Medications in Geriatric Otolaryngology

Add to Favorites
Collapse All

Medications in Geriatric Otolaryngology - #17

Take Quiz

Review use and side affects of common medications for otolaryngologic diseases.

Assessment

A thorough knowledge of common medications (and their alternative medication) used in the geriatric patients with otolaryngologic diseases can prevent adverse drug events in the elderly.  See Tables 1 and 2 below.

Link to PDF of Table 1

Link to PDF of Table 2

TABLE 1

Class

Adverse Affects

Notes and Alternatives

Analgesics:

Meperidine (Demerol)

Codeine

 

 

 

Meperidine: Confusion, convulsions, tremors, myoclonus

 

Codeine: Pro-drug with cytochrome P450 enzyme conversion to morphine that can vary between patients leading to variable levels of morphine and unpredictable half-life.

Acetaminophen (<4gm/day), tramadol, trisalicylate, morphine, hydrocodone, oxycodone, hydromorphone (Dilaudid)

 

 

 

Antihistamines:

  • Brompheniramine (Bromfed)
  • Cetirizine (Zyrtec)
  • Dimenhydrinate (Dramamine)
  • Diphenhydramine (Benadryl)
  • Hydroxyzine (Vistaril, Atarax)
  • Loratadine (Claritin)
  • Meclizine (Antivert)

Anti-cholinergic, highly sedating, delirium, cognitive decrease, especially in first generation antihistamines.

 

 

 

 

Consider use of loratadine or cetirizine. Although anti-cholinergic side effects can still be seen.

 

 

 

 

Antispasmodics

Scopolamine

Highly anticholinergic

Avoid

Benzodiazepines, anxiolytics:

Short Acting:

  • Alprazolam (Xanax)
  • Estazolam (ProSom and Eurodin)
  • Lorazepam(Ativan)
  • Oxazepam (Alepam and Medopam)
  • Temazepam(Restoril and Normison)
  • Triazolam

Long acting:

  • Clorazepate
  • Chlordiazepoxide
  • Chlordiazepoxide-amitriptyline
  • Clidinium-chlordiazepoxide
  • Clonazepam
  • Diazepam (Valium)
  • Flurazepam(Dalmane)

Increased risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults

 

 

 

 

 

 

 

 

 

 

 

Avoid for treatment of insomnia, agitation or delirium.

 

If necessary, consider lorazepam or oxazepam (lowest dose, shortest duration of therapy possible)

 

 

 

 

 

 

 

 

Histamine-2 receptor antagonists

  • Cimetidine (Tagamet)
  • Famotidine (Pepcid)
  • Ranitidine (Zantac)

May have anti-cholinergic effects such as antihistamines. Also, may alter cytochrome P450 pathway.

Proton pump inhibitors. Consider omeprazole (Prilosec) and lansoprazole (Prevacid)

Non-steroidal anti-inflammatory (NSAIDs):

  • Ibuprofen
  • Indomethacin
  • Ketorolac (Toradol)
  • Naproxen (Aleve)
  • Piroxicam (Feldene)

Increases risk of GI bleeding/peptic ulcer disease in geriatric patients. Concurrent oral or parenteral corticosteroids, anticoagulants, or antiplatelet agents also increase risk.

 

Acetaminophen (<4gm/day), tramadol, trisalicylate , morphine, hydrocodone , oxycodone, hydromorphone (Dilaudid)

 

 

Link to PDF of Table 2

TABLE 2

Class

Drugs to avoid

Alternatives and notes

Vertigo

Antihistamines

Dimenhydrinate (Dramamine)

Diphenhydramine (Benadryl)

Meclizine (Antivert)

Benzodiazepines

Alprazolam (Xanax)

Clonazepam

Diazepam (Valium)

Lorazepam(Ativan)

Antiemetics

Metoclopramide (Reglan)

Prochlorperazine (Compazine)

Promethazine (Phenergan)

Antispasmodics

Scopolamine

Favor physical therapy and vestibular therapy over medications for vertigo symptoms.

Antiemetics

Domperidone (Motilium)

Ondansetron (Zofran)

BPPV –canalith repositioning or liberatory maneuvers.

Méni`er’s- low-salt diet, diuretics
 

Context

Outpatient or inpatient

Action

Perform a review of medications to treat common otolaryngology complaints and avoid unwanted medical side effects.

Incidence / Prevalence

Unwanted medical side effects and medication related problems in the elderly are common, costly and often preventable. Recent studies of adverse drug events in elderly patients in the primary care setting and long-term care setting showed that 27% and 42% could have been prevented, respectively(1,2). The total estimated healthcare expenditures related to potentially inappropriate medications was reported at $7.2 billion(3).

Underlying Sciences

Common medications used in treating otolaryngologic diseases and symptoms may have unwanted side effects in the elderly population. With increasing age, pharmacokinetics changes can lead to unfavorable medical side effects. The effects of the age related pharmacokinetic changes are variable and difficult to predict. Most factors that affect pharmacokinetics change with age. These include: absorption, distribution, metabolism, elimination, and tissue sensitivity (4, 5).

 

Although drug absorption does change with age, the degree of change is often not clinically significant. Drug distribution is effected by decreased total body water and lean body mass, increased body fat, decreased serum albumin and altered protein binding. These changes result in higher concentration of drugs in body fluids and prolonged half-lives of fat-soluble drugs.

 

Metabolism of drugs changes with age. There is a reduced hepatic mass, hepatic blood flow, and decrease phase I metabolism. This can result in decreased first-pass metabolism and decreased rate of biotransformation of some drugs. Elimination of drugs is also altered by a reduced renal plasma flow, glomerular filtration rate, and tubular secretion function. Decreased renal elimination can have affects on levels of drugs and metabolites. Lastly, tissue sensitivity is altered by the number of receptors, changes in receptor affinity, alteration in second-messenger function and cellular and nuclear responses. The geriatric patient can therefore be more or less sensitive to a drug or its metabolites.

Science Principles

Impaired homeostasis
Post-mitotic tissue and age related degeneration

Objectives

  1. Identify specific medications or medication classes often used in otolaryngology that have unfavorable side effects in geriatric patients.
  2. Identify alternative medications and treatments for geriatric otolaryngology patients.

Keywords/Tags

References

  1. Gurwitz JH, Field TS, Harrold LR, Rothschild J, Debellis K, Seger AC, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 2003 Mar 5;289(9):1107-1116.
  2. 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 Mar;118(3):251-258.
  3. Fu AZ, Jiang JZ, Reeves JH, Fincham JE, Liu GG, Perri M,3rd. Potentially inappropriate medication use and healthcare expenditures in the US community-dwelling elderly. Med Care 2007 May;45(5):472-476.
  4. Duthie EH, Katz PR, Malone ML, ScienceDirect. Practice of geriatrics. 2007:681.
  5. Tallis R, Fillit H, Brocklehurst JC. Brocklehurst's textbook of geriatric medicine and gerontology. 6th ed. London: Churchill Livingstone; 2003.
  6. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med 2003 Dec 8-22;163(22):2716-2724.
  7. The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 2012 Apr;60(4):616-631.
This GFF ___ my competence in geriatrics.

Authors

Luke Jakubowski MD, Thomas Kidder MD, Steven Denson MD

Author Affiliation

Medical College of Wisconsin, Milwaukee, Wisconsin

Copyright

Collapse All
Report a problem about this Fast Fact