Warfarin, Insulin and Digoxin are

the most Dangerous drugs in the

elderly.
Do we believe that?

No Drugs are
Dangerous if
used properly

All Drugs are

Dangerous

Some drugs
have a low
therapeutic ratio

Some drugs have a

low incidence of
horrendous effects

Some drugs are

dangerous in
acute poisoning
but not when
used
therapeutically

The most
dangerous drugs
have the greatest
potential for
benefit

Some adverse
effects occur
after a delay or
after stopping

BAD

GOOD

How dangerous a drug

is depends on the skill of
the prescriber

Some adverse
effects can be
predicted if you
know the
pharmacology
(Type A); some
are not (Type B)

The Risk to Benefit Ratio

When prescribing drugs a doctor must assess
risk to benefit ratio in the individual patient by
Choosing an appropriate class of drug then an
appropriate individual agent
RISK

BENEFIT

Is it effective ?
What are the chances of adverse effect ?
Are there features in this patient which
affect choice eg other drugs, organ failure,
aged
Tailoring the dose
Considering duration of treatment

The Risks when prescribing

drugs with a low therapeutic
ratio are greatly increased if
1. Pharmacokinetic process is
complicated eg high hepatic
extraction, or zero order
elimination
2. Wide interindividual
variation in kinetics and / or
response
3. Pharmacokinetics sensitive
to drug interaction, disease
or ageing

Adverse drug reactions

An ADR is any unwanted effect
resulting from a drugs use in
treatment.

Epidemiology
4% of hospital admissions
1 in 1000 deaths in medical wards
10 to 20 % of in-patients
5% of patients in general practice

More frequent in elderly:

erratic drug taking
multiple pathology
altered pharmacokinetics
increased sensitivity of CNS
and CVS

Drugs - anti-coagulants,
NSAIDs,corticosteroids, antihypertensives, anti-biotics,
diuretics and insulin.

Occur in circumstances related to

drugs pharmacology,
predisposing factors in the patient
and care taken in choosing the
drug and the dose.

The BNF appendices

Drug Interactions
Liver disease
Renal impairment
Pregnancy
Breast feeding

BNF chapters of relevance

Adverse reactions to drugs

Prescribing in the elderly
Prescribing for children
Emergency treatment of poisoning

Detecting Adverse Effects

If a new drug causes a bizarre effect in 1 in 6000
patients it would need 18000 patients to use the
drug for it to occur in 3 patients
It would take twice as many before there was any
suspicion that the effect was due to the drug
If the effect also occurs naturally then it would
take many times more patients
Most early trials involve about 2000 patients

Detecting Adverse Effects

MRHA (Medicine and Healthcare products
Regulatory Agency) freephone service for
reporting and information about suspected
ADRs
Self reporting by patients and relatives using
Yellow cards available at pharmacies
Prescription event monitoring
New drugs black triangles and yellow
cards
Established drugs

Measuring danger
MHRA activity
through Yellow card
reporting and
prescription
monitoring
Huge increase
in reports over
recent years

Who reports to the MHRA?

Under-reporting estimated at 94% in hospital practice
(Smith et al 1996)
MRHA activity good at detecting adverse effects
Not very good at assessing the risk ratio

Prevention of Adverse Drug

reactions
Never use any drug unless there is good
indication. If the patient is pregnant do not
use the drug unless the need is imperative.
Allergy and idiosyncrasy are important
causes of ADRs. Ask if the patient had
previous reactions.
Ask if the patient is already taking other
drugs including self medication

Preventing ADRs contd

Age, hepatic and renal disease may impair clearance
of drugs so smaller doses may be needed. Genetic
factors may also predispose to certain ADRs
Prescribe as few drugs as possible and give clear
instructions
Where possible use familiar drugs. With new drugs
be particularly alert for ADRs and unexpected event.
If serious ADRs are liable to occur warn the patient

Some websites

www.yellowcard.gov.uk
http://medicines.mhra.gov.uk
www.dsru.org
http://eis.bris.ac.uk/~pmcjcr/Drug%20Safety
.pdf