The incidence of both systolic and diastolic hypertension is increased in elderly patients, therefore antihypertensive drugs are commonly used in this population. In addition to changes in blood pressure, the aging process also causes numerous changes in other physiological parameters, resulting in altered pharmacokinetic and pharmacodynamic responses to the drugs. The dosage regimens for thiazide diuretics and amiloride must be individually titrated in the elderly patient, since the elimination of these agents decreases concurrently with decreased renal function, as indicated by compromised creatinine clearance. The initial doses of the calcium antagonists should be decreased in elderly patients, since representative compounds from all 3 chemically heterogeneous classes have been shown to have decreased clearance in these patients which appears to be primarily due to the status of hepatic function in the patient. However, with verapamil, the dosage should be further decreased in association with compromised renal function. The dosage of the angiotensin converting enzyme (ACE) inhibitors should be adjusted according to renal function rather than age. Lisinopril, which is primarily eliminated unchanged, is usually given in lower doses in the elderly, and doses of both captopril and enalapril may need to be reduced, depending on renal function. While there is no need to adjust the dosage regimen for the alpha-adrenoceptor blocking drugs (prazosin, terazosin), caution should be used with the beta-adrenergic blockers, particularly the hydrophilic agents, since they are renally eliminated. Labetalol may be a suitable alternative beta-blocker for the elderly patient, since its pharmacodynamic properties of decreased systemic vascular resistance without changes in heart rate or stroke volume are preferential for the elderly patient, and its pharmacokinetics are relatively unchanged in this population. Drugs that act primarily through the central nervous system, such as clonidine, methyldopa and guanfacine, require smaller doses in the presence of renal dysfunction. In contrast, guanabenz is metabolised primarily by the liver, so it would appear to be useful in elderly patients with renal dysfunction despite the lack of studies in this population. Guanadrel, an adrenergic neuron blocking drug, also requires a dosage reduction in patients with impaired renal function. In addition to the pharmacokinetic changes that occur in the elderly patient, pharmacodynamic changes may also be anticipated due to receptor modifications. Older patients have a decrease in beta-receptor sensitivity, while alpha-receptor sensitivity does not change. When designing the dosage regimen for a senior patient with hypertension, the combination of all these variables must be considered.
The concern over rising health care costs has created an environment that is favorable for the development of efficient health care programs. Pharmacists have been instrumental in developing and implementing programs to reduce drug costs, but many of these lack adequate documentation in the literature. One such area is the impact of disseminating drug bulletins to prescribers. This study was undertaken to assess quantitatively the impact of drug bulletins on physician prescribing habits and to measure the resultant changes in drug cost. This was a retrospective examination of Prime Health's acquisition of certain drugs described in five separate drug bulletins before and after issuance of the bulletins. We were able to demonstrate statistically significant changes in the proportions of drugs acquired after dissemination of each bulletin. In some cases, these changes persisted for the duration of the study (one year after issuance of the bulletin); in other cases, they reverted to pre-bulletin proportions. These changes resulted in mean drug cost reductions of 30 percent per calendar quarter for all of the post-bulletin period. Our findings suggest that the issuance of certain types of drug bulletins to prescribers is associated with a significant change in their prescribing habits, with resultant cost savings.
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