F

F



famciclovir


(fam-sye’-kloe-veer)


image Brand Name(s): Famvir


Chemical Class: Acyclic purine nucleoside analog


image Clinical Pharmacology:


Mechanism of Action: A synthetic nucleoside that inhibits viral DNA synthesis. Therapeutic Effect: Suppresses replication of herpes simplex virus and varicella-zoster virus.

Pharmacokinetics: Rapidly and extensively absorbed after PO administration. Protein binding: 20%-25%. Rapidly metabolized to penciclovir by enzymes in the GI wall, liver, and plasma. Eliminated unchanged in urine. Removed by hemodialysis. Half-life: 2 hr.

image Available Forms:


• Tablets: 125 mg, 250 mg, 500 mg.

image Indications and Dosages:


Herpes zoster: PO 500 mg q8h for 7 days.

Genital herpes, first episode: PO 250 mg 3 times a day for 7-10 days.

Recurrent genital herpes: PO 125 mg twice a day for 5 days.

Suppression of recurrent genital herpes: PO 250 mg twice a day for up to 1 yr.

Recurrent herpes simplex: PO 500 mg twice a day for 7 days.

Dosage in renal impairment: Dosage and frequency are modified based on creatinine clearance.




















Creatinine Clearance Herpes Zoster Genital Herpes
40-59 ml/min 500 mg q12h 125 mg q12h
20-39 ml/min 500 mg q24h 125 mg q24h
less than 20 ml/min 250 mg q24h 125 mg q24h

Dosage in hemodialysis patients: For adults with herpes zoster, give 250 mg after each dialysis treatment; for adults with genital herpes, give 125 mg after each dialysis treatment.


image Contraindications: Hypersensitivity to penciclovir cream



image Side Effects



Frequent

Headache (23%), nausea (12%)

Occasional (10%-2%)

Dizziness, somnolence, numbness of feet, diarrhea, vomiting, constipation, decreased appetite, fatigue, fever, pharyngitis, sinusitis, pruritus

Rare (less than 2%)

Insomnia, abdominal pain, dyspepsia, flatulence, back pain, arthralgia


image Serious Reactions



• Urticaria, hallucinations, and confusion (including delirium, disorientation, confusional state, occurring predominantly in the elderly) have been reported.


Special Considerations



• Reserve chronic suppressive therapy for patients without prodromal symptoms who have frequent recurrences


image Patient/Family Education



• Drink adequate fluids

• Keep fingernails short and hands clean

• Do not touch the lesions for the duration of an outbreak to prevent cross-contamination and spreading the infection to new sites

• Space doses evenly around the clock and take famciclovir for the full course of treatment

• Notify the physician if the lesions fail to improve or if they recur


image Monitoring Parameters



• Assess for signs and symptoms of neurologic effects, including dizziness and headache

image Geriatric side effects at a glance:


image CNS

image Bowel Dysfunction

image Bladder Dysfunction

image Falls


image U.S. Regulatory Considerations



image FDA Black Box

image OBRA regulated in U.S. Long Term Care


famotidine


(fa-moe’-ti-deen)


image Brand Name(s): Pepcid, Pepcid RPD


OTC: Mylanta AR, Pepcid AC


Combinations


OTC: with calcium carbonate and magnesium hydroxide (Pepcid Complete)


Chemical Class: Thiazole derivative


Clinical Pharmacology:


Mechanism of Action: A GI H2-blocker and gastric acid secretion inhibitor that inhibits histamine action at histamine 2 receptors of parietal cells. Therapeutic Effect: Inhibits gastric acid secretion when fasting, at night, or when stimulated by food, caffeine, or insulin.

Pharmacokinetics:



image

Rapidly, incompletely absorbed from the GI tract. Protein binding: 15%-20%. Partially metabolized in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 2.5-3.5 hr (increased with impaired renal function).


image Available Forms:


• Oral Suspension (Pepcid: 40 mg/5 ml.

• Tablets: 10 mg (Pepcid AC), 20 mg (Pepcid, Pepcid AC), 40 mg (Pepcid).

