Post on 02-Mar-2018
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DRUG NUTRIENTINTERACTIONS
IN OLDER ADULTS
Prof. dr. M. Aris Widodo, MS, Sp.FK, Ph.D
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opu as manu aheterogen, tidak
homogen
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Manula rentan
terhadap interaksi
obat-makanan (DNI)
karena praktekpolifarmasi, jumlah
macam obat >> dan
dosis besar
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Mekanisme DNI padaManulaMakanan berperan dalam:
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Tuuan pengo!atan pada manula
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"pidemiolog# of Drug$Drug orDrug$Disease Intera%tions
Incidence of potential drug-drug interactions ranges from -!"# of all $%&s and up to '-# of elderl patients*
Incidence of potentiall clinicall significant drug interactions
is lo+ in the elderl (usuall must inole narro+ therapeuticrange drug and inhibitorinducer of drug metabolism or renale%cretion)
.here is eidence suggesting that aderse health outcomesassociated +ith drug-drug interactions is infre/uent*
Drug-disease interactions occur in '*-0# of elderl patients
Drug disease interactions ma result in higher risk of aderseoutcomes (e*g*, decline in functional status and increasedhealth serices use) due to alterations in homeostaticmechanisms and diminished functional resere*
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Manula banak mendapatkan obat (usa)
1agaimana di Indonesia 2
.idak semua manula mampu membeli obat
1eralih ke alternatif herbal
3bat ang banak digunakan oleh manula
314. 54$DI3647589$ ;;*;#
314. 5N7 "*< #
M87=8937=9.49 *"#$7?I$7I @*' #
ND3=$IN *#
AI-.$45. *
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Obat yang sering menyebabkan efek samping di RS:
53$.I537.$3ID, DIA3IN, N74IDs , 4N.I CI?$.N7I
1NE3DI4E?IN*
Efek samping meningkat pada manula oleh karena:
Fumlah macam obat ang diberikan (polifarmasi)1anakna penakit ang diderita saat masuk rs
?erubahan farmakodinami dan farmakokinetik
?erubahan fisiologis komposisi lemak dan otot?erubahan penerapan obat, metabolisme dan ekskrsi
3bat serta perubahan farmakodinami menebabkan
Interaksi obat dan makanan meningkat pada manula
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Drug Intera%tions Are A&oida!le
Aosne et al* 9ancet !
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Tipe interaksi o!at
Drug-Drug ?harmacokinetic
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PERUBAHAN !S!O"O#!S $ANU"A
%& Penurunan fungsi organ
'& Penurunan mekanisme homeostatis
(& Penurunan kapasitas )adangan
tidak mampu menghadapi stres fisik *
psikis
+O$POS!S! ,UBUH%& ,otal air tubuh turun'& "ean body mass turun(& "emak tubuh meningkat-& Albumin turun.& #likoprotein meningkat
+U"!,%& /ollagen elastin turun'& $elanosit turun;) olikel rambut turun
SENSOR!S%& Hearing loss'& 0egenrasi ma)ula(&Penglihatan turun
1AN,UN# PE$BU"UH 0ARAH%& $asa 2antung berkurag'& Hipertropi(& Sensiti3itas re)4 Beta kurang-& /op turun
.& Resistensi periper meningkat
#!5,RA/,%& ,ekanan spin)ter turun'& ph lambung meningkat(& Pengosongan lambung lama-& Aliran darah usus turun.& $ukosa uus kurang
HEPAR%& $asa li3er menurun'& Aliran darah hepar menurun
(& $etabolisme obat menurun
