9/5/2014 1 Impact of Medications on Physical Therapy Outcomes Angela S. Garcia PharmD, MPH, CPh Assistant Professor, Public Health Nova Southeastern University Adjunct Assistant Professor, Dept. of Physical Therapy and Human Performance Florida Gulf Coast University [email protected]Objectives 1. Review mechanisms of action for targeted drug classes 2. Discuss relevant drug class side effects that impact the rehabilitation process 3. Provide recommendations to patients that maximize rehabilitation outcomes 4. Identify specific measures that will improve patient safety and decrease risks of complications during physical therapy appointments 5. Engage in discussion on presented case examples and recent literature to overcome medication limitations and facilitate reaching physical therapy goals
Transcript
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Impact of Medications on Physical Therapy Outcomes
Angela S. Garcia PharmD, MPH, CPhAssistant Professor, Public HealthNova Southeastern University
Adjunct Assistant Professor, Dept. of Physical Therapy and Human PerformanceFlorida Gulf Coast University
Objectives1. Review mechanisms of action for targeted drug
classes
2. Discuss relevant drug class side effects that impact the rehabilitation process
3. Provide recommendations to patients that maximize rehabilitation outcomes
4. Identify specific measures that will improve patient safety and decrease risks of complications during physical therapy appointments
5. Engage in discussion on presented case examples and recent literature to overcome medication limitations and facilitate reaching physical therapy goals
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Pharmacokinetics vs Pharmacodynamics
• Pharmacokinetics (PK) – what body does to drug (ADME)▫ Absorption▫ Distribution▫ Metabolism▫ Excretion
• Pharmacodynamics (PD) – what drug does to body▫ AUC (area under the curve total drug
concentration)▫ Cmin – minimum drug level (typically in 24 hours)▫ Cmax – maximum drug level (typically in 24 hours)
Pharmacokinetic (PK) Properties• Impact of route of administration ▫ Absorption▫ Distribution▫ Metabolism▫ Excretion
• Dosing schedules and plasma concentration▫ Onset and Duration of Action
• Factors that lead to variations in drug responses▫ Age▫ Gender▫ Comorbidities ▫ Drug interactions▫ Functional status
Why do PK Properties Matter?• By knowing PK properties, we are able to:▫ Predict maximal drug level achieved following
administration▫ Predict the time to a desired effect▫ Estimate the length of a therapeutic effect
• Determine the effective dosing regimen to achieve & maintain maximal therapeutic effects to increase the impact of rehabilitation
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PK Variability Impacts Physical Therapy
• Critical to discuss with patients & care team• Equal doses don’t produce equal concentrations
in all patients inter-patient variability▫ Drug-food / drug-drug interactions▫ Gender differences▫ Pregnancy▫ Genetics▫ Disease▫ Environmental/Occupational
Routes of Administration
• Impacts absorption of the drug and all other processes leading to efficacy & toxicity
GI tract distributed through circulatory system (bloodstream)
• Typically takes between 30 and 60 minutes▫ Depends on dosage form (XR vs IR vs enteric
coating vs)▫ Motility of GI tract▫ What part of GI breaks down the drug▫ Liver breakdown of drug before circulatory
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Buccal, Sublingual, Rectal
• More rapid onset of action because absorption is through mucous membranes directly enter into the bloodstream (avoiding GI)▫ Onset in 5 minutes▫ Rectal leads to more variable absorption but
begins within 5 minutes (good alternative when nausea and vomiting are high)
Topical/Transdermal• Transdermal bypasses GI absorbed through skin▫ Must be applied to area where circulation and adipose
tissue are adequate to enhance or facilitate absorption
• Administration through slow release mechanism (need to be replaced every 1 to 7 days▫ Local irritation means that alternating sites is
necessary
• Patch removal is critical to avoid overdose (dumping of medication or duplicating therapy with multiple patches)
Inhalation
• Considered a topical medication• Inhalation route is very effective ▫ Bypass GI & absorbed directly rapid onset of
action▫ Lower doses required & generally lower side
effects
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Distribution of Medications• Once the medication is absorbed, we see the effects
of distribution▫ Bloodstream (circulation) is responsible for moving
the drug to the target organ, system, or tissue
• Medications have unique properties impacting it’s distribution and volume in the body▫ Variations in patients bodies and functional status
create differences between expected drug effects and unexpected or unanticipated drug effects
▫ Awareness increases patient safety and therapeutic outcomes
Built in Protections for Medication Use
• Following administration, the drug is disseminated throughout the body
