PRESCRIPTION AND DRUG INTERACTIONS IN THE ELDERLY
Plan
introduction
Basic Principles
Antibiotic prescription
Anti-inflammatory prescription
Painkiller prescription
How to write a prescription? Recommendations
Conclusion
I/ Introduction:
The management of oral diseases is essentially based on local action (oral care), sometimes supported by a drug prescription. The dentist is thus led to prescribe drugs of various types. However, a drug can only be prescribed after:
- Make a diagnosis.
- Assess the benefit/risk ratio
- Taken into account
- contraindications
- Drug Interactions
- associated pathologies (: liver failure, kidney failure, etc.)
- allergies
II/ Basic principles: the choice of medication depends on:
- The effectiveness of the molecule.
- Its safety (tolerance and fewer side effects).
- Its cost.
- Its availability.
- Its dosage
- Its route of administration:
• Oral route+++: tablets, capsules, syrup, oral suspensions,
• Rectal route: suppository,
• Parenteral routes (emergency): intramuscular (IM) and intravenous (IV) injections
III/ Prescription of antibiotics
- Reserved for bacterial infections.
- Perhaps preventive or curative.
- Among the main families of antibiotics;
-Betalactamines (penicillins + cephalosporins)
-True macrolides and related macrolides
-Imidazoles
-Tetracyclines
A/ Preventive antibiotic therapy
Its purpose is to prevent the occurrence of infections.
• In case of particular general pathology.
• In the case of relatively heavy surgical intervention
It can be done in different ways:
§ Preoperatively.
§ Postoperatively.
B/ Curative antibiotic therapy
As first-line treatment (ATB probabilistic therapy and monotherapy), Amoxicillin:
The molecule of choice for the dentist (bactericidal, broad spectrum, bioavailability, etc.).
It is used at an average dose of 2g/day in 2 doses over a period of 6 to 7 days.
Second-line treatment: combination antibiotic therapy
Macrolides / Spiramycin (Rovamycin®). The molecule has a longer half-life;
With Metronidazole (Flagyl®) => anaerobic bacteria / 500 mg
Dosage: 1g to 1.5g/day.
Examples:
Amoxicillin + clavulanic acid = augmentin
Amoxicillin + flagyl
Spiramycin + flagyl= birodogyl
PRESCRIPTION AND DRUG INTERACTIONS IN THE ELDERLY
Preoperatively: situations?
- Patients irradiated in the cervicofacial region
- Patients undergoing chemotherapy
- Patients on bisphosphonates
- For the prevention of Osler’s endocarditis: Administered as a flash dose one hour before the procedure in a single dose:
ANTIBIOPROPHYLAXIS PROTOCOL :
In the hour before an invasive procedure, the patient must take: orally:
2 g of amoxicillin in adults;
NB: if allergic to penicillins:
600 mg clindamycin in adults,
Post-operatively: situations?
Surgical act
In certain patients (immunocompromised condition, risk of delayed healing):
- diabetic
- cancerous
- long-term corticosteroid therapy
- AIDS AND HIV
- renal failure
- etc …….
IV/ Prescription of non-steroidal anti-inflammatory drugs:
The inflammatory reaction is a physiological reaction process of defense of the organism, triggered by the aggression of a pathogenic agent.
Characterized by: redness, warmth, pain and swelling.
A/ Indication: Symptomatic management of acute painful phenomena of inflammatory origin.
ž Properties:
- Anti-inflammatory
- Painkiller
- Antipyretic
- Platelet activation inhibitor
Examples:
ž Ibuprofen (Upfen®, Sapofen®) +++ better efficacy-toxicity balance
ž Ketoprofen (Profenid®)
ž Naproxen (Nopain®) / 275 mg
ž Mefenamic acid (Nifluril®) / 700 mg / 400 mg
ž Diclofenac (Voltaren®, Vosx®, Clofenal®)/ 50 mg and 75 mg
ž Acetyl salicylic acid (Aspirin®)/non-dental
B/ contraindication of NSAIDs
Known allergy.
History of gastroduodenal ulcer
ž History of asthma attack related.
žSevere renal or hepatocellular insufficiency
ž Heart failure
ž Patient on anticoagulant
ž Progressive infectious process.
V/ Prescription of steroidal anti-inflammatory drugs (AIS or corticosteroids):
Very similar in nature to cortisone, AIS significantly inhibit all phases of the inflammatory reaction.
Indication:
- In case of emergency (injectable)
- Control of postoperative inflammation
– Prevention of allergic reactions
– Autoimmune or dysimmune diseases of the oral mucosa
Cortisone is a natural glucocorticoid hormone synthesized by the adrenal glands that plays an essential role in regulating body functions: sugar metabolism, immune defenses and inflammation.
Two types of treatment depending on the duration of treatment
– Short-term treatments < one week
-Prolonged treatment
Prescription examples
Prednisolone (Solupred®) 1mg/kg/day in the morning for 3 days.
ž Methylprednisolone (Medrol ®, Solumedrol ®) injectable 1 mg/kg/day in the morning for 3 days.
PRESCRIPTION AND DRUG INTERACTIONS IN THE ELDERLY
VI/ Prescription of analgesics / Painkillers
The WHO classifies painkillers into 3 levels
Level 1: Non-morphine analgesics , peripheral or minor analgesics. Represented by paracetamol
Level 2: Weak morphine agonists. Consisting of combinations of level 1 analgesics and weak morphine analgesics/ codeine.
Level 3: Grouping of strong morphine agonists (morphine)
- LEVEL 1
Paracetamol: analgesic, antipyretic.
-Efficiency +++
-Dose 1000mg.
-Excellent tolerance,
-Very few side effects.