#!N1A"%& $assa gin2al turun'& Aliran darah urun(& ungsi tubulus gn2al turun-& iltrasi glomerulus naik.& raksi filtrsi meningkat
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PERUBAHAN PA0A #!5,RA/,
ORA" U"/ERA,!ON6 POOR ORA" H7#!ENE6 POOR NU,R!,!ON
BEBRAPA OBA, SEPER,!PEN!,O!N6 /O,!O S,ERO!0 !$$UNO SUPRESAN,
AN,!B!O,!+4 $EN7EBAB+AN HA" 0!A,AS
$U"U, +ER!N# 8EROS,O$!ASER!N# PA0A $ANU"A 0AN 0APA, 0!PERBERA, O"EH OBA, AN,! +O"!N
NER#!+4 9AN,! H!S,A$!N6 0E/ON#ES,AN6 !PRA,ROP!$6 AN,!PS7/HO,!+
AN,! 0PRESAN,6 AN,!SPAS$O0!+
A/H"ORH70R!A6 PEN#OSO#AN "A$BUN# ,ERHA$BA,6 "UAS $U+OSA "A$BUN#
UN#S! HEPAR $ENRUN -;< PA0A $ANU"A =; ,AHUN O"EH +ARENA$ASA BERA, ,URUN6 A"!RA 0ARAH +EHEPAR $ENURUN $EN7EBAB+AN
PENURUNAN $E,ABO"!S$E4 $EN!N#+A,+AN +A0AR OBA, P"AS$A
E+S+RES! #!N1A" PENURUNAN UN#S! #!N1A" BER0A$PA+ 1E"AS PA0A
PEN#OBA,AN$ASA #!N1A" $ENURUN6 A"!RAN 0ARAH #!N1A" $ENURUN6
PENURUNAN #"O$ERU"! 7AN# UN#S!ONA"
,UBU"AR UN/,!ON BER+URAN#
+REA,!N! N /"EARAN/E $ENURUN SE,E"AH US!A -; ,AHUN PEN!N#+A,AN
SERU$ +REA,!N!N 0!AR,!+AN +A0AR OBA, 1U#A $EN!N#+A, +ARENA
PENURUNAN E+S+RES! OBA, O"EH #!N1A"4
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PROSES PENUAAN $EN7EBAB+AN
PERUBAHAN AR$A+O+!NE,!+ PA0A
ABSORBS! OBA,0!S,R!BUS! OBA,
$E,ABO"!S$E OBA,
E+S+RES! OBA,
0OS!S6 !N,ER>A" 0!SESUA!+AN
EE+ PENUAAN PA0A $E,ABO"!S$E$EN#URAN#! EE+ SA$P!N#
ABSORBS! OBA,
+E/EPA,AN 0AN 1U$"AH
ABSORBS! PER ORA" ABSORBS! SUB/U,AN, ,!0A+
BERUBAH
ABSORBS! OBA, 9!RS, PASSE0
$E,ABO"!S$E& ??
ABSORBS! 0EN#AN A/,!>E
,RANSPOR, /a 0AN >!, 0
0!S,R!BUS! OBA,
A"BU$!N ,URUNOBA, 7AN#
$EN#!+A, ABU$!N @;< A+AN
$EN!N#+A,+AN OBA, BEBAS4
PEN!N#+A,AN A"PHA % A/!0 #"!/O
PRO,E!N $ENURUN+AN +ONS4
OBA, 7AN# S!A,N7A BASA
PENURUNAN 0!S,R!BUS! A,ERSO"UB"E 0RU#S/ON/4 OBA,
$EN!N#+A,4
PEN!#+A,AN 0!S,R!BUS! "!P!0
SO"UB"E 0RU#S$ENURUN+AN
/ON/EN,RAS! OBA,
PERUBAHAN >O"U$E 0!S,R!BUS!
$EN7EBAB+AN PERUBAHAN
"OA0!N# 0OSE
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$E,ABO"!S$E
OBA, 0EN#AN RAS!OE+S,RA+S! 7AN# ,!N##! 0!PEN#ARUH! +ON0!S!
$ANU"A 9 A"!RAN 0ARAH BER+URAN#& SEH!N##A +A0AR OBA, 0A"A$P"AS$A $EN!N#+A, 9B!OA>A!"AB!",7 $EN!N#+A, $!SA"N7A OBA,
PROPANO"O"6 >ERAPRA$!"&
$E,ABO"!S$E OBA, +E"O$PO+ BENO0!AEP!N6 90!AEPA$6
/H"OR0!AEPO8!0E 0!PERPAN1AN# ,ER1A0! A+U$U"AS! EE+
$ANU"A SENS!,! ,ERHAAP PEN#OBA,AN BENO0!AE!N $EN!N#+A,+ANEE+ SE0A,! 0AN AN8!O"!,!/4 6
E+S+RES! OBA,
/"EARN/E /REA,!N!N $ENURUN SERU /RE,!N!N C NOR$A"D O"EH +ARENAPRO0U+S! /REA,!N!N PA0A $ANU"A 1U#A $ENURUN4
0OS!S OBA, HARUS 0!SESUA!+AN PA0A $ANU"A O"EH +ARENA 0APA,
$EN7EBAB+AN EE+ ,O+S!+ 0AN EE+ SA$P!N# 0AN 1U#A EN!N#+A,+AN
+E$UN#+!NAN !N,ERA+S! OBA,4
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Peru!ahan Farmakodinami pada'ansia
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Peru!ahan Farmakodinami pada'ansia
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Peru!ahan Status (i)i pada'ansia
?ada
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Peru!ahan Status (i)i pada'ansia
MDI54.I3N
735I49 ?$319M7 .NI53$49 ?$319M74.INA ?$319M77H493HINA DB7?C4AI4N3 M3NB 33DN.$I5 M494173$1.I3N
49=3C39I7 4N3$I493H 749. 93H 4.CB?$.CB$3IDH4ND$INA DMN.I494. 9I ?4$4N3I4M3.I3N49 D?$7I3N
7 74DN77
4 4918MIN MN8$8N(IN41I9I.B ?$36IDINA M497)7 7C3?CINA ?$319M5 5C397.$39 MN8$8N 4.INA ?$319M79 9377 3 HIAC.