• Built in protective effects of the body to balance drug exchange across the blood brain barrier & placenta▫ BBB requires carrier proteins to cross
preventing toxic effects of many medications▫ Placenta low rate of blood flow leads to
reducing extent and rate of diffusion of drugs from the mother into the fetus reducing exposures
Dosing and Concentration
• Medication use may lead to the following:▫ Variable onset of fatigue▫ Rapid or delayed onset of sedation▫ Changes in cognition & awareness▫ Interference in normal/expected motor function▫ Increases in fall risk
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Concentration Effects & PT• Important to consider current functional status
and medication history of patients▫ Monitor for changes to prescription and non-
prescription therapies
• Schedule rehabilitation sessions to optimize patient participation or therapeutic outcomes▫ Timing of medication (administration) to
anticipate effects ▫ Note changes/concerns and communicate with
other care providers and PCP
Review of Medication Formulation & Onset of Action
A. Injection
B. Oral Medication with Immediate or ‘Normal’ release
C. Oral Medication with “Extended or Sustained Release”
Immediate & Controlled Release• Therapeutic Effect may take time to build with
Immediate Release Medications (IR) but less likely with Controlled Release (CR, SR, XR)
• Toxic Effects may show up after use without previously noted or observed problems in IR Medications
Dru
g P
lasm
a L
evel
Time
Minimum Toxic Concentration
Minimum Effective Concentration
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Medication Concentration & Dosing Effects that Impact Rehabilitation
Concentration Over Time & Maximizing
Rehabilitation Outcomes
Metabolism & Elimination• Metabolism converts medications into metabolites to
enhance elimination▫ Changes from an active form to an inactive form▫ Some change from one active form into another active form▫ Involves Cytochrome P450 enzymes (largest concentration
in liver)
• Elimination is dependent on characteristics of the drug & mechanisms of metabolism▫ Liver – (CYP 450 Enzymes) lipid soluble, larger molecular
size feces or kidney▫ Kidney – water soluble, ionized, smaller molecular size
urine▫ Both Liver & Kidney▫ Other route (breast milk, saliva, respiration, tears, sweat)
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PK Variations Impacting Metabolism & Elimination• Age effects extent of absorption, rate of
metabolism, rate of renal elimination▫ Pediatric patients – metabolism and elimination
require medication adjustment as aging occurs
• Metabolism and renal elimination diminish with age (decreased efficiency with each decade)▫ Seniors require lower doses to maintain levels ▫ Elderly increased risks of side effects and
toxicity (adherence becomes an issue) impairs progress during PT
• Perfusion (circulation) & protein binding (keeps drug in the blood) impact drug delivery to specific organs (heart, brain, liver, kidneys are high vs muscle, skin, fat) and onset of action
• Nutritional status can impact amount of plasma proteins available in the bloodstream (poor nutritional status increased drug in tissue increased toxicity at normal doses)
• Oral route is affected by effectiveness of GI lubrication, level of acidity in the stomach, rate of motility
alternative medications can alter the effects or anticipated effects of prescription medications
• Medications can significantly impact progress during rehabilitation▫ Need to know usual or anticipated effects in order
to anticipate how it will impact therapy participation and outcomes
Medication Considerations by the Physical Therapist • Medications are prescribed to achieve specific
therapeutic effects & appropriate use may still lead to undesired effects▫ Potentiation▫ Antagonism
• Therapist must monitor for any adverse effects cause by changes to treatment which includes physical therapy ▫ If a side effect is identified (or suspected) PT
needs to communicate with primary
Importance of Medication Reviews• Physical therapists should review medications to
ensure no changes to medications to maximize therapy options▫ Prescription▫ Nonprescription medications▫ Herbals & other alternative meds
• Changes to medication regimens may lead to changes in outcomes or functional status▫ New medications▫ Stopping medications▫ Changing doses of medications
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Pharmacodynamic Properties
• Drug Receptor Interactions▫ How and where a drug will elicit a specific
(desired) action by binding the drug & target area
• Mechanisms of Action▫ Sites where medications interact to produce the
desired outcomes (therapeutic effects)
Drug Receptors
• Selective – concentration dependent & targeted action with minimized side effects
• Non-selective – not concentration dependent, not targeted & can lead to undesired side effects
• Agonist – triggers a desired outcome• Antagonist – prevents action or outcome
Receptors & SelectivitySelective Drug Non-selective Drug
Primary Effect (beneficial)Therapeutic Outcome
Secondary Effect (negative)Side Effect
