Farmakoterapi pada Lansia

dr. Ave Olivia Rahman, MSc.

Sub Pokok Bahasan

1.
2.
3.
4.

Hipertensi
Asma
Nyeri
Inkontinensia Urin

Lansia
Terjadi perubahan fisiologis tubuh, antara lain :
Penurunan
Penurunan
Penurunan
Penurunan

rasio massa tubuh

fungsi ginjal dan hepar
kadar albumin serum
fungsi saluran gastrointestinal

Keadaan ko morbid (penyakit penyerta)

Mempengaruhi farmakokinetik (absorpsi, distribusi,
metabolisme dan ekskresi obat) dan farmakodinamik
(efek obat terhadap tubuh, 2-3 x lebih berisiko
mengalami efek samping obat)
Pemilihan selektif jenis obat, penyesuaian dosis obat

Golongan Obat Antihipertensi

O
ACE
Diuretics
Angiotensin
Ca

thers
Channnel
Inhibitors
IIBlockers
Receptor Blockers

Farmakoterapi Hipertensi pada

Lansia
Pemilihan golongan obat didasari
adanya penyakit penyerta, riwayat
penggunaan obat sebelumnya.
First line/initial therapy : diuretika, Ca
Channel Blocker, ACEI, Angiotensin II
receptor Blocker

Diuretika
ALLHAT trial a diuretic
(chlorthalidone), given once-daily,
was comparable in efficacy to a
calcium channel blocker or ACE inhibitor
for the treatment of hypertension, and
slightly superior in preventing adverse
cardiovascular outcomes.
Diuretic is a good first step in treating
hypertension in the elderly (a thiazide or
thiazide-like diuretic).
Inappropriately high doses may provoke
hypotension, electrolyte disturbances or

Lanjutan...
Although "low-dose" thiazide-type diuretics
are generally recommended for BP treatment,
outcome benefits of diuretics as firstline agents have been demonstrated
only at moderate doses (equivalent to
25 mg hydrochlorothiazide).[36]
Further, most outcome trials in the United
States, including ALLHAT, have used
chlorthalidone, a thiazide-like diuretic that is
twice as potent as and has a longer duration
of action than hydrochlorothiazide.[37,38]
In ALLHAT, the average dose of chlorthalidone
was 20 mg, roughly equivalent to 40 mg of
hydrochlorothiazide.[7]

Diuretics
I. Thiazide& Thiazide-like diuretics :
Thiazide diuretics include:
bendroflumethiazide, chlorothiazide,
hydrochlorothiazide (HCT),
hydroflumethiazide, methyclothiazide,
polythiazide.
Thiazide-like diuretics include:
chlorthalidone, indapamide, metolazon

II. Loop diuretics : bumetanide,

ethacrynic acid, and furosemide

Continue...
III. Potassium Sparing Diuretic
Diuretics that do not promote
secretion of potassium in the urine.
As adjunctive drugs, combination
with other drugs
Actions :

Aldosterone antagonis : spironolactone,

eplerenone
Block sodium channel : amiloride,
triamteren

Ca Channel Blocker
Dihydropyridine type of calcium channel
blocker may be better suited than a
nondihydropyridine type if the hypertension is
severe or if there is coincident treatment with a
negative inotrope (eg, a beta-blocker),
Nondihydropyridine may be preferred if there is
a personal or family history of ischemic stroke.
CCB have performed particularly well in
preventing stroke in elderly hypertensives.
Advantages : CCBs are metabolically neutral
and, except for peripheral edema, are relatively
free of adverse effects.

3 classes of CCB
Diphenylalkylamine : verapamil.
Benzothaizepines : diltiazem.
Dihydropyridines :
1 st generation : nifedipine
2nd generation : amlodipine,
felodipine, isradipine, nicardipine,
nisoldipine.

ACEI & ARB

An ACE inhibitor or an angiotensin II receptor
blocker may be given as a first step when there
are signs of heart failure or left ventricular
hypertrophy.
ACE Inhibitors and ARBs have outcome
advantages for patients with concomitant
cardiovascular diseases, diabetes with
albuminuria, or chronic kidney disease.
When administered alone or in combination with
other antihypertensive drugs, ACE inhibitors and
ARBs reduce the incidence of new-onset
diabetes by about 25% compared with other
active treatments, a clear advantage in the
elderly.
These agents have less robust BP-lowering

ACE INHIBITORS

Benazepril
Captopril
Enalapril
Enalaprilat (the only ACE inhibitor thats
administered I.V.)
Fosinopril
Lisinopril
Moexipril
Quinapril
Ramipril
Trandolapril

ANGIOTENSIN II RECERPTOR
BLOCKERS

Candesartan cilexetil
Eprosartan
Irbesartan
Losartan
Olmesartan
Telmisartan
Valsartan

JNC 7

Avoid !!!!
Beta blockers be no longer used in the
primary treatment of hypertension in the
elderly
Centrally-acting sympathetic agonists
(such as clonidine or guanfacine) have
little role in the elderly, because of
sedation and other side-effects.
Use of peripheral alpha-adrenoceptor
blockers is subject to a risk of postural
hypotension.