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Mekanisme DNI pada manula
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Mekanisme DNI padamanula
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Mekanisme DNI padamanula
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Drug$Food*Nutrient Intera%tions
Drug ffect
?hentoin J olate
IsoniaKid J 6it 1'
?hentoin J 4bsorption +ith NA feedings
9eodopa Cigh protein meals effect blood-brain transport
5aptopril 4ltered taste sensation
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+lini%all# Signi%antDrug -St. ohn Wort Intera%tions
3bject Drug 3utcome
4ntidepressants serotonergic sndrome
5closporine leels, transplant rejection
Digo%in digo%in leelsstrogen breakthrough bleeding
Indinair indinair leels
Methadone +ithdra+al s%Ls
.acrolimus leels
.heophlline .heophlline leels
Harfarin IN$
5?. 00G"@:!-!
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/ther +lini%all# Signi%ant 0er!$Drug Intera%tions
Ob2e)t 0rug !ntera)ting 0rug Out)ome4nticonulsants Horm+ood seiKure threshold4nticonulsants Aingko biloba seiKure thresholdDigo%in Ca+thorne digo%in actiit7a/uinair Aarlic sa/uinair leelsHarfarin eerfe+ risk of bleedingHarfarin Aarlic risk of bleedingHarfarin Ainger risk of bleeding
Harfarin Ainkgo risk of bleedingHarfarin Ainseng anticoagulant
9ancet 000G;@@:!;-
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Drug$Drug Intera%tions A1e%tingA!sorption and Distri!ution
?recipitant Drug(s) 3bject Drug(s) 3utcome
4ntacids, Iron .etraccline, 5iproflo%acin abs*
5hloral hdrate Harfarin ?l con
Aenerall absorption and distribution drug-drug-interactions are not clinicall important*
Drugs 4ging !
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0epati% Meta!olism
?hase I (5B? @0) 3%idation
Cdro%lation
Dealklation
7ulfo%idation $eduction
Cdrolsis
?hase II
5onjugation
A9858$3NID4.I3
N
7894.I3N
A9B5IN
45.B94.I3N
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+#to%hrome P234 Phase I Isoen)#mes,5 Total and Su!strate "6amples
IsoenKmes # 7ubstrate
5B?!4 !" 3lanKapine, .heophlline
5B?5! ' ?hentoin, Harfarin
5B?D' -5odeine, Desipramine, .ramadol
5B?! -!0 5hlorKo%aKone, thanol
5B?;4 ;@-@ DiaKepam, .riaKolam, uinidine,
Methadone, 5arbamaKepine
+++*drug-interactions*com
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Inhi!itors of 0epati% +#to%hromeP234
!4 5! D' ;4luo%amine 4miodarone luo%etine rthromcin5imetidine luconaKole ?aro%etine4Kole antifungal5iproflo%acin luastatinuinidine NefaKodone
luo%etine $itonair 5larithromcinIsoniaKid 1upropion $itonair7ertraline 5imetidine 5imetidine3mepraKole
5imetidine
+++*drug-interactions*com
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Strategies to Pre&ent*ManageDrug Intera%tions
!* ncourage patients to report all prescription, oer-the- counter and complementar and alternatiedrugs at eer health care encounter*
* 7upport the implementation of electronic prescribing
andor the use b patients of one pharmac +ithupdated drug interaction soft+are*
;* Hork +ith pharmacists and be familiar +ith drug
interaction information sources
* 5onsider +hether drug therap is necessar
@* Hhen adding a ne+ drug to regimen, screen forpotential drug-drug interactions*
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Strategies to Pre&ent*ManageDrug Intera%tions
'* Hhen adding a ne+ drug to regimen in a patient,
screen for potential drug-disease interaction*
"* If drug interaction can not be aoided, adjust
doses and ordosage interals for affected
medication and monitor the patient closel*
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Drugs That Intera%t 7ithTheoph#lline
Inhibitors 5imetidine ?ropafenone Me%iletine ?ropranolol rthromcin 5iproflo%acin luo%amine
Drugs 4ging* 00;G0:"!-
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Drug$Drug Intera%tions With Warfarin
Interacting DrugMechanism 4nticoagulant ffect4spirin ?D 1arbiturate ?= 5imetidine ?= Dipridamole ?D ibrates ?D