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Mechanism of Action• Ultimately we administer a medication to elicit a
desired response or outcome
• Drug is absorbed and distributed into the bloodstream
• Drug travels to the desired or targeted site of action
• The receptor activity creates change at the cellular level and elicitsan effect▫ Magnitude of the response tends to increase with
dose/concentration
Mechanism of Action• Therapeutic index – levels of concentration to
achieve desired outcome but avoid toxicity
• Half-life (rate of elimination) is medication specific and can be used to determine safety when changing medication regimens
• Steady state builds over time (dose given is equivalent to dose eliminated) and is highly patient specific
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Sedative Hypnotics and Antianxiety AgentsAntidepressants and AntipsychoticsAntiepileptics and Movement DisordersAnesthetics
General CNS Medications
• Most CNS medications target synaptic transmission and work by modifying (increasing or decreasing) action at specific synapses1. Presynaptic action potentials & autoreceptors2. Synthesis, storage, release & reuptake of
neurotransmitters3. Enzymatic degradation of neurotransmitter4. Postsynaptic receptors 5. Membrane effects
Sedative-Hypnotic & Antianxiety Agents
• Typically used for sedation, to decrease internal stressors, or for sleep
• CNS depressant effects (sedatives at higher doses hypnotic or anesthetic states)
• Decrease levels of alertness, induce drowsiness (sleep) when taken as a single dose at bedtime
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Sedatives• Two main categories: benzodiazepines and non-
Buspirone+ BuSpar 10 – 15mg BID/ TID Short-intermediate
+ low risk of tolerance, lower risk of psychomotor impairment, low risk of abuse
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Affective Disorders• Comprised of depression, bipolar and other mood
disorders ▫ Depression is the most prevalent mental illness in the
US
• High incidence in the general population increases likelihood that physical therapists will work with patients on this medication class and should be aware of symptoms that warrant review and/or monitoring
• Multiple drug classes have increased use in treatment for issues other than mental health▫ Requires good history not only of medication but what
the medication is used for with the specific patient
Antidepressant Medications• Classified by chemical structure or function▫ First-generation: Tricyclics & Monoamine Oxidase
• Basic goal of antidepressant use is to increase aminergic transmission (monoaminergic transmission)▫ Neurotransmitters (catecholemines) are dopamine,
norepinephrine, epinephrine, serotonin
• Side effect profiles are important factors that may impact rehabilitation
Generic BrandTricyclic
AntidepressantMechanism of Action
Amitriptyline Elavil • First generation• Block reuptake of amine NT
into the presynaptic terminal increased effect & stimulation of norepinephrine
• Amitriptyline and Nortriptyline were the standards of comparison for measuring newer medications
Isocarboxazid Marplan • First generation• Block enzymatic destruction
in the synaptic cleft increased effect
• Not typically the drug of choice in depression
• Relatively nonselective• High drug-food and drug-
drug interactions• Higher side-effect profiles
(increases orthostasis)
Phenelzine sulfate Nardil
Tranylcypromine sulfate
Parnate
Selegiline Emsam
Generic BrandSelective Serotonin Reuptake Inhibitors Mechanism of Action
Citalopram Celexa • Second generation• Increased selectivity to
block reuptake of serotonin • Improved side effect profile
and tolerance (less sedation, no orthostasis, less cardiovascular issues)
• Less toxicity in the event of overdose
Escitalopram Lexapro
Fluoxetine Prozac
Paroxetine Paxil
Sertraline Zoloft
Trazodone
**Serotonin Antagonist & Reuptake Inhibitor
Desyrel
Generic BrandSerotonin/Norepinephrine
Reuptake Inhibitors Mechanism of Action
Venlafaxine Effexor • Second generation• Increased selectivity to block
reuptake of serotonin & norepinephrine
• Improved side effect profile and tolerance (less sedation, no orthostasis, less cardiovascular issues)
• Increased onset of action• Less toxicity in the event of
overdose
Duloxetine Cymbalta
Desvenlafaxine Pristiq
Levomilnacipran Fetzima
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Antipsychotic Medications• Used to treat a class of disorders with
characteristics of thought disturbances & impaired reality perceptions▫ Most common is schizophrenia▫ Others include psychosis & paranoia▫ Typically caused by overactivity of dopamine
• Involve neurologic changes▫ Movement to treat disorder with neuroleptics
rather than sedation only▫ Typical agents▫ Atypical agents
Typical Antipsychotics
• Increased side effect profile▫ Extrapyramidal side effects (motor)▫ Bind to multiple dopamine receptors
• Increased patient intervariability in medication
Atypical Antipsychotic
• Key characteristics involve improved side effect profile▫ Do not block D2 receptors (decreased motor
