Drug Management in the Elderly Adult With Chronic Kidney Disease: A Review for the Primary Care Physician

Abstract

With advancing age, the functional reserve of many organs tends to decrease. In particular, the lean body mass, the levels of serum albumin, the blood flow to the liver, and the glomerular filtration rate are reduced in elderly individuals and can be further impaired by the concomitant presence of acute or chronic kidney disease. Moreover, patients with kidney disease are often affected by comorbid processes and are prescribed multiple medications. The aging process also modifies some drug interactions, including the affinity of some drugs for their receptor, the number of receptors, and the cell responses upon receptor activation. Therefore, older patients with kidney disease are particularly susceptible to the risks of adverse drug reactions. Planning a pharmacological regimen in such patients is confounded by the paucity of information available on the pharmacokinetic and pharmacodynamic profiles of a large number of drugs commonly used in this group of patients. Finally, many aged patients suffer from unintentional poor compliance. In this review, the problems physicians face in designing safe and effective medication management in elderly individuals are discussed, paying attention to those more frequently used, which may be potentially harmful in patients with kidney disease. The risks of overdosing and underdosing are outlined, and some recommendations to reduce the risk of adverse drug reactions are provided. A review of the literature covering the field of drug management in older patients with kidney disease was performed by selecting those articles published between January 1, 1990, and December 1, 2014, using PubMed as a search engine with the keywords elderly, kidney disease, drugs, drug interaction, and renal function.

The Role of Nurse in Drug Management in Elderly Individuals

“…İlaçların emilimi, dağılımı, metabolizması ve atılım/ boşaltım gibi özel süreçler bulunmaktadır. İlaçların sistemik dolaşıma katılması bu süreçlerin tamamlanmasıyla gerçekleşmektedir (6,22,23) .…”

“…İlacın fizyolojik etkisi reseptör ile etkileşimine bağlıdır. Yaşlanma süreci, bazı ilaçların reseptör etkileşimlerini, hücre başına düşen reseptör sayısını ve reseptör aktivasyonu üzerine hücresel tepkileri değişikliğe uğratabilmektedir (23) . Reseptör duyarlılığının azaldığı durumlarda ise ilacın etkinliğini göstermesi için daha yüksek dozda ilaca gereksinim duyulabilir.…”

In reply—New Oral Anticoagulants in Elderly Adults With Chronic Kidney Disease

“…Similar steps can be followed for the other NOAs, and we need to adhere to their respective guidelines. 2,3 If NOAs are to be used in patients with nonvalvular AF, the CHA 2 DS 2 -VASc score (congestive heart failure, hypertension, age 75 years [doubled], diabetes, stroke/transient ischemic attack/thromboembolism [doubled], vascular disease [prior myocardial infarction, peripheral artery disease, or aortic plaque], age 65-75 years, sex category [female]) should be determined. This score gives special attention to congestive heart failure, hypertension, age 75 years and older, diabetes, women, and history of stroke, transient ischemic attack, or systemic embolism.…”

“…This score gives special attention to congestive heart failure, hypertension, age 75 years and older, diabetes, women, and history of stroke, transient ischemic attack, or systemic embolism. 2,3 A score of 2 is assigned to patients who have a stroke or are 75 years or older. A score of 1 is assigned to each of the remaining risk factors, if present.…”

“…Moreover, a renal risk stratification should be done for all NOAs using a comprehensive metabolic panel before treatment begins and 1 week after initiation of the NOA or if there is a change in the patient's clinical condition. 2,3 It should be noted that the suggested dosing of the NOAs based on CKD stages has not been validated for clinical use. However, the actual dosing is the same for equivalent stages of renal dysfunction based on CGe and the current NOA prescribing information.…”