– Recommended doses: 1g/dose every 6 hours
- LEVEL 2
Associations Paracetamol + minor opioid derivatives such as codeine or dextropropoxyphene
– Their clinical use implies a dosage restriction.
- ALIER 3
Strong opioids
ž The most powerful.
ž Used in severe pain and in pain of cancer origin.
ž Not used exceptionally in odonto-stomatology
VII/ Prescription of antifungals : we distinguish between:
- Topical medications with only local action, without any systemic effects.
- Topical drugs with local and systemic action.
- Topical medications with only local action :
- Belonging to the polyene family,
- They act by direct contact and are fungistatic and fungicidal.
- Their disadvantages are the need for a long treatment period (at least 3 weeks) and often a taste problem.
- They involve good cooperation from the patient.
Examples:
– Locally acting drugs
FUNGIZONE® (amphotericin B): suspension
MYCOSTATIN® (nystatin): cream
-Medicines with local and systemic action .
These azole derivatives are relatively well tolerated, act for shorter periods than polyenes and have a local and general action.
DAKTARIN® (miconazole ):
- Its general action is very weak;
- It is therefore used mainly for its local action.
- Mouth gel:
The advantage of the gel is the adhesion of the product to the mucous membranes or under a prosthesis, and consequently the improvement of the contact time of the molecule on the lesion.
It can also be used for digital massage or brushing.
TRIFLUCAN® / 50 mg (fluconazole)
Its general action is important and its good salivary diffusion is extremely interesting in the context of oral candidiasis due to Candida Albicans.
EXAMPLE OF TREATMENT OF PROSTHETIC ERYTHEMATOUS CANDIDIASIS
- Disinfect the prosthesis by brushing it after each meal with a chlorhexidine-based toothpaste.
- Every evening, leave it to soak for at least 1 hour in a chlorhexidine-based mouthwash.
- This candidiasis if associated with cheilitis or glossitis, will require both topical treatment and systemic treatment:
- DAKTARIN® oral gel: thinly coat the inside of the prosthesis after each meal before putting it back in the mouth,
- and TRIFLUCAN® 50mg,
loading dose 200mg to 400mg on the 1st day
next dose 100mg to 200mg /1 time/day / 14 to 30 days
The prosthesis will not be worn at night (especially since nocturnal salivation is reduced)
VIII/How to write a prescription: a prescription must include:
-The date
-The patient’s first and last name.
-The stamp of the prescribing practitioner and his signature.
-It must be readable
-It will include one or more medications and will therefore contain:
* Name of the medicine
* International common name (INN) or specialty name (non-commercial) * Pharmaceutical form: capsules, tablets, syrup, suppository, etc.
* The duration of treatment.
* Dosage and daily distribution.
A prescription must be prioritized: the prescription (go from the most important treatment to the least important).
IX/ Pharmacokinetic and pharmacodynamic modifications
Elderly people are not only victims of physiological aging but often also of multiple pathologies.
This combination will modify:
– pharmacokinetics and pharmacodynamics of drugs,
– with increased risks of toxicity, adverse effects, and interactions.
* Pharmacokinetic changes are observed at different levels
- Absorption : Oral intake is little modified by age.
- Distribution: Body weight composition changes with age.
There is an increase in adipose tissue and a decrease in total water.
a reduction in the concentration of plasma proteins (albumin).
These changes alter the distribution of lipophilic, hydrophilic, or plasma protein-binding drugs and predispose the elderly patient to adverse effects and toxicities.
Water-soluble drugs, such as antibiotics (except penicillins), can reach concentrations that are too high due to insufficient dilution.
Similarly, drugs bound to plasma proteins, such as salicylates or penicillins, see their toxic effect increased by an increase in the free fraction
*Pharmacodynamic changes: decrease:
- of liver function
- liver volume,
- and hepatic enzyme activity.
- Renal function: Renal function is reduced by 35 to 50% in the elderly. Thus, drugs and metabolites eliminated by this route can accumulate, increasing side effects and potential toxicity.
Whatever the pharmacokinetic modification observed, it is in the direction of an overdose and therefore requires an adaptation of the prescription.
X/ Drug interactions in the elderly
Definition: The combination of two drugs responsible for a modification
of the activity or toxicity of one and/or the other
The simultaneous prescription of two or more drugs is a common situation in geriatrics due to the multiple health problems that this population presents.
Many medications can be combined without any problems.
| Medicine | Drug interaction | Mechanism | Effect |
| Aspirin | Warfarin (AVK) | Effects on platelet function , coagulation and gastric mucosal integrity | Gastrointestinal and oral bleeding |
| Diuretics | NSAIDs | Orthostatic hypotension Reduced renal perfusion | Falls, weakness, fainting Renal failure |
| Methotrexate | Penicillins, salicylate | Decreased active renal tubular secretion | Methotrexate poisoning |
| AVK | NSAIDs | Effects on platelet function , coagulation and mucosal integrity | Gastrointestinal and oral bleeding |
| AVK | Miconazol | Effect on coagulation | Mouth bleeding |
Conclusion
Prescribing in gerodontology is a medical act which engages the professional responsibility of the practitioner.
It follows precise rules based on scientific knowledge in order to ensure adequate therapeutic conduct while avoiding as much as possible the harmful effects of medication.
PRESCRIPTION AND DRUG INTERACTIONS IN THE ELDERLY
Baby teeth need to be taken care of to prevent future problems.
Periodontal disease can cause teeth to loosen.
Removable dentures restore chewing function.
In-office fluoride strengthens tooth enamel.
Yellowed teeth can be treated with professional whitening.
Dental abscesses often require antibiotic treatment.
An electric toothbrush cleans more effectively than a manual toothbrush.