effects)▫ Decreased extrapyramidal symptoms▫ Increased anticholinergic side effects & sedation▫ Increased safety profile and increased
predictability or consistency in anticipated/expected outcomes
▫ Low potency higher doses required
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Generic BrandTypical AntipsychoticsMechanism of Action
Chlorpromazine Thorazaine • Dopamine receptor blockade• Chemical diverse group of
medications• Specific side effects related to
blocking different receptors with the most significant as D2 (D1, D2, D3, D4)
• High incidence of extrapyramidal effects (motor)
• Moderate to high incidence of sedation
Haloperidol Haldol
Perphenzine Trilafon
Prochlorperazine Compazine
Thioridazine Mellaril
Fluphenazine decanoate
Fluphenazine (no brand)
Fluphenazine hydrochloride
Prolixin
Promethazine Phergan
Trifluoperazine Stelazine
Loxapine Loxitane
Generic BrandAtypical Antipsychotics
Mechanism of Action
Aripiprazole Abilify • Dopamine receptor blockade• Chemical diverse group of
medications• Lower incidence of extrapyramidal
effects (motor) effects• Outside of Clozapine, very low
anticholinergic effects• Outside of Clozapine, low
incidence of sedation
Clozapine Clozaril
Iloperidone Fanapta
Lurasidone Latuda
Olanzapine Zyprexa
Paliperidone Invega
Quetiapine Seroquel
Risperidone Risperdal
Ziprasidone Geodon
Extrapyramidal Symptoms
• Most significant side effect of typical antipsychotics▫ Dopamine is required for normal motor
movement• Antipsychotics (especially typicals) are non-
selective blockers of CNS dopamine receptors potentiates movement disorders▫ Distinct movement disruptions▫ Tardive dyskinesia
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0-3 months 3-6 months 6-9 months 9-12 months
Acute Dystonic Reactions
Akathisia Pseudo-Parkinsonism
Tardive Dyskinesia
• Torticollis • Restlessness • Motor retardation • Tongue protrusion
• Facial grimacing • Difficulty sitting still
• Mask-like facialexpression
• Puffing of cheeks
• Abnormal eye movement
• Strong urge to move about
• Tremor • Chewing movements
• Involuntarymuscle movement
• Pill rolling • Involuntary movements of extremities
• Rigidity • Involuntary movement of trunk
• Salivation
• Shuffling gait
Onset of Extrapyramidal Effects of Antipsychotics
Generic Brand ExtrapyramidalEffects
Sedation Effects
Anticholinergic Effects
Typicals
Chlorpromazine Thorazaine +++ ++++ +++
Haloperidol Haldol ++++ + +
Perphenzine Trilafon +++ ++ ++
Prochlorperazine Compazine ++++ ++ +
Thioridazine Mellaril +++ ++++ ++++
Fluphenazine decanoate Fluphenazine ++++ + +
Fluphenazine hydrochloride
Prolixin ++++ + +
Promethazine Phergan +++ ++++ +++
Trifluoperazine Stelazine +++ ++ ++
Loxapine Loxitane +++ +++ ++
Atypicals
Aripiprazole Abilify + ++ +
Clozapine Clozaril + ++++ ++++
Iloperidone Fanapta ++ ++ ++
Lurasidone Latuda + ++ +
Olanzapine Zyprexa ++ ++ ++
Paliperidone Invega + ++ +
Quetiapine Seroquel + ++ +
Risperidone Risperdal ++ ++ +
Antiepileptic Medications
• Epilepsy is considered a chronic neurologic disorder with recurrent seizures (episodic/transient cerebral excitation)
• Seizure type depends on localization or spread of neuronal activity
• May be congenital or related to a trauma or incident▫ Stroke, tumor, head injury, CNS issue, infection,
metabolic disorder (causing damage to neurons and altering threshold)
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Antiepileptic Medications
• Most seizures are self-limiting however uncontrolled seizures or frequent recurrence may lead to injury or further damage and advanced cerebral impairment
• Many drugs available to treat varying classes of seizures
• Side effect profile of the medications have some similarities and some unique characteristics
Antiepileptic Medication Mechanisms of Action• The general mechanism of action for
antiepileptic medications does one of the following:▫ Increasing the inhibitory effects of gamma-
aminobutyric acid (GABA)▫ Decreasing the effects of excitatory amino acids
(glutamate & Aspartate)▫ Altering movement of sodium & calcium ions
Zonisamide (Zonegran) Sedation, ataxia, loss of appetite, fatigue
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Movement Disorders• Parkinson disease has hallmark characteristics▫ Resting tremor▫ Bradykinesia▫ Rigidity▫ Postural instability & gait abnormalities
• Progressive degeneration of dopamine-secreting neurons in the basal ganglia (5th/6th decade)▫ Dopamine cannot cross the BBB precursor agents
• Clinical syndromes may be secondary to trauma, infection, antipsychotic medications, cerebrovascular disease, cortical degeneration (Alzheimer)
Movement Disorders
• Medications do not cure the disease diminished symptoms▫ Improve motor function▫ Increase mobility
• Medications cannot prevent deterioration of motor function completely but can increase quality of life and functional status while slowing onset
Anti-Parkinsonian Class
Medication Side Effects
L-isomer of Dopa Levodopa (transformed into dopamine via dopa decarboxylase)
In peripheral circulation GI upset, cardiovascular side effects (arrhythmias), postural hypotension, dyskinesias, depression, anxiety **diminished response over time
