Warfarin, Insulin and Digoxin are

the most Dangerous drugs in the

elderly.
Do we believe that?

No Drugs are
Dangerous if
used properly

All Drugs are

Dangerous

Some drugs
have a low
therapeutic ratio

Some drugs have a

low incidence of
horrendous effects

Some drugs are

dangerous in
acute poisoning
but not when
used
therapeutically

The most
dangerous drugs
have the greatest
potential for
benefit

Some adverse
effects occur
after a delay or
after stopping

BAD

GOOD

How dangerous a drug

is depends on the skill of
the prescriber

Some adverse
effects can be
predicted if you
know the
pharmacology
(Type A); some
are not (Type B)

The Risk to Benefit Ratio

When prescribing drugs a doctor must assess
risk to benefit ratio in the individual patient by
Choosing an appropriate class of drug then an
appropriate individual agent
RISK

BENEFIT

Is it effective ?
What are the chances of adverse effect ?
Are there features in this patient which
affect choice eg other drugs, organ failure,
aged
Tailoring the dose
Considering duration of treatment

The Risks when prescribing

drugs with a low therapeutic
ratio are greatly increased if
1. Pharmacokinetic process is
complicated eg high hepatic
extraction, or zero order
elimination
2. Wide interindividual
variation in kinetics and / or
response
3. Pharmacokinetics sensitive
to drug interaction, disease
or ageing

Adverse drug reactions

AnADRisanyunwantedeffect
resultingfromadrugsusein
treatment.


Epidemiology
4%ofhospitaladmissions
1in1000deathsinmedicalwards
10to20%ofin-patients
5%ofpatientsingeneralpractice

Morefrequentinelderly:
erraticdrugtaking
multiplepathology
alteredpharmacokinetics
increasedsensitivityofCNS
andCVS

Drugs-anti-coagulants,
NSAIDs,corticosteroids,antihypertensives,anti-biotics,
diureticsandinsulin.

Occurincircumstancesrelatedto
drugspharmacology,
predisposingfactorsinthe
patientandcaretakenin
choosingthedrugandthedose.

TheBNFappendices

DrugInteractions
Liverdisease
Renalimpairment
Pregnancy
Breastfeeding

BNFchaptersofrelevance

Adversereactionstodrugs
Prescribingintheelderly
Prescribingforchildren
Emergencytreatmentofpoisoning

DetectingAdverseEffects
Ifanewdrugcausesabizarreeffectin1in6000
patientsitwouldneed18000patientstousethe
drugforittooccurin3patients
Itwouldtaketwiceasmanybeforetherewasany
suspicionthattheeffectwasduetothedrug
Iftheeffectalsooccursnaturallythenitwould
takemanytimesmorepatients
Mostearlytrialsinvolveabout2000patients

DetectingAdverseEffects
MRHA(MedicineandHealthcareproducts
RegulatoryAgency)freephoneservicefor
reportingandinformationaboutsuspected
ADRs
Selfreportingbypatientsandrelativesusing
Yellowcardsavailableatpharmacies
Prescriptioneventmonitoring
Newdrugsblacktrianglesandyellow
cards
Establisheddrugs

Measuringdanger
MHRAactivity
throughYellowcard
reportingand
prescription
monitoring
Hugeincrease
inreportsover
recentyears

WhoreportstotheMHRA?
Under-reporting estimated at 94% in hospital practice
(Smith et al 1996)
MRHA activity good at detecting adverse effects
Not very good at assessing the risk ratio

PreventionofAdverseDrug
reactions
Neveruseanydrugunlessthereisgood
indication.Ifthepatientispregnantdonot
usethedrugunlesstheneedisimperative.
Allergyandidiosyncrasyareimportant
causesofADRs.Askifthepatienthad
previousreactions.
Askifthepatientisalreadytakingother
drugsincludingselfmedication

PreventingADRscontd
Age,hepaticandrenaldiseasemayimpairclearance
ofdrugssosmallerdosesmaybeneeded.Genetic
factorsmayalsopredisposetocertainADRs
Prescribeasfewdrugsaspossibleandgiveclear
instructions
Wherepossibleusefamiliardrugs.Withnewdrugs
beparticularlyalertforADRsandunexpectedevent.
IfseriousADRsareliabletooccurwarnthepatient

Somewebsites

www.yellowcard.gov.uk
http://medicines.mhra.gov.uk
www.dsru.org
http://eis.bris.ac.uk/~pmcjcr/Drug%20Safety
.pdf