Glossary

13.1 Pediatric and geriatric pharmacology

6 min read•august 16, 2024

Pediatric and geriatric patients have unique physiological differences that impact drug therapy. From body composition to organ function, these variations affect how medications are absorbed, distributed, metabolized, and excreted in these special populations.

Dosing challenges arise due to weight-based calculations, age-specific guidelines, and limited clinical data. Monitoring drug therapy is crucial, with regular assessments of drug levels, therapeutic response, and potential adverse effects. Medication-related problems require extra vigilance in these vulnerable groups.

Physiological differences in pediatric and geriatric populations

Body composition and organ function

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  • Pediatric patients have higher percentage of body water and lower percentage of body fat compared to adults affects drug distribution and volume of distribution
  • Immature hepatic enzyme systems in neonates and infants result in slower drug metabolism and prolonged half-lives of certain medications (acetaminophen, caffeine)
  • Renal function in pediatric patients not fully developed until 6-12 months of age impacts drug excretion and necessitates dose adjustments
  • Geriatric patients experience age-related changes in body composition
    • Decreased lean body mass and increased adipose tissue affects drug distribution (lipophilic drugs like diazepam)
    • Reduced total body water alters distribution of hydrophilic drugs (digoxin)
  • Hepatic blood flow and enzyme activity decrease with age in geriatric patients
    • Potentially leads to reduced drug metabolism and clearance (warfarin, benzodiazepines)
  • Age-related decline in renal function in geriatric patients affects drug excretion
    • Increases risk of drug accumulation and toxicity (metformin, gabapentin)

Gastrointestinal changes

  • Changes in gastric pH, motility, and absorption surface area in both pediatric and geriatric populations impact drug absorption and bioavailability
    • Pediatric patients have higher gastric pH, potentially reducing absorption of acid-labile drugs (penicillin)
    • Geriatric patients often experience decreased gastric acid secretion, affecting absorption of certain drugs (calcium carbonate, iron supplements)
  • Reduced gastrointestinal motility in geriatric patients can alter drug absorption kinetics
    • May lead to delayed onset of action for some medications (acetaminophen, levodopa)

Pharmacokinetics and pharmacodynamics in pediatric vs adult populations

Absorption and distribution

  • Absorption in pediatric patients affected by differences in gastric pH, gastric emptying time, and intestinal transit time alters drug bioavailability
    • Higher gastric pH can reduce absorption of acid-labile drugs (erythromycin)
    • Faster gastric emptying may lead to incomplete absorption of some medications (sustained-release formulations)
  • Distribution in pediatric patients influenced by higher total body water content and lower plasma protein binding capacity affects volume of distribution for many drugs
    • Increased volume of distribution for water-soluble drugs (aminoglycosides)
    • Decreased protein binding can lead to higher free drug concentrations (phenytoin)

Metabolism and excretion

  • Metabolism in pediatric patients varies with age, with some enzyme systems being immature at birth and reaching adult levels at different rates during development
    • CYP3A4 enzyme activity lower in neonates, affecting metabolism of drugs like midazolam
    • Glucuronidation pathways develop more slowly, impacting metabolism of drugs like morphine
  • Excretion in pediatric patients affected by immature renal function, with glomerular filtration rate reaching adult levels by 6-12 months of age
    • Requires dose adjustments for renally excreted drugs (gentamicin, vancomycin)
  • Geriatric patients experience reduced hepatic blood flow and decreased enzyme activity
    • Leads to decreased first-pass metabolism and altered drug clearance (propranolol, lidocaine)
  • Age-related decline in renal function in geriatric patients affects drug excretion
    • Potentially leads to drug accumulation and increased risk of adverse effects (NSAIDs, ACE inhibitors)

Pharmacodynamic considerations

  • Pharmacodynamic changes in both pediatric and geriatric populations result in altered drug sensitivity and response, necessitating dose adjustments and careful monitoring
    • Increased sensitivity to certain CNS depressants in geriatric patients (benzodiazepines)
    • Altered receptor sensitivity in pediatric patients can affect drug response (beta-blockers)

Dosing challenges for pediatric and geriatric patients

Pediatric dosing considerations

  • Weight-based dosing often necessary for pediatric patients requires careful calculations and consideration of patient's body surface area or weight
    • Use of mg/kg or mg/m2 dosing for many medications (antibiotics, chemotherapy agents)
  • Age-specific dosing guidelines needed for certain medications in pediatric patients due to developmental changes in drug metabolism and excretion
    • Neonatal dosing different from infant or child dosing for drugs like caffeine or acetaminophen
  • Limited clinical trial data in pediatric populations makes it challenging to establish appropriate dosing regimens for many medications
    • Off-label use common in pediatrics, requiring careful consideration of risk-benefit ratio