Peripheral Decarboxylase Inhibitor
Carbidopa (given with levodopa to prevent peripheral decarboxylation) Sinemet (carbidopa:levodopa) 1:4 or 1:10
Dyskinesias/fluctuations in resopnse, end-of-dose akinesia, on-off phenomenon
Dopamine Agonists Bromocriptine (Parlodel), Pergolide (Permax), Pramipexole (Mirapex), Ropinirole (Requip), Cabergoine (Dostinex) in conjunction with levodopa
When used alone do not cause the typical dyskinesias/fluctuations in motor responses, nausea/vomiting, postural hypotension, CNS-related effects (confusion, hallucinations)
Dyskinesia, arthralgia, dyspepsia, falls, nausea, vomiting, constipation, postural hypotension, dizziness,
COMT inhibitors Entacapone (Comtan) Diarrhea, increased levodopa SE, bright-orange urine, GI bleed, constipation, confusion , EPS, postural hypotension, syncope, dyskinesias
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Anesthetics
• Ideally smooth & rapid induction with prompt recovery after discontinuation▫ Wide safety margin & low side effects
• Reality no single agent can achieve the desired effects
• Practice involves the use of combinations of intravenous and inhaled medications, attempting to minimize side effects and maximize anesthetic properties
Anesthetics
• Residual effects of the use of anesthetics may influence rehabilitation outcomes for several days after use
• Short-acting agents in smaller doses is ideal but sometimes reversal agents are required
• Selection of agents may be made on the side effect profile and characteristics of the patient▫ Drug with little cardiovascular effects for patients
with cardiovascular diseases
RelaxantsOpioids analgesics and NSAIDSsRheumatoid Arthritis and Osteoarthritis Drugs
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Muscle Relaxants• Spasticity and symptoms of muscle spasm are common
in rehabilitation and muscle relaxants are commonly prescribed to improve rehabilitation outcomes and functional status▫ Spasticity injury to the CNS (congenital, metabolic, or
trauma)▫ Muscle spasm musculoskeletal injury or spinal nerve
root compression
• Medications modify centrally mediated inhibitory effects on the final common pathway (motor neurons originating in spinal cord/brainstem, the axon, muscle fibers)▫ Quantifying the spasticity with Ashworth Scale can
facilitate appropriate medication selection and monitoring of progress/effects of treatment
Muscle Relaxants
• GABA plays a key role in spasticity▫ Medications may be oral or injectable and cover a
wide range of classes and therapeutic receptor targets
• Muscle spasm often occurs as a result of the body trying to exert protective effects following an injury (guarding to stabilize the injured joint or body part)▫ Electrical stimulation, anti-inflammatory agents,
polysynaptic inhibitors block afferent input & prevents firing of alpha motor neuron in muscle
Addressing Pain
• Pain is actually consistently undertreated clinically and poor management leads to abuse and misuse of medications▫ Fear of prescribing appropriate treatment▫ Unethical treatment practices▫ Attitudes and beliefs of prescribers, health care
providers, and patients▫ Barriers for effectiveness include age, cognitive
ability, and comorbid conditions▫ Preventing pain is better than regaining control
(acute and chronic pain)
Addressing Pain• Awareness or suspicion of developing tolerance,
dependence, addiction/pseudoaddiction, and withdrawal are important to communicate with the entire health care team including the patient▫ Initial and Ongoing Pain History▫ Teach and educate about signs of concern▫ Adherence and medication monitoring ▫ Ongoing education & assessment of efficacy▫ Alternatives and adjuvants to pain medications
Medication Therapy• Mild & Intermittent Pain▫ Analgesic medications as needed
• More severe or constant/chronic pain▫ Scheduled, around the clock dosing of short
and/or long-acting medications Short acting for breakthrough Long acting for constant suppression Often allows lower doses for effective treatment
• Short acting is beneficial within 1 hour of therapy session to provide optimal control and participation
Opioid Analgesics
• In Florida, effective August 18th Tramadol is a now CIV; effective October 6th, hydrocodone combination products will change from CIII to CII
• Should be reserved for severe pain• Should be titrated up to reach goal of pain
control• Start with immediate-acting on scheduled basis• Titration should be NO MORE than 25%
graduated to reach pain goal
Opioid Analgesic Class Side Effects
• If pain is anticipated for long-term, then short-acting is converted into a long-acting equivalent dose with a short acting on board for breakthrough (short acting is at 10-25% of long-acting dose)▫ Weak and strong opioids have been combined
with acetaminophen and NSAIDs ▫ Sedation, N/V, constipation, pruritus, myoclonus,
respiratory depression, accumulation of toxic metabolites,
▫ Tolerance develops within a few days
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Treatment of Moderate Pain: Weak Opioids
Generic Brand
Timeto
Onset
Time to
Peak Effect
Durationof Action
Misc.
