Geriatrics (week 5): Pearls from a Pharmacist
contact: pharmacist at creative-compounds.com
writing an RX:
drug name, strength (no leading decimals or trailing zeroes)
sig/directions (never "use as directed", insurance will not cover)
dispense: #quantity in units
refills: #
sarna = old crm with methol and camphor, for dermatitis
pain topicals
ketoprofen 10-20%, hangs out in joint fluids
diclofenac 4-10%
ibu 10-20% (pretty weak at 100-200mg dose)
prioxicam 1-2% (20mg typical oral dose)
bromelain 4%
indomethacin 2-5%
% x10 is mg/ml
neuroleptics for neuropathic pain
gabapentin 6-10% (expensive but less SE's/drowsy dt decr 1st pass)
ketamine 5-10% (is detromethorphan DM in cough syrup, related to PCP/angel dust)
amitriptyline 1-2%
clonidine 0.2% (used for HTN)
baclofen 2% (more centrally acting)
anesthetics
lidocaine 2-10% (watch for cardiac arrhythmias at higher doses in elders, not for large body areas)
bupivicaine 0.25-1% max 5% (expensive and no point in over 2%)
procaine 2-10% (use instead of trigger pt injx)
tetracaine 1-4%
benzocaine very short acting, rarely used, allodynia
to improve blood flow
nifedipine 5-16%
arginine 4-30% more affordable
pentoxifylline 2-5% makes plts more slippery
ALA 1-10%
capsaicin she doesn't like in topical
pts have been kept up all night with "feet on fire"
if pt wants it, get separate OTC product
mm relaxants
cyclobenzaprine 1-2%
benzodiazepines
guaifenesin 10-15% great for pts with fibromyalgia, oral or topical, for charley horses, inexpensive*
magnesium 10-15% great one
dry eyes
water intake
drops with viscosity, refresh is popular
ointments blur vision
dry mouth
glycerine and a touch of lemon in water can be compounded
spritz in mouth with spray bottle
common drug interactions
cytochrome p450 and isoforms
a lot has changed since she went to pharmacy school 20 yrs ago
long list of drugs/hormones that are metabolized via p450 (no surprises)
ethynol alc, phenytoin and carbamazepine induce, the rest inhibit
increase in anticholinergic effects
due to reduced receptors and production of ACTH
unisom? antipsychotics? antidepressants?
female hormones
lowest dose oral of E2 is 0.5mg
can get far smaller dose using creams
treat based on pt sx not just on labs
want menopausal E2 at 50-100
prog has no bad SE's, huge 1st pass effect so double oral dose relative to SL troches or PV or transdermal
Jonathan Wright doesn't do transdermal anymore
testosterone and DHEA
men with high chol and test in basement get put on statin and told to exercise
muscle aches and depression due to statin-->decline in mood and health
serum T 300-900 is what you want, she says go for at least 400 even in elder
monitor PSA each 6mo
no evidence shows T supp incr Ca
use Vit C and zinc to facilitate breakdown of T
men do best with shots or transdermal, lozenges usu not best approach
men need to apply 1-2ml of topical to get good enough absorption
there is evidence that T helps with tx of prostate CA