Geriatric dosing considerations

  • Geriatric patients often require dose adjustments due to age-related changes in pharmacokinetics and pharmacodynamics, as well as presence of multiple comorbidities
    • "Start low, go slow" approach often recommended for initiating new medications
  • common in geriatric patients increases risk of drug interactions and necessitates careful consideration of medication combinations and dosing
    • Potential for drug-drug interactions increases with number of medications (warfarin-amiodarone, SSRI-NSAID)
  • Renal function decline in geriatric patients often requires dose adjustments for renally cleared medications to prevent toxicity and adverse effects
    • Use of Cockcroft-Gault equation or other methods to estimate creatinine clearance and adjust doses accordingly

Adherence challenges

  • Both pediatric and geriatric populations may have difficulty with medication adherence due to factors such as taste preferences, swallowing difficulties, or cognitive impairment
    • Liquid formulations or flavoring agents may improve adherence in pediatric patients
    • Pill organizers or medication reminders can assist geriatric patients with complex regimens

Monitoring drug therapy in pediatric and geriatric populations

Pediatric monitoring considerations

  • Regular monitoring of drug levels and therapeutic response crucial in pediatric patients due to rapid physiological changes during growth and development
    • Frequent monitoring of anticonvulsant levels (phenytoin, carbamazepine) to maintain therapeutic range
  • Dose adjustments may be necessary as pediatric patients grow and mature, requiring frequent reassessment of medication regimens
    • Weight-based doses of medications like enoxaparin need adjustment as child grows
  • Therapeutic drug monitoring particularly important for medications with narrow therapeutic indices in pediatric populations
    • Monitoring of drugs like digoxin, aminoglycosides, and immunosuppressants essential for safety and efficacy

Geriatric monitoring considerations

  • Geriatric patients often require close monitoring of renal function and electrolyte balance due to age-related changes and increased susceptibility to adverse effects
    • Regular monitoring of serum creatinine and electrolytes for patients on diuretics or ACE inhibitors
  • Regular medication reviews essential in geriatric patients to assess continued need for each medication and minimize polypharmacy-related risks
    • Annual comprehensive medication review recommended for older adults taking multiple medications
  • Monitoring for adverse drug reactions critical in geriatric populations, as they may present differently or be more severe compared to adult patients
    • Vigilance for signs of cognitive impairment or falls with use of sedating medications

Therapeutic adjustments

  • Adjusting drug therapy based on individual patient response and tolerability crucial to optimize treatment outcomes and minimize risks in these vulnerable populations
    • Dose titration of antihypertensive medications based on blood pressure response and side effects
    • Adjustment of pain medications based on efficacy and tolerability in both pediatric and geriatric patients

Pediatric medication issues

  • Pediatric patients at increased risk of medication errors due to weight-based dosing and need for dose calculations, requiring extra vigilance in prescribing and administration
    • Use of standardized dosing charts and double-checking calculations can reduce errors
  • Adverse drug reactions in pediatric patients may manifest differently than in adults, necessitating careful observation and prompt recognition of atypical symptoms
    • Paradoxical reactions to sedatives (midazolam) causing agitation instead of sedation
  • Pediatric patients may experience growth-related adverse effects from certain medications, requiring careful monitoring of growth parameters during treatment
    • Growth suppression with long-term corticosteroid use (prednisone)
    • Dental staining with tetracycline use in young children

Geriatric medication issues

  • Geriatric patients more susceptible to anticholinergic side effects, including confusion, dry mouth, and urinary retention, due to age-related changes in cholinergic function
    • Commonly seen with medications like diphenhydramine, tricyclic antidepressants, and some antipsychotics
  • Increased sensitivity to sedative medications in geriatric patients leads to elevated risk of falls, cognitive impairment, and delirium
    • Benzodiazepines and z-drugs (zolpidem) particularly problematic in older adults
  • Geriatric patients more prone to orthostatic hypotension and electrolyte imbalances as adverse effects of various medications
    • Antihypertensives and diuretics can cause orthostatic hypotension and hyponatremia

Common issues in both populations

  • Both pediatric and geriatric patients at higher risk of drug-induced renal injury due to immature or declining renal function, respectively
    • NSAIDs and aminoglycosides can cause acute kidney injury in both populations
  • Increased risk of drug-drug interactions in both groups due to polypharmacy or altered pharmacokinetics
    • Interactions between antibiotics and other medications (warfarin-ciprofloxacin) more likely to cause problems in these populations

Key Terms to Review (16)