Codeine 45 mins
1 – 2 hours
3 – 4 hours
Weak, prodrugmorphine
Hydrocodone Vicodin, Lortab
45 mins
1 – 2 hours
3 – 5 hours
Combined with APAP & NSAIDs; change to CII
Tramadol Ultram, Ultracet (w APAP)
45 mins –1 hour
1 – 2 hours
3 – 6 hours
High N/V, not for acute pain, neuropathic pain, increased risk of seizure and serotonin syndrome, change to CIV
• GI upset, dyspepsia, xerostomia, oral ulceration, glossitis, GI mucosal hemorrhage, abrupt acute renal insufficiency, fluid retention, worsening of CHF, memory loss, confusion, dizziness, headache
• Reversible inhibition of platelet aggregation (lasts up to 3 days)
• Increased bleed risk when used with oral anticoagulant Warfarin (Coumadin)
Etodolac Lodine
Ibuprofen Motrin/Advil
Indomethacin Indocin
Ketoprofen Orudis
Ketorlac Toradol
Meloxicam Mobic
Nambutone Relafen
Naproxen Aleve Naprosyn
Naproxen sodium
Anaprox, Naprelan
Oxaprozin Daypro
Piroxicam Feldene
Sulindac Clinoril
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Osteoarthritis
• Osteoarthritis is the most prevalent form of arthritis in the US (~22%) and effects seniors (70% aged 55 – 78 yrs)
• Typically the weight bearing joints (hips and knees) but no effect on other organs
• May be primary (wear & tear) or secondary (disease or condition)▫ Weight reduction often primary recommendation▫ Ligaments & muscles weaken as joints weaken▫ Inhibits muscle function atrophy
Osteoarthritis
• Progression bone change, muscle weakness & atrophy, loss of joint integrity (deformity) disability▫ Patient education, joint conservation, joint-
sparing exercise▫ Pain management with pharmacologic and non-
pharmacologic treatment▫ No progressive prevention with pharmacologic use APAP, NSAIDs, Opioids Topicals, Supplements Injections (Corticosteroids, Hyaluronic Acid)
Rheumatoid Arthritis
• Chronic, inflammatory autoimmune disease that affects multiple tissues/organs (predominantly synovium) pain, stiffness, symmetrical swelling, limited range of motion▫ Periods of exacerbation and remission▫ 1% of adult population in US (women 3x men)▫ Patient education is paramount (self-
• Typical medications in RA treatment are NSAIDs for symptomatic relief and disease modifying antirheumatic drugs (DMARDS) to reduce progressive destruction▫ Orals monitor for toxicity, onset is slow, many
have N/V, risks for drug interactions, comorbidities
▫ Injectables site reactions, immune issues, latent infections
DiureticsSympatholytics, Vasodilators, Calcium Channel BlockersACE Inhibitors and Angiotensin II BlockersAntiarrhythmic DrugsAnticoagulation DrugsAntihyperlipidemic Drugs
Cardiovascular Disease
• Several heart diseases may exist or co-exist increasing the challenge of management while avoiding side effects of medications and progression of the disease▫ Congenital defects▫ Arrhythmias▫ Acquired inflammatory heart disease▫ Heart valve problems▫ Degenerative cardiovascular disorders▫ Heart failure▫ Atherosclerosis-related
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Cardiovascular Medications
• Following non-pharmacologic measures such as weight loss, heart-healthy diet, restricted salt & alcohol intake, smoking cessation & exercise
• Nine classes of drugs with variations in targeted mechanisms▫ Choice of medication is dependent on concurrent
disease state▫ Progressive addition of medications▫ Implications of risk factors, gender, age, ethnicity
impact mediation selection ▫ Guidelines from AHA & Am College of Cardiology
Diuretics
• Reduce blood volume promotion of sodium and water excretion through the kidneys
• Thiazide diuretics: reducing edema and blood volume in patients with normal renal function, helpful in elderly patients with systolic HTN, more effective than loop diuretics
• Loop diuretics: used with CHF patients, creatinine clearance <30ml/min
• Potassium sparing diuretics: used often with CHF &in combination with other diuretics
Diuretics
Thiazide Dizziness, orthostatic hypotension,increased risk of falls, cardiac arrhythmias, weakness, muscle fatigue, cramps, orthostasis, electrolyte imbalances, hypokalemia, hypomagnesemia, hypercalcemia, hyperuricemia, hyperglycemia, sexual dysfunction, noted side effects with medications (inducing toxicity), NSAIDs reduce effects
• Inhibit calcium influx into cardiac and smooth muscle relaxation & decreased contractility
• Bradycardia, nausea, peripheral edema, hypotension, increased risk of falls
• Verapamil high constipation• Caution with statins
Calcium Channel Blockers (-dipine)
Antagonists Dihydropyridines cause vasodilation without controlling heart rate must be combined with other medications
Drug C S F Miscellaneous
Amlodipine (Norvasc)Felodipine (Plendil)Nicardipine (Cardene)Nifedipine SR (Adalat, Procardia)Nifedipine IR (Sular)
Very low
0 L • Vascular vasodilation (not cardio) and may lead to compensatory increase in heart rate with increased cardiac output and O2 demand in patients with angina and CHF
• Dizziness, orthostasis, increased risk of falls, flushing headache, gingival hyperplasia, peripheral edema, GI side effects, mood changes
• Drug interactions with statins
ACE Inhibitors• Reduce peripheral arterial resistance without
impacting cardiac output and heart rate• ACE is primarily located in endothelial cells (blood
vessels)• ACE converts Angiotensin I Angiotensin II▫ Angiotensin II = potent vasoconstrictor & stimulates
aldosterone & antidiuretic hormone▫ Promotes retention of sodium and water in kidney
• ACE Inhibitors cause vasodilation lowered BP & decreased fluid retention▫ Blocks bradykinin & stimulates other vasodilators▫ Prevent or reverse left ventricular hypertrophy,
• To treat inefficient or incomplete cardiac contraction or inefficient movement of blood through the heart or inefficient delivery of oxygenated blood to the body▫ Congenital, trauma related, medication induced▫ Signs: palpitation, chest pain, lightheadedness,