Asthma Therapy
Mild and intermittent symptoms
an inhaled beta 2-adrenergic agent
may be all that is required.
Persistent symptoms daily inhaled
corticosteroids and be increased in a
stepwise fashion according to the
patient's needs, short-acting beta 2agonists acute symptomatic relief

Farmakoterapi Nyeri
The prevalence of persistent pain
increases with age; increases in joint
pain and neuralgias are particularly
common.
It is relatively simple to implement
and consists of NSAIDs, muscle
relaxants, opioids, and other
adjuvant therapy.

WHO Recommendations: Analgesic

Ladder
1. Administration of drugs by the
clock (eg, every 36 hours),
2. Medication by mouth individualized
for the patient,
3. The analgesic ladder

The analgesic ladder

1. For mild pain, the most appropriate first choice for
relatively safe analgesia is acetaminophen.
2. For mild to moderate pain or pain uncontrolled with
acetaminophen, the use of NSAIDs is appropriate.
3. For pain refractory to NSAIDs, or pain rated as moderate
initially, a weaker opioid (eg, codeine) is the appropriate
first choice. Other weak opioids that may be used
include hydrocodone, propoxyphene, and oxycodone in
combination with acetaminophen.
4. For pain refractory to the previous plan, or pain rated as
severe, a purse opioid agonist (eg,morphine) is selected.
Other pure opioids to consider include hydromorphone,
fentanyl, levorphanol, and oxycodone.
5. Adjuvant medication may be used to relieve fear and
anxiety in the patient as well as for synergism with the

Acetaminophen
Nonopioids
As initial and ongoing pharmacotherapy in the
treatment of persistent pain, particularly
musculoskeletal pain, owing to its demonstrated
effectiveness and good safety profile.
Absolute contraindications: liver failure
Relative contraindications and cautions: hepatic
insufficiency, chronic alcohol abuseor
dependence.
Maximum daily recommended dosages of 4 g
per 24 hours.

NSAIDs
Nonselective NSAIDs and cyclooxygenase 2 (COX2) selective inhibitors may be considered rarely,
and with extreme caution, in highly selected
individuals.
Absolute contraindications: current active peptic
ulcer disease, chronic kidney disease, heart failure.
Relative contraindications and cautions:
hypertension, Helicobacter pylori, history of peptic
ulcer disease, concomitant use of corticosteroids
or selective serotonin reuptake inhibitors.

Lanjutan...
Older persons taking nonselective NSAIDs should
use a proton pump inhibitor or misoprostol for
gastrointestinal protection
Patients taking a COX-2 selective inhibitor with
aspirin should use a proton pump inhibitor or
misoprostol for gastrointestinal protection
Patients should not take more than one
nonselective NSAID or COX-2 selective inhibitor
for pain control
Patients taking aspirin for cardioprophylaxis
should not use ibuprofen .
Patients taking nonselective NSAIDs and COX-2
selective inhibitors should be routinely assessed
for gastrointestinal and renal toxicity,

Opioids
Patients with moderate to severe pain,
painrelated functional impairment, or
diminished quality of life because of
pain.
Patients taking opioid analgesics should
be reassessed for ongoing attainment of
therapeutic goals, adverse effects, and
safe and responsible medication use.
Newer opiates :oxymorphone.

Medications that cause

UI

Loop Diuretics
Antipsychotics
Tricyclic antidepressants
Alpha adrenergic blockers
Calcium channel blockers
ACE inhibitors
Gabapentin

Treatment of UI in
elderly

Behavioral Treatment
Medications
Anti-incontinence rings
Minimally Invasive Surgery

Anti-cholinergic
Medications
Use if behavioral treatment fails,
monitor carefully
Annoying Side-effects : Dry mouth,
constipation
Elderly vulnerability to toxicity:
Cognitive S.E.
Low efficacy in clinical practice
Adherence is shockingly low: 10% at 1
yr

 Antimuscarinic agents for urge UI, overactive

bladder, and mixed UI.
oxybutynin (immediate and extended release,
and topical patch), tolterodine (immediate and
extended release), solifenacin, darifenacin, and
trospium.
These five antimuscarinics have similar
efficacy, resulting in continence rates of
approximately 30% and reduce UI by an
average of half an episode or more per day
over placebo

Post test
1. Line pertama obat antihipertensi pada
lansia yang juga efektif mencegah onset
diabetes adalah...
2. Terapi asma persisten pada lansia adalah ...
3. Terapi lini pertama untuk nyeri derajat
ringan adalah...
4. Contoh NSAIDs non selektif ......
5. Terapi medikamentosa pada UI diberikan
obat golongan.....efek sampingnya.....
6. Efek samping NSAIDS ....