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Digital PharmD

Digital PharmD

Informatics in Pharmacy

Geriatrics

Dementia

August 13, 2018 By Dr. G, PharmD

Cognitive Screening

  • Mini – Mental Status Exam – MMSE
  • Montreal Cognitive Assessment – MOCA
  • St Louis University Mental Scale – SLUMS

Mood screening:  Geriatric Depression.Scale
IADL: Instrumental Activities Of Daily Living

Diagnosing Dementia:

  • Rule out delirium and drug-related causes.
  • Other causes: vitamin B12 deficiency, hypothyroidism, depression, NPH, opioids, sedative-hypnotics, antidepressants, anticholinergics, antiparkinson’s drugs

Treatment:

Initiate a cholinesterase inhibitor in patients with mild to moderate Alzheimer’s disease.

  • Donepezil 5-10 mg daily
  • Rivastigimine 1.5-6 mg BID or patch
  • Galantamine 4-12 mg BID (renal adjustment)
  • Memantine 5-10 mg BID (not a CI,  NMDA Antagonist, but can be used alone or added to a CI in moderate and severe disease)
  • Herbal medicines are not effective, but diet and exercise may help.
  • CIs cause nause, vomitting, headache, insomnia, dizziness, bradycardia, orthostatic hypertension, syncope, incontinence, anorexia, falls
  • Memantine causes agitation, urinary incontinence, insomnia, diarrhea,
    dizziness, confusion, headache.
  • Can add SSRI/ SNRI or atypical antipsychotic for symptoms.

Osteoporosis

August 13, 2018 By Dr. G, PharmD

All women over 65 and men over 70 should have bone mineral density (BMD) testing.  If fractures or risks, test sooner.

Initiate therapy if:

  • Hip or spine fracture and BMD T-score -2.5 or below at hip, spine or femoral neck
  • T-score is between -1.0 and -2.5 at femoral neck or spine and the 10-year probability of hip fracture (FRAX score) is 3% or greater
  • The 10-year probability of major fracture (FRAX score) is 20% or greater according to

Treatment:

  • Bisphosphonates: Standard.
    • Alendronate and risedronate are first line
    • Zoledronic acid, ibandronate and pamidronate are available in IV forms.
  • Calcium is recommended for all patients with osteoporosis. Give 1000-1200 mg/day
  • Vitamin D is recommended for all patients. Give 800-1000 IU daily
  • Raloxifene (SERM) reduces bone resorption
  • Conjugated estrogen and bazedoxifene is like a SERM.
  • Calcitonin is not first-line, but can be useful in bone pain.  Nasal route.
  • Teriparatide is reserved for high-risk patients.  Increases calcium concentration, but also increases digoxin toxicity
  • Denosumab inhibits bone resorption, alternate to first-line, can lead to cellulitis (subQ) and hypocalcemia

Urinary Incontinence

August 12, 2018 By Dr. G, PharmD

Causes (DRIP):

  • Drugs, delirium
  • Retention, Restricted mobility
  • Impaction, infection, inflammation
  • Polyuria, prostatitis

Treatment:

  • Urge:
    • Anti-muscarinic and anticholinergic: oxybutynin, tolterodine, fesoterodine, trospium, solifenacin, darifenacin
    • B-agonist: mirabegron
  • Stress:
    • alpha-adrenergic agonists: pseudoephedrine, phenylephrine
    • topical estrogens if other signs of estrogen deficiency
    • SSRI/SNRI: only duloxetine
  • Overflow:
    • alpha-adrenergic agonists: alfuzosin, tamsulosin
    • 5-alpha-reductase inhibitors: finasteride, dutasteride
    • Parasympathomimetic: bethanechol
    • Phosphodiesterase inhibitor: tadalafil
  • BPH:
    • Meds that exacerbate: alpha-adrenergic agonists like decongestants, anticholinergic drugs (antispasmodics, antihistamines, tricyclics, phenothiazines), diuretics and testosterone.
    • Treatment:
      • alpha-blockers: doxazosin and terazosin are non-specific and also lower blood pressure.  Newer agents (tamsulosin, silodosin, alfuzosin)
        are more specific.
      • alpha- reductase inhibitors:  dutasteride and finasteride are reserved for men with large prostate volume (>40 grams).  Takes 6 months for full effect.
      • Phosphodiesterase inhibitors: tadalafil 5 mg