weakness, fatigue, dizziness, syncope• Classified by location of origination in the heart • Medications establish normal sinus rhythm,
suppress excitability & control ventricular rate
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Antiarrhythmic Medications
Type 1: Sodium Channel Blockers
Type 1a Maintain sinusrhythm & prevent ventricular arrhythmia
QuinidineProcainamideDisopyramide
Diarrhea in 50% (Quinidine)High side effect profile with other medicationsTaste changes, blurred vision, dry mouth
Type 1b Treatventricular arrhythmia
LidocaineMexiletine
High side effect profileLidocaine increase respiratory depressionConfusion dizziness, coordination issues
Type 1 c Maintain sinus rhythm
FlecanidePropafenone
Dizziness, fatigue, tremorAdditive effects w BBHypotension, torsades de pointes (propafenone)High drug interaction profile
Antiarrhythmic Medications
Type II: Beta Blockers
Type III: Potassium Channel Blockers
Amiodarone (Cordarone)
Pulmonary fibrosis, hypothyroidism, elevated liver enzymes, jaundice, blue-grey discoloration of skin, high side effect profile with other medications
Sotalol (Betapace)
Moderate cognitive, sedation and fall risk, fatigue, bradycardia, high side effect profile
Dofetilide (Tikosyn)
Bradycardia, headache, torsades de pointes, no effect on cognitive or sedation, moderate for falls
Ibutilide (Corvert)
Low cogntive, sedation and fall risk, SE: arrhythmia & nausea, no drug interactions identified
Type IV: Calcium Channel Blockers
Anticoagulation Drugs
• Interfere with clot formation decrease risk of stroke, heart attack, DVT & PE▫ Claudication medications used to treat peripheral
artery disease are slightly different in mechanism and SE profile
• Immobile patients may need injectable formulations until they can be transitioned to oral medication options ▫ May be single situation treatment or for recurrent
prevention▫ Wide variation in patient responses
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Anticoagulation Drugs
• Post surgery, immobile patients, post-stroke, ICU patients▫ Low-dose Subcutaneous Heparin to prevent clot
Useful with high PPG, obese patients, or at-risk for hypoglycemia, slow titration, food dependent & GI upset (monotherapy doesn’t lead to hypoglycemia)
Dipeptidyl peptidase-4inhibitor (DPP-4)
Prevents degradation of GIP & GLP-1 increases effects and slowing of insulin response to meals, improves insulin secretion & inhibit glucogon production
Sitagliptin (Januvia)Saxagliptin (Onglyza)
Monotherapy orCombinationtherapy
No hypoglycemia as monotherapy, generally well-tolerated, renal adjustments, modest antihyperglycemic effects in elderly
Improved glucose with reduced risk of hypoglycemia, modest improvements in BP, transient N/V, monitor other medications to reduce risk of hypoglycemia, potential to increase drug absorption complications due to gastric emptying
Amylin derivative Synthetic analog of human amylin, used when glucose control is suboptimal despite insulin therapy, slows gastric emptying
Pramlintide (Symlin) Combination with insulin
Improves long-term control, reduces spikes in PPG/glucagonsecretion & regulates food intake with appetite suppression, dose adjustments to insulin, SE: nausea, potential to increase drug absorption complications due to gastric emptying
Antiarrhythmics, Antihypertensives, Antidiabetics, GI agents, Antibiotics, NSAIDs,
Opioids,
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Other Medications to Consider• Anticoagulants▫ Bruising can be anticipated & supportive handling
should be used to minimize additional problems• Respiratory ▫ All patients with Asthma or COPD should pretreat
with SABA and have inhaler with them• Cardiovascular Medications▫ Heart rate will not peak as expected▫ Orthostasis & thermoregulation issues
• Diabetic Medications▫ Having glucose available and knowing exercise
impacts on blood sugar levels
CNS• These drugs are not typically used to influence
the outcomes of rehabilitation therapy; however, the number of patients on CNS medications warrants special consideration during sessions▫ Peak effects are around 2 -4 hours▫ Some patients may benefit from a more relaxed
state (increasing cooperation) but caution should be used
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CNS
• Lingering effects of long-acting medications can increase fall risks for morning scheduled appointments or for medications with high sedative and/or hypnotic effects▫ Problematic for gait training▫ Interfere with cognitive processing
• Timing of medications and timing of therapy sessions should be well matched for patients with movement disorders (Parkinson)
Antidepressants
• Side effects of Antidepressants may limit or create challenges for therapy sessions▫ Sedation effects may require caution when
changing between equipment ▫ Issues of nausea may increase with exertion
Sweating and increases in heart rate may further complicate anticholinergic effects
▫ Caution should be exercised to prevent orthostasis
Antipsychotics• Side effects of Antipsychotics▫ Lingering effects of evening dosing or morning
dosing may increase difficulties with coordination and effort
▫ Assessments and evaluations of functional status should be ongoing to determine if extrapyramidal symptoms (EPS) are increasing risk of falls or interfering with participation
▫ Sweating and increases in heart rate may further complicate anticholinergic effects
▫ Patient exertion and endurance should be monitored to prevent cardiac complications or seizure (medication specific not class)
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Antiepileptics• Side effects of Antiepileptics▫ Lingering effects of evening dosing or morning
