. 2006;166(6):605-9.
Steinman MA, Hanlon JT. Managing medications in clinically complex elders: "There's got to be a happy medium". Jama. 2010;304(14):1592-601.
Griffin MR, Piper JM, Daugherty JR, Snowden M, Ray WA. Nonsteroidal anti-inflammatory drug use and increased risk for peptic ulcer disease in elderly persons. Ann Intern Med. 1991;114(4):257-63.
Gurwitz JH, Soumerai SB, Avorn J. Improving medication prescribing and utilization in the nursing home. J Am Geriatr Soc. 1990;38(5):542-52.
Mamdani M, Juurlink DN, Lee DS, Rochon PA, Kopp A, Naglie G, et al. Cyclo-oxygenase-2 inhibitors versus non-selective non-steroidal anti-inflammatory drugs and congestive heart failure outcomes in elderly patients: a population-based cohort study. Lancet. 2004;363(9423):1751-6.
Wolf MS, Curtis LM, Waite K, Bailey SC, Hedlund LA, Davis TC, et al. Helping patients simplify and safely use complex prescription regimens. Arch Intern Med. 2011;171(4):300-5.
Wolf MS, Shekelle P, Choudhry NK, Agnew-Blais J, Parker RM, Shrank WH. Variability in pharmacy interpretations of physician prescriptions. Med Care. 2009;47(3):370-3.
