Cultural diversity and Medication Safety

Agenda – 9/25/07 Article presentations Narayanasamy (2003) - Gina de Chesnay, Ch. 8 - Gina Chesnay, Ch. 10 - Gina Leininger (1993).- Susie Salimbene, S. (1999) – Susie Wheeler (2004) – Susie Cultural diversity and medication safety

Assumptions Ethnic culture affects beliefs about health, illness, medications, interactions with healthcare providers, & comply with prescribed med. as well as response physiologically to med. Culturally competent care involves knowledge not only of pt’s beliefs and values about health care and illness, but also of their responses to treatment

Beliefs about health, illness, medications White Intolerance to pain High expectation to be cured or well managed through technology, powerful drugs Management of microbes > bolster resistance to them Asians Drug’s safety profile > its effectiveness Use lower doses and fewer reported side effects Quick remove of S/S does not equal to a permanent cure Drug’s safety profile > its effectiveness -> use lower doses and fewer reproted side effects

Interaction with healthcare providers Language barrier Nonverbal communication Trusting relationships Attire, attitude Family involvement Decision maker Attire, appearance, attitude of health care providers are important in Asian population

Adherence to prescribed medications Beliefs on the medication Discontinue the med when symptoms ease Thwart the acceptance of drugs with a delayed onset of action Stop taking the med. – esp if the dis is not common in their original country S/S reliefed -> discontinue the med –African Americans and Native Americans often doubt the need for medications when S/S ease; it is not good for antibiotics Stop taking the med if the dis is not common in their original country ie. Chinese does not believe dietary requirements is important for DM Being culturally competent involves knowledge not only of pat’s beliefs and values about health and illnss, but also of their responses to treatment

Physiologic response to medications Genetic polymorphisms 3-5% of whites compare to 15-20% of Asians are poor metabolizers of drugs affected by mephenytoin polymorphism ie. Diazepam, imipromine Asians and Eskimos need lower doses of anxiolytics than white Diet and tobacco use can influence a gene’s expression, which can in turn alter a drug’s effect Polymorphisms (multiple forms of enzymes used for drug metabolism) affect the metabolism of medications Asians, Indians, and Pakistanis require lower doses of lithium and antipsychotic drugs.

Pharmacology Pharmacokinetics Pharmacodynamics Absorption Metabolism Distribution Elimination Pharmacodynamics Mechanism of action Effects at the target site Drug metabolism involves two phases, an oxidation phase (phase 1) and conjugation (phase 2) , Genetic abnormalities in the CYP (cytochrome P-450) enzymes are not only extremely common but have profound implications for drug response. Enzymes are responsible for the phase 1 metabolism of many drugs ie antipsychotic and antidepressants. Drug metabolism affects drug plasma levels at a given dosage.

Culture & lifestyle factors Preference -Ways of taking the med. ie. Oral, injection, Rituals ie. Fasting -> affects drug absorption Fear- Concerns about addictive effects -> cut the dose Fasting -> medicaiton schedules or interfere with drug absorption

Medicine example- Psychotropic agents Antipsychotics Typical – thorazine, haldol Atypical – Risperdal, Clozaril, Antidepressants- tricyclic antidepressants Anti-anxiety Mood stabilizer - Lithium Effectiveness and side-effects Lithium – similar dosage-> Blacks reported more lethargy and dizziness than whites does

Medicine example- Antihypertension ACE (angiotensin-converting enzyme) inhibitor – work better for whites than blacks Captopril (Capoten) Enalapril Losartan Thiazide diuretics – better for blacks than whites Hydrochlorothiazide (Esidrix and others) Calcium channel blockers

Non-adherence to treatment Interpretation of the drug effects including side effects Positive or negative Culture-bound syndromes complicate evaluation of drug response- inadvertent misdiagnosis, ineffective treatment, & inappropriate prescribing Others -language barrier, clinician’s beliefs and preconceptions, and pt’s distrust of the health care system Bipolar Chinese pt rarely complained of “missing the highs” and regarded polydipsia, polyuria, and weight gain as part of the therapeutic effect. Meanwhile attributed lethargy and poor memory to the drug

Roles of the care provider Therapeutic range of the medication and the risk of toxicity – serum level of the medication and the side effect Skill in communication – attitude, terminology Touchy subject - fear of offending people Avoid a “we/they” attitude Respect Individual difference Asian cultures value patience and modesty; rarely complains, likely to express their problems in behavioral or somatic terms rather than in emotional ones. Blacks – hypertension = high blood; anemia= low blood

Prepare for next week Article presentations Ethics de Chesnay, Ch. 11- Gigi /Heaven Purnell & Paulanka (2005) – Gigi Munoz, C. & Hilgenberg, C. (2005). -Gigi Ethics