• Tablets (Chewable [Pepcid AC]: 10 mg.

• Capsules (Pepcid AC: 10 mg.

• Injection (Pepcid: 10 mg/ml.

Indications and Dosages:


Acute treatment of duodenal and gastric ulcers: PO 40 mg/day at bedtime.


Duodenal ulcer maintenance: PO 20 mg/day at bedtime.


Gastroesophageal reflux disease: PO 20 mg twice a day.


Esophagitis: PO 2-40 mg twice a day.


Hypersecretory conditions: PO Initially, 20 mg q6h. May increase up to 160 mg q6h.


Acid indigestion, heartburn (over-the-counter): PO 10-20 mg 15-60 min before eating. Maximum: 2 doses per day.


Usual parenteral dosage: IV 20 mg q12h.


Dosage in renal impairment: Dosing frequency is modified based on creatinine clearance.














Creatinine Clearance Dosing Frequency
10-50 ml/min q24h
less than 10 ml/min q36-48h

image Unlabeled Uses: Autism, prevention of aspiration pneumonitis, Helicobacter pylori eradication


image Contraindications: None known.




image Side Effects



Occasional (5%)

Headache

Rare (2% or less)

Constipation, diarrhea, dizziness


image Serious Reactions



• None known.


Special Considerations



• No advantage over other agents in this class, base selection on cost


image Patient/Family Education



• Stagger doses of famotidine and antacids

• May take famotidine without regard to meals but that it’s best taken after meals or at bedtime

• Notify the physician if headache occurs

• Avoid alcohol, aspirin, and coffee, all of which may cause GI distress, during famotidine therapy

• Contact the physician if persistent acid indigestion, heartburn, or sour stomach persists despite the medication


image Monitoring Parameters



• Pattern of bowel activity and stool consistency

Geriatric side effects at a glance:


image CNS

image Bowel Dysfunction

image Bladder Dysfunction

image Falls Other: Cognitive impairment

image Use with caution in older patients with: Renal impairment, Cognitive impairment



image U.S. Regulatory Considerations



image FDA Black Box

image OBRA regulated in U.S. Long Term Care

image Other Uses in Geriatric Patient: Acute allergic reactions, urticaria (in addition to antihistamine therapy)


image Side Effects:


Of particular importance in the geriatric patient: Delirium, confusion, dizziness, headache, constipation, diarrhea


image Geriatric Considerations – Summary: Adjust dose based on creatinine clearance. Not effective in preventing NSAID-induced gastric ulceration and bleeding; proton pump inhibitors should be used for this indication instead.



References



1 Gawrich S, Shaker R. Medical management of nocturnal symptoms of gastro-oesophageal reflux disease in the elderly. Drugs Aging. 2003;20:509-516.


2 Thomson ABR. Gastro-oesophageal reflux in the elderly. Role of drug therapy in management. Drugs Aging. 2001;18:409-414.


3 Drugs that may cause cognitive disorders in the elderly. Med Lett. 2000;42:111-112.



felodipine


(fell-o’-da-peen)


image Brand Name(s): Plendil


Combinations


Rx: with enalapril (Lexxel)


Chemical Class: Dihydropyridine


Clinical Pharmacology:


Mechanism of Action: An antihypertensive and antianginal agent that inhibits calcium movement across cardiac and vascular smooth-muscle cell membranes. Potent peripheral vasodilator (does not depress SA or AV nodes). Therapeutic Effect: Increases myocardial contractility, heart rate, and cardiac output; decreases peripheral vascular resistance and BP.

Pharmacokinetics:



image

Rapidly, completely absorbed from the GI tract. Protein binding: greater than 99%. Undergoes first-pass metabolism in the liver. Primarily excreted in urine. Not removed by hemodialysis. Half-life: 11-16 hr.


image Available Forms:


• Tablets (Extended-Release: 2.5 mg, 5 mg, 10 mg.

