1. Copyright © 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved. Chapter 9 to 11 Drug Therapy Across the Lifespan

2. Copyright © 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved. Drug Therapy During Pregnancy and Breast-Feeding  There is a shortage of reliable data regarding toxicity from drug use during pregnancy or breast-feeding  In 2009, the U.S. Food and Drug Administration (FDA) launched the Medication Exposure in Pregnancy Risk Evaluation Program (MEPREP) 2

3. Copyright © 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved. Drug