dosing may increase difficulties with coordination and effort
▫ Assessments and evaluations of functional status should be ongoing to determine if extrapyramidal symptoms (EPS) are increasing risk of falls or interfering with participation
▫ Careful monitoring of heat rate, orthostasis, dizziness and fatigue may be required depending on rehabilitation goals
Pain Management
• Adequate pain management needs to be on board to allow the patient the ability to participate in therapy effectively▫ Most medications will have onset of action within an
hour (muscle relaxants, opioids, NSAIDs) and should be taken prior to the appointment
▫ Patients need to be cautioned that they may have inhibition in sensing pain (knowing their limits) and should scale back effort to avoid injury
▫ Orthostasis increases with the use of strong opioids and cognitive impairment may impact safely transitioning between stationary and movement exercises
Cardiovascular Impacts• Patients on diuretic must be monitored for
orthostasis and for dehydration in patients during rehab
• Beta Blockers will reduce heart rate and contractility and therapy goals should be adjusted accordingly
• Calcium Channel Blockers will lead to vasodilation and may or may not impact heart rate
• All patients should be carefully transitioned between laying, sitting and standing activities (including getting off equipment)
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Cardiovascular Impacts
• Core body temperature should be assessed as well as dizziness and fatigue for cardiovascular patients
• Patients should have issues of edema they do not recognize and those should be communicated back to the PCP as well as pointed out to the patient to continue to monitor
• Age and other comorbid disease states may lead to ‘nontraditional’ side effects such as sedation and cognition complications
Anticoagulants• Patients on anticoagulants will experience increased
bruising following rehab ▫ Massage & assisted movement of legs ▫ Issues of mobility may indicate clots and should be
communicated immediately▫ Exercise additional caution with patients to avoid falls
and increased risks of bleed
• Bleed caused from anticoagulants and antithrombotics may cause myalgia and arthralgia in patients & complications with wound care healing▫ You may be the person who identifies this occurrence
before bruising is visible
Statins
• Patients may present with muscle pain or limited range of motion due to pain from rhabdomyolysis▫ Assess level of medication, length of time on
medication and length of time experiencing pain▫ Typically presents in major skeletal muscle groups
(not actually the joints) assess for site of pain▫ Weakness of muscles may be an indicator ▫ Monitor patients to assess limitations in
circulation, viral infections and inflammation which can exacerbate or trigger rhabdo
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Respiratory medications
• Patients with asthma or COPD need to have their inhalers with them at all times
• Patients should pretreat at least 20 minutes prior to exercise or activities that will increase respiration▫ Adequate rest periods may be necessary to
alleviate bronchospasm▫ Any audible wheezing should be treated and
therapy should be postponed until control is achieved
Diabetic medications• Primarily, the major issue with diabetic medications
is hypoglycemia which may be induced with exercise• Some patients may need adjustments in insulin or
glucose depending on the level of exertion▫ As patients become more physically active they need
reminders to monitor blood sugar so adjustments can be to prevent complications
• Having orange juice or hard candy available for patients experiencing hypoglycemia or emergencies is good practice
• Advanced diabetes may lead to neuropathies and difficulty with muscle function – monitor patients for fall prevention
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Patient Safety and Risk Reduction• Balance training to reduce falls for patients with
CNS medications• Environmental clearing (avoid items that can
increase trips, stumbles, falls, slips etc.)• Implement non-pharmacologic interventions to
Improved Clinical Outcomes• Ensuring the patient is aware of the importance
of medication adherence, side effects & impact of physical therapy on certain disease states or medications
• Documentation of any observed side effects and communication to primary care provider of observations during rehabilitation is necessary and may prevent emergent issues
Bringing it all together
• Which medications/classes may require caution during massage techniques?
• Which medications/classes will effect balance, gait, coordination?
• Which medications/classes will effect heart rate when walking on the treadmill, using the cycle, or may be impacted by heat?
• Which medications/classes will effect muscle strength and fatigue?
• Which medications/classes will mask sensation of pain or may impact exertion?
• Which medications/classes will may cause body aches/pain which may be misrepresented as simple musculoskeletal pain?
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Peer Roundtable
• What issues have you experienced with medication limitations during rehab with patients?
• What therapeutic modality has created the greatest challenge to overcome with a patient due to their medication limitations at your practice site?
Peer Roundtable
• What opportunities have you had to identify a drug interaction or side effect missed by other health care providers?
• What issues have you experienced with patients taking herbals, vitamins, or other supplements that have led to complications with prescription medications and/or rehabilitation?