Indications and Dosages:


Hypertension: PO Initially, 2.5 mg/day. Adjust dosage at no less than 2-wk intervals. Maintenance: 2.5-10 mg/day. Range: 2.5-20 mg/day. Patients with impaired hepatic function. Initially, 2.5 mg/day. Adjust dosage at no less than 2-wk intervals. Maintenance: 2.5-10 mg/day. Range: 2.5-20 mg/day.


image Unlabeled Uses: Treatment of CHF, chronic angina pectoris, Raynaud’s phenomenon


image Contraindications: None known.



image Side Effects



Frequent (22%-18%)

Headache, peripheral edema

Occasional (6%-4%)

Flushing, respiratory infection, dizziness, light-headedness, asthenia (loss of strength, weakness)

Rare (less than 3%)

Paresthesia, abdominal discomfort, nervousness, muscle cramping, cough, diarrhea, constipation


image Serious Reactions



• Overdose produces nausea, somnolence, confusion, slurred speech, hypotension, and bradycardia.


Special Considerations



• Results of V-HeFT III indicate felodipine may be used safely in patients with left ventricular dysfunction


image Patient/Family Education



• Administer as whole tablet (do not crush or chew)

• Avoid grapefruit juice (see drug interactions)

• Do not abruptly discontinue felodipine; compliance with the therapy regimen is essential to control hypertension

• Rise slowly from a lying to a sitting position and wait momentarily before standing to avoid felodipine’s hypotensive effect

• Avoid tasks that require mental alertness or motor skills until response to the drug has been established

• Notify the physician if an irregular heartbeat, nausea, prolonged dizziness, or shortness of breath occurs


image Monitoring Parameters



• Liver function

• Pulse for bradycardia

• Skin for flushing

image Geriatric side effects at a glance:


image CNS

image Bowel Dysfunction

image Bladder Dysfunction

image Falls


image U.S. Regulatory Considerations



image FDA Black Box

image OBRA regulated in U.S. Long Term Care


fenofibrate


(fen-oh-fye’-brate)


image Brand Name(s): Antara, Lipidil Supra, Lofibra, Tricor, Triglide


Chemical Class: Fibric acid derivative


Clinical Pharmacology:


Mechanism of Action: An antihyperlipidemic that enhances synthesis of lipoprotein lipase and reduces triglyceride-rich lipoproteins and VLDLs. Therapeutic Effect: Increases VLDL catabolism and reduces total plasma triglyceride levels.

Pharmacokinetics: Well absorbed from the GI tract. Absorption increased when given with food. Protein binding: 99%. Rapidly metabolized in the liver to active metabolite. Excreted primarily in urine; lesser amount in feces. Not removed by hemodialysis. Half-life: 20 hr.

image Available Forms:


• Capsules: 43 mg (Antara), 67 mg (Lofibra), 87 mg (Antara), 130 mg (Antara), 134 mg (Lofibra), 200 mg (Lipidil Supra, Lofibra).

• Tablets: 48 mg (Tricor), 50 mg (Triglide), 145 mg (Tricor), 160 mg (Triglide).

Indications and Dosages:


Hypertriglyceridemia: PO (Antara) 43-130 mg/day. PO (Lofibra) 67-200 mg/day with meals. PO (Tricor) 48-145 mg/day. PO (Triglide) 50-160 mg/day.


Hypercholesterolemia: PO (Antara) 130 mg/day. PO (Lofibra) 200 mg/day with meals. PO (Tricor) 145 mg/day. PO (Triglide) 160 mg/day.


image Contraindications: Gallbladder disease, severe renal or hepatic dysfunction (including primary biliary cirrhosis, unexplained persistent liver function abnormality)



image Side Effects



Frequent (8%-4%)

Pain, rash, headache, asthenia or fatigue, flu symptoms, dyspepsia, nausea or vomiting, rhinitis

Occasional (3%-2%)

Diarrhea, abdominal pain, constipation, flatulence, arthralgia, decreased libido, dizziness, pruritus

Rare (less than 2%)

Increased appetite, insomnia, polyuria, cough, blurred vision, eye floaters, earache


image Serious Reactions



• Fenofibrate may increase excretion of cholesterol into bile, leading to cholelithiasis.

• Pancreatitis, hepatitis, thrombocytopenia, and agranulocytosis occur rarely.