Glaucoma

August 12, 2018 By Dr. G, PharmD

Angle-closure is a medical emergency: 1 drop of timolol, apraclonidine, pilocarpine stat until ophthalmologist.

Open-angle: brinzolamide, dorzolamide (carbonic anhydrase inihibitors) or latanoprost: prostaglandin

Arthritis

August 12, 2018 By Dr. G, PharmD

Osteoarthritis:
Risk factors: age, female sex, obesity, genetics, sports, occupation, injury, acromegaly and other illnesses.
Treatment:

  • Lifestyle: weight loss, exercise, PT and surgery
  • Drugs:
    • APAP up to 3g daily
    • NSAIDS if APAP not working.  Take ASA at least 30 minutes before NSAID if on ASA.
    • Topical agents, especially for the knee (capsaicin, diclofenac 1% gel)
    • Intraarticular glucocorticoid injections with methylprednisolone or triamcinolone, 10 – 40 mg, may repeat every 3 months. *only for knee
    • Intraarticular hyaluronan *only for the knee and only 3-4 lifetime injections.
    • Glucosamine
    • Opioids like Vicodin are better than chronic NSAIDS.

Rheumatoid Arthritis
Patients present with joint stiffness, fatigue, warmth, redness and/or swelling of joints. Lab tests will reveal a positive rheumatoid factor., elevated sedimentation rate a, C-reactive protein and normochromic, normocytic anemia.

Treatment:

  • Lifestyle changes: rest during disease exacerbations, PT, maintain a normal
    weight, surgery
  • Start DMARD within 3 months of diagnosis.
    • Methotrexate is preferred. Start with an anti-inflammatory drug and reduce the anti-inflammatory slowly.
    • Methotrexate is followed by hydroxychloroquine (slow onset) and sulfasalazine (DOC in pregnancy).  Can also use leflunomide.
    • Biologic DMARDs used in combo with methotrexate in severe disease
      • TNF inhibitors: etanercept, infliximab, adalimumab, certolizumab,
        golimumab
      • Non – TWF: abatacept, anakinra, rituximab, tocilizumab
      • Biological kinase inhibitor: Tofacitinib
    • Methotrexate: Takes 3 – 6 weeks to see onset. Anything that changes
      kidneys function interacts.

ACR RA Classification Guidelines

  • RA Classified with synovitis in 1 joint or more in absence of a better diagnosis that explains the symptoms and a score of 6 or more in the following domains:
    • Large joint involvement: 1 = 0 pts, 2-10 = 1 pt
    • Small joint involvement: 1-3 = 2 pts, 4-10 = 3 pts
    • Any joints:  >10 = 5 pts
    • Low positive RF or ACPA = 2 pts
    • High positive RF or ACPA = 3 pts
    • Abnormal CRP or ESR = 1 pt
    • Symptoms greater than 6 weeks = 1 pt

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acid base acidosis acute coronary syndrome alkalosis analgesics anaphylaxis aortic dissection arrhythmia bcps Beta-Blockers biostatistics blood pressure cardiac markers CHA2DS2-VasC cocaine COVID-19 diabetes diabetes inspidius heart failure Heparin hypersensitivity hypertension hypovolemic shock intubation ionotropes journal club lipids LMWH medication safety morphine conversions myocardial infarction needs work NOAC NSTEMI obstructive shock pharmacoeconomics pheochromocytoma pressors reference materials right mi sedation septic shock shock STEMI Updated 2020