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Prescribing in Disease

Prescribing in Disease. Clive Roberts. Pain Inflammation Infection Fluid retention Heart problems High blood pressure Epilepsy Parkinsonism Asthma / COPD Peptic ulcer disease. Diarrhoea/constipation Depression Anxiety/sleeplessness Psychosis Metabolic /endocrine diseases

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Prescribing in Disease

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  1. Prescribing in Disease Clive Roberts

  2. Pain Inflammation Infection Fluid retention Heart problems High blood pressure Epilepsy Parkinsonism Asthma / COPD Peptic ulcer disease Diarrhoea/constipation Depression Anxiety/sleeplessness Psychosis Metabolic /endocrine diseases Malignant disease Degenerative disease Haematological problems Etc Etc So what are drugs good at treating (or preventing)?

  3. What could happen to this man? • Massive fluid overload • Hepatic encephalopathy • Gross electrolyte abnormality • Renal Failure • GI or other Haemorrhage • Metabolic abnormaility • Exacerbation of liver disease • Infection • Drug accumulation

  4. And so the risks of drug use in decompensated liver disease • Precipitate encephalopathy • CNS effect • Electrolyte effect • GI effect • Worsen metabolic effect/features of hepatic failure • Fluid retention • Sodium retention • Electrolyte abnormality • Hypoglycaemia • Clotting abnormalities

  5. Continued: • Profound pharmacokinetic disturbance leading to drug accumulation and dose related adverse effects • Decreased systemic clearance of lipid soluble drugs • Increased bioavailability of drugs with high extraction ratio • Decreased plasma protein binding • Altered apparent volume of distribution • Associated impairment of renal function • Failure of pro-drugs • Hepatic blood flow reduction • Worsened hepatic state • Hepatotoxic drugs

  6. Some examples from the BNF table • Anticoagulants • Antidepressants, anxiolytics and hypnotics • Anti-psychotics • NSAIDs • Diuretics • Phenytoin, Carbamazepine • Glibenclamide • Opioids • Rifampicin

  7. Co-amoxyclav, clarythromycin, erythromycin, ketoconazole, isoniazid • Chloramphenicol • Clopidogrel • Cyclophosphamide, methotrexate • Lignocaine • ACE inhibitors • Metformin • Verapamil and some dihydropyridine Ca blockers

  8. Statins • Antacids • Theophylline

  9. Other risk situations • Renal disease • The Elderly • Need for many drugs • Allergy • Lung disease • Heart disease • Gastrointestinal disease • Inherited diseases • Blood diseases • Bone disease • Skin disease • Pregnancy

  10. The renal patient • Pharmacokinetic disturbance • Mainly affecting drug clearance • Also protein binding • Increased sensitivity • Poor tolerance of adverse effects • Decreased effectiveness of some drugs

  11. Drugs in the elderly • Multiple indications leads to polypharmacy • Pharmacokinetic disturbance of metabolism, excretion, protein binding and drug distribution • Increased sensitivity to the actions of drugs on CVS, CNS, GIT • Poor tolerance of adverse effect

  12. Other risk situations • Renal disease • The Elderly • Need for many drugs • Allergy • Lung disease • Heart disease • Gastrointestinal disease • Inherited diseases • Blood diseases • Bone disease • Skin disease • Pregnancy

  13. Remember • Every disease represents a potential contra-indication to particular drugs • Prescribing any drug should only follow a decision that potential benefit outweighs potential risk

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