Special Considerations



• Plasma concentrations of fenofibric acid after administration of 54-mg and 160-mg tablets are equivalent to 67-mg and 200-mg capsules


image Patient/Family Education



• Signs, symptoms, and resources for management of myositis

• Take with food

• Notify the physician if constipation, diarrhea, or nausea becomes severe

• Notify the physician if dizziness, insomnia, muscle pain, rash, or skin irritation occurs


image Monitoring Parameters



• Serum cholesterol, triglycerides, LDL-cholesterol, HDL-cholesterol, LFTs (serum transaminases), periodic CBC, serum CK

image Geriatric side effects at a glance:


image CNS

image Bowel Dysfunction

image Bladder Dysfunction

image Falls


image U.S. Regulatory Considerations



image FDA Black Box

image OBRA regulated in U.S. Long Term Care


fenoldopam mesylate


(fhe-knowl’-doh-pam mes’-sil-ate)


image Brand Name(s): Corlopam


Chemical Class: Benzazepine derivative


Clinical Pharmacology:


Mechanism of Action: A rapid-acting vasodilator. An agonist for D1-like dopamine receptors; also produces vasodilation in coronary, renal, mesenteric, and peripheral arteries. Therapeutic Effect: Reduces systolic and diastolic BP and increases heart rate.

Pharmacokinetics: After IV administration, metabolized in the liver. Primarily excreted in urine. Unknown if removed by hemodialysis. Half-life: Approximately 5 min.

image Available Forms:


• Injection: 10 mg/ml.

Indications and Dosages:


Short-term management of severe hypertension when rapid, but quickly reversible emergency reduction of BP is clinically indicated, including malignant hypertension with deteriorating end-organ function: IV Infusion (continuous) Initially, 0.1 mcg/kg/min. May increase in increments of 0.05-0.1 mcg/kg/min until target BP is achieved. Usual length of treatment is 1-6 hr with tapering of dose q15-30min. Average rate: 0.25-0.5 mcg/kg/min. Maximum rate: 1.6 mcg/kg/min.


image Unlabeled Uses: Prevention of contrast media-induced nephrotoxicity


image Contraindications: Sensitivity to sulfites



image Side Effects



Expected

Beta-blockers may cause unforeseen hypotension.

Occasional

Headache (7%), flushing (3%), nausea (4%), hypotension (2%)

Rare (2% or less)

Nervousness or anxiety, vomiting, constipation, nasal congestion, diaphoresis, back pain


image Serious Reactions



• Excessive hypotension occurs occasionally.

• Substantial tachycardia may lead to ischemic cardiac events or worsened heart failure.

• Allergic-type reactions, including anaphylaxis and life-threatening asthmatic exacerbation, may occur in patients with sulfite sensitivity.


Special Considerations



• Preparation of infusion solution: Contents of ampules must be diluted prior to infusion: 1 ml of 10 mg/ml solution in 250 ml 0.9% sodium chloride or 5% dextrose yields a final concentration of 40 mcg/ml

• Potential advantage over sodium nitroprusside in hypertensive crisis: Induction of natriuresis, diuresis; ability to increase creatinine clearance, preserve renal function


image Patient/Family Education



• Change positions slowly to avoid orthostasis


image Monitoring Parameters



• Blood pressure, pulse, serum electrolytes, urine volume, urinary sodium, serum creatinine, blood urea nitrogen, electrocardiogram, hepatic function tests, infusion rate

Geriatric side effects at a glance:


image CNS

image Bowel Dysfunction

image Bladder Dysfunction

image Falls


image U.S. Regulatory Considerations



image FDA Black Box

image OBRA regulated in U.S. Long Term Care


fenoprofen calcium


(fen-oh-proe’-fen kal’-see-um)


image Brand Name(s): Nalfon


Chemical Class: Propionic acid derivative


Clinical Pharmacology:


Mechanism of Action: An NSAID that produces analgesic and anti-inflammatory effects by inhibiting prostaglandin synthesis. Therapeutic Effect: Reduces the inflammatory response and intensity of pain.

