lifelong effects as a result of toxicity occurring at a sensitive point in development (a ‘critical window’) during fetal or neonatal life (‘programming’) as with thalidomide/ phocomelia or hypothyroid drugs/congenital hypothyroidism RESEARCH Research in paediatric clinical pharmacology is limited. Not only is there concern about the potential for adverse effects of new drugs on those who are growing and developing mentally, but there are also considerable ethical problems encountered in research involving individuals who are too young to give informed consent. New drugs are often given to children for the first time only when no alternative is available or when unacceptable side effects have been encountered in a particular individual with established drugs. Pharmaceutical companies seldom seek to license their products for use in children. When drugs are prescribed to children that are not licensed for use in this age group, it is important to make careful records of both efficacy and possible adverse effects. Prescribers take sole responsibility for prescribing unlicensed preparations (e.g. formulated to appeal to children) or for prescribing licensed preparations outside the licensed age range. Parents should be informed and their consent obtained. Case history FURTHER READING RESEARCH 55 A 14-year-old boy with a history of exercise-induced asthma, for which he uses salbutamol as necessary (on average two puffs twice daily and before exercise) is seen by his GP because of malaise and nocturnal cough. On examination, he has a mild fever (38°C), bilateral swollen cervical lymph nodes and bilateral wheeze. Ampicillin is prescribed for a respiratory tract infection. The next day the boy develops a widespread maculopapular rash. Question 1 What is the cause of the rash? Question 2 What is the likely cause of the nocturnal cough and how may this be treated? Answer 1 Ampicillin rash in infectious mononucleosis (glandular fever). Answer 2 Poorly controlled asthma. Regular inhaled glucocorticosteroid or cromoglicate. Baber N, Pritchard D. Dose estimation in children. British Journal ofClinicalPharmacology 2003; 56: 489–93. British National Formulary for Children 2007. www.bnfc.org Kearns GL, Abdel-Rahmen SM. Developmental pharmacology – drug disposition, action and therapy in infants and children. New England Journal of Medicine 2003; 349: 1157–67. Paediatric Special Issue. British Journal ofClinicalPharmacology 2005; 59 (6). Paediatric formulary, 7th edn. London: Guy’s, St Thomas’, King’s College and Lewisham Hospitals, revised 2005.
● Introduction 56 ● Pharmacokinetic changes 56 ● Pharmacodynamic changes 57 ● Compliance in the elderly 58 INTRODUCTION CHAPTER 11 DRUGS IN THE ELDERLY The proportion of elderly people in the population is increasing steadily in economically developed countries. The elderly are subject to a variety of complaints, many of which are chronic and incapacitating, and so they receive a great deal of drug treatment. There is a growing evidence base for the use of drugs in elderly patients, with important implications for prescribing of many important classes of drugs, including statins, β-adrenoceptor antagonists, thrombolytics, ACE inhibitors, angiotensin receptor blockers, vitamin D and bisphosphonates (see reviews by Mangoni and Jackson, 2006). Adverse drug reactions and drug interactions become more common with increasing age. In one study, 11.8% of patients aged 41–50 years experienced adverse reactions to drugs, but this increased to 25% in patients over 80 years of age. There are several reasons for this. 1. Elderly people take more drugs. In one survey in general practice, 87% of patients over 75 years of age were on regular drug therapy, with 34% taking three to four different drugs daily. The most commonly prescribed drugs were diuretics (34% of patients), analgesics (27%), tranquillizers and antidepressants (24%), hypnotics (22%) and digoxin (20%). All of these are associated with a high incidence of important adverse effects. 2. Drug elimination becomes less efficient with increasing age, leading to drug accumulation during chronic dosing. 3. Homeostatic mechanisms become less effective with advancing age, so individuals are less able to compensate for adverse effects, such as unsteadiness or postural hypotension. 4. The central nervous system becomes more sensitive to the actions of sedative drugs. 5. Increasing age produces changes in the immune response that can cause an increased liability to allergic reactions. 6. Impaired cognition combined with relatively complex dose regimens may lead to inadvertent overdose. ● Effect of drugs on some major organ systems in the elderly 58 ● Practical aspects of prescribing for the elderly 60 ● Research 60 PHARMACOKINETIC CHANGES ABSORPTION Absorption of carbohydrates andof several nutrients, including iron, calcium and thiamine, is reduced in elderly people. Lipid-soluble drugs are absorbed by simple diffusion down the concentration gradient (Chapter 3), and this is not impaired by age. Intestinal blood flow is reduced by up to 50% in the elderly. However, age per se does not affect drug absorption to a large extent (Figure 11.1). ↑Gastric motility ↓Intestinal blood flow ↓Hepatic blood flow ↓Renal blood flow ↓GFR Metabolism↓ Drug Figure 11.1: Pharmacokinetic changes with age. Absorption↔ ↓Weight ↓Lean body mass ↑Fat ↓Concentration of fat-soluble drugs ↑Concentration of water-soluble drugs Excretion↓
Soliman s Auricular Therapy Textbook: New Localizations and Evidence Based Therapeutic Approaches was created ( M.D. Nader Soliman )
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Soliman s Auricular Therapy Textbook This textbook is considered the finest ever written in the field of auricular therapy. The auricular acupuncture microsystem is one of the most widely used special acupuncture techniques. This textbook is dedicated to teaching the sound foundations of this unique approach as introduced by its founder Dr. Paul Nogier of France. The scientific bases of the acupuncture microsystem with its three dime... Full description
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