5. IOM Pada Lansia

7/26/2019 5. IOM Pada Lansia

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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



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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



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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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