Pharmacokinetics: Rapidly absorbed following PO administration. Protein binding: 99%. Metabolized in liver. Primarily excreted in urine; small amount excreted in feces. Half-life: 3 hr.

image Available Forms:


• Capsules: 200 mg, 300 mg.

• Tablets: 600 mg.

Indications and Dosages:


Mild to moderate pain: PO 200 mg q4-6h as needed.


Rheumatoid arthritis, osteoarthritis: PO 300-600 mg 3-4 times a day.


image Unlabeled Uses: Treatment of ankylosing spondylitis, psoriatic arthritis, vascular headaches


image Contraindications: Active peptic ulcer disease, chronic inflammation of GI tract, GI bleeding or ulceration, history of hypersensitivity to aspirin or NSAIDs, significant renal impairment




image Side Effects



Frequent (9%-3%)

Headache, somnolence, dyspepsia, nausea, vomiting, constipation

Occasional (2%-1%)

Dizziness, pruritus, nervousness, asthenia, diarrhea, abdominal cramps, flatulence, tinnitus, blurred vision, peripheral edema and fluid retention


image Serious Reactions



• Overdose may result in acute hypotension and tachycardia.

• Rare reactions with long-term use include peptic ulcer disease, GI bleeding, gastritis, severe hepatic reaction (jaundice), nephrotoxicity (hematuria, dysuria, proteinuria), and a severe hypersensitivity reaction (bronchospasm, angioedema).


Special Considerations



• No significant advantage over other NSAIDs; cost should govern use


image Patient/Family Education



• Swallow fenoprofen capsules whole and do not chew or crush them

• Take with food or milk if GI upset occurs

• Avoid tasks that require mental alertness or motor skills until response to the drug has been established

• Avoid alcohol and aspirin during fenoprofen therapy because these substances increase the risk of GI bleeding


image Monitoring Parameters



• Initial hematocrit and fecal occult blood test within 3 mo of starting regular chronic therapy; repeat every 6-12 mo (more frequently in high-risk patients [>65 years, peptic ulcer disease, concurrent steroids or anticoagulants]); electrolytes, creatinine, and BUN within 3 mo of starting regular chronic therapy; repeat every 6-12 mo

• Pattern of daily bowel activity and stool consistency

• Therapeutic response, such as improved grip strength, increased joint mobility, and decreased pain, stiffness, and swelling

Geriatric side effects at a glance:


image CNS

image Bowel Dysfunction

image Bladder Dysfunction

image Falls

image Other: Gastropathy

image Use with caution in older patients with: Renal impairment, Hepatic impairment, CHF, HTN, PUD, History of GI bleeding, GERD, Bleeding and platelet disorders, History of aspirin sensitivity reaction. Also use with caution in patients taking Anticoagulants, Aspirin, and Antihypertensive agents.



image U.S. Regulatory Considerations



image FDA Black Box

• Cardiovascular risk

• Gastrointestinal risk

image OBRA regulated in U.S. Long Term Care

image Other Uses in Geriatric Patient: Acute Gout


image Side Effects:


Of particular importance in the geriatric patient: Confusion, cognitive impairment, delirium, dizziness, dyspepsia, fluid retention, renal impairment


image Geriatric Considerations – Summary: Use with caution due to the higher risk of GI adverse events. Not a preferred NSAID in older adults. Use of NSAIDs in older adults increases the risk of GI complications including gastric ulceration, bleeding, and perforation. These complications are not necessarily preceded by less severe GI symptoms. Concomitant use of a proton pump inhibitor or misoprostol reduces the risk for gastric ulceration and bleeding, but may not prevent long-term GI toxicity.



References



1 COX-2 alternatives and GI protection. Med Lett Drugs Ther. 2004;46:91.


2 Drugs that may cause cognitive disorders in the elderly. Med Lett Drugs Ther. 2000;42:111-112.



fentanyl citrate


(fen’-ta-nill sit’-trate)


image Brand Name(s): Injection: Sublimaze

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Jun 8, 2016 | Posted by in GERIATRICS | Comments Off on F

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