luo%amine ?= Macrolides ?= ?hentoin ?= uinolones ?= $ifampin ?=
7ulfinpraKone ?=?D .hroid hormones ?D .iclopidine ?D
N ngl F Med* 00;G !G;:'"@-
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+lini%all# Signi%antDrug$Drug Intera%tions 7ith A"Ds
3bject Drug Interacting Drug 3utcome5arbamaKepine DanaKol 51E leel
5arbamaKepine DiltiaKem 51E leel
5arbamaKepine Macrolides 51E leel
5arbamaKepine ?ropo%phene 51E leel5arbamaKepine 6erapamil 51E leel
?hentoin 4miodarone D?C leel
?hentoin 5imetidine D?C leel
?hentoin luo%etine D?C leel?hentoin INC D?C leel
?hentoin 3mepraKole D?C leel
Neuropharmacolog 00G@:
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Indu%ers of 0epati% +#to%hromeP234
!4 5! D' ;4
7moking $ifampin None 5arbamaKepine
3mepraKole ?henobarbital ?hentoin
?hentoin ?hentoin ?henobarbital$ifampin
7t* FohnLs +ort
+++*drug-interactions*com
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Sele%ted Phen#toinIndu%tion Intera%tions
3bject Drug Interacting Drug 5B? IsoenKme Induced
Methadone ?hentoin ;4
uinidine ?hentoin ;4
.heophlline ?hentoin !4
Harfarin ?hentoin 5
Neuropharmacolog 00G@:
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Sele%ted Drugs Se%reted!# 8enal Tu!ules
1asic (cationic) 4gents
4miodarone
5imetidine
Digo%in ?rocainamide
uinidine
$anitidine
.rimethoprim 6erapamil
4cidic (4nionic) 4gents
5ephalosporins
Indomethacin
Methotre%ate
?enicillins
?robenecid
7aliclates
.hiaKides
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Drug$Drug Intera%tions WithDigo6in
Interacting Drug ffect on 9eels
4miodarone
5larithromcin
?ropafenone uinidine
6erapamil
Drug 7af* 000G;:@0-;G F4?C4 00G:!-@!
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Drugs that Intera%t 7ith 'ithium
Diuretics
45-I
N74IDs
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Drug$Drug PD Intera%tions
3bject Drug Interacting Drug (s)
45-I =O =O sparing diuretics
1eta blockers 6erapamil
Digo%in DiureticsM43I 77$I, De%tromethorphan,
?seudoephedrine, 4nore%iants
Meperidine M43I
Cdro%ine .hioridaKine
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Drug$ T+A PD Intera%tions
5oncurrent use +ith an other drugs +ith
antimuscarinic properties
5oncurrent M43I
.pe I antiarrhthmics
5lonidine
Auanadrel
Auanethidine
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Drug$NSAID PD Intera%tions
3bject Drug Interacting Drug3utcome
4ntihpertensies N74IDs 1?
5orticosteroids N74IDs risk of ?8D
Diuretics N74IDs diuretic effect.riamterene Indomethacin =O
Harfarin N74IDs anticoagulant
effect
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+NS Pol#pharma%# and Falls in"lderl# Persons
Heiner D, et al* Aerontol !
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+lini%all# Important Drug$Disease Intera%tions Determined !# "6pert Panel+onsensus
0rug 0iseaseAnticholinergics 1?C, constipation, dementia4ntiarrhthmics (.pe !4) 5C (sstolic dsfunction)4mphetamines C.N, insomnia4spirin ?8D4tpical antipschotics DM
1arbiturates Depression1enKodiaKepines 53?D,dementia, falls1eta-blockers 53?D, DM, sncope551 !stgeneration 5C (sstolic dsfunction)5hlorpromaKine ?ostural hpotension, seiKures5loKapine 7eiKures5orticosteroids DM, ?8DDecongestants InsomniaDigo%in Ceart block
9indblad 5, Canlon F et al* (abstract) F 4m Aeriatr 7oc 00G@:7!;@
+li i ll i
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+lini%all# Important Drug$DiseaseIntera%tions Determined !# "6pert Panel+onsensus
Drug DiseaseMetoclopramide ?arkinsonLs diseaseNitrofurantoin 5hronic renal failureNon-aspirin N74IDs 5$, 5C, C.NNon-aspirin, non-53 II N74IDs ?8D
3pioid analgesics 1?C, constipation, dementia7edatiehpnotics alls7keletal muscle rela%ants 1?C77$Is alls.heophlline Insomnia.hioridaKine ?ostural hpotension, seiKures.horaKine 7eiKures.ricclic antidepressants 4rrhthmias, 1?C, constipation
dementia, falls, heart block
postural hpotension.pical antipschotics alls
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SE"A$A, BE"A1AR