Acetaminophen for fever: Acetaminophen is a widely used analgesic and antipyretic medication that helps reduce fever and relieve pain. It is often recommended for pediatric and geriatric patients due to its favorable safety profile and effectiveness in managing febrile conditions without causing gastrointestinal irritation, making it suitable for these vulnerable populations.
Adjustment of dosages: Adjustment of dosages refers to the process of modifying the amount of medication given to patients based on various factors that affect their response to the drug. This practice is particularly crucial in pediatric and geriatric populations, as these groups may have different pharmacokinetics and pharmacodynamics compared to adults. Individual responses to medications can vary widely, making it essential to tailor dosages for safety and efficacy in these vulnerable populations.
Adverse drug reactions in the elderly: Adverse drug reactions (ADRs) in the elderly refer to harmful or unintended responses to medications that occur more frequently or with greater severity in older adults. As this population often experiences polypharmacy—taking multiple medications simultaneously—the risk of ADRs increases, complicating treatment outcomes and healthcare management. Understanding these reactions is crucial due to age-related physiological changes that can affect drug metabolism and excretion.
Age-related changes in drug absorption: Age-related changes in drug absorption refer to the physiological alterations that affect how drugs are taken up by the body as individuals age. These changes can lead to variations in drug efficacy and safety, particularly impacting both pediatric and geriatric populations due to differences in gastrointestinal function, body composition, and metabolic processes.
Anticholinergic medications: Anticholinergic medications are drugs that block the action of acetylcholine, a neurotransmitter in the nervous system, which can lead to decreased secretion of mucus and saliva, relaxation of smooth muscles, and increased heart rate. These medications are commonly used to treat various conditions like asthma, COPD, and some gastrointestinal disorders, but their use in pediatric and geriatric populations raises specific concerns due to age-related pharmacokinetic and pharmacodynamic differences.
Asthma medications in children: Asthma medications in children refer to the various pharmacological treatments specifically designed to manage asthma symptoms and improve respiratory function in pediatric patients. These medications are crucial for controlling asthma, which can significantly impact a child's quality of life and ability to engage in daily activities. Treatment options typically include long-term control medications, such as inhaled corticosteroids, and quick-relief medications, also known as rescue inhalers, which provide immediate relief during asthma attacks.
Beers Criteria: The Beers Criteria is a set of guidelines that identifies potentially inappropriate medications for older adults, aiming to reduce the risk of adverse drug events in this population. These criteria emphasize the importance of careful medication selection and management in geriatric patients, considering their unique pharmacological needs and increased vulnerability to drug-related problems. The guidelines also address considerations for pediatric populations and those with hepatic or renal impairment, ensuring safer pharmacotherapy across different age groups and health statuses.
Drug metabolism in children: Drug metabolism in children refers to the biochemical processes that modify pharmaceutical compounds within the body of pediatric patients, impacting their efficacy and safety. This process is influenced by developmental factors such as age, organ maturity, and genetic variations, which can lead to differences in drug response compared to adults. Understanding these metabolic pathways is crucial for optimizing medication dosing and minimizing adverse effects in the pediatric population.
Drug-drug interactions in geriatrics: Drug-drug interactions in geriatrics refer to the effects that occur when multiple medications prescribed to elderly patients influence each other's pharmacokinetics or pharmacodynamics, leading to altered therapeutic outcomes or increased risks of adverse effects. Given the complexity of health conditions in older adults and their higher likelihood of polypharmacy, understanding these interactions is essential for safe and effective medication management. It’s important to monitor these interactions closely to ensure that the elderly population receives optimal care without unnecessary complications.
Geriatric pharmacokinetics: Geriatric pharmacokinetics is the study of how the body processes drugs in older adults, taking into account changes in absorption, distribution, metabolism, and excretion due to aging. This field recognizes that the physiological alterations that occur with age can significantly influence how medications work and how they are eliminated from the body, requiring careful consideration when prescribing treatment to elderly patients.
Monitoring for side effects: Monitoring for side effects refers to the ongoing assessment of patients after they have received medication, focusing on identifying any adverse reactions or unintended consequences that may arise. This process is crucial, especially in vulnerable populations, as it helps ensure the safe and effective use of pharmacological treatments by facilitating timely interventions and modifications to therapy when necessary.
Pediatric dosing: Pediatric dosing refers to the calculation and administration of medication dosages specifically tailored for children based on their age, weight, and clinical condition. Since children metabolize and respond to medications differently than adults, it is crucial to adjust dosages to ensure safety and efficacy. This process takes into account the unique physiological characteristics of children, making it a vital aspect of pediatric pharmacology.
Pediatric drug interactions: Pediatric drug interactions refer to the effects that occur when medications are taken together by children, potentially leading to altered therapeutic outcomes or increased side effects. Given the unique physiological differences in children compared to adults, including differences in metabolism, absorption, and organ maturity, understanding these interactions is crucial for safe medication management in pediatric populations.
Polypharmacy: Polypharmacy refers to the concurrent use of multiple medications by a patient, often defined as taking five or more medications simultaneously. This practice can be particularly problematic as it increases the risk of drug interactions, adverse effects, and medication non-adherence. As individuals with complex health issues often require several drugs for treatment, understanding polypharmacy is crucial for managing medication regimens effectively and ensuring patient safety.
Stopp/start criteria: Stopp/start criteria refer to the specific guidelines and thresholds that determine when to initiate or discontinue a particular treatment or medication regimen. These criteria are crucial in pediatric and geriatric pharmacology, as they help healthcare providers make informed decisions regarding medication management, ensuring safety and efficacy for these vulnerable populations.
Therapeutic Index: The therapeutic index is a measure of the safety of a drug, calculated as the ratio between the toxic dose and the effective dose. A higher therapeutic index indicates a greater margin of safety, meaning that there is a larger difference between the dose that produces a desired therapeutic effect and the dose that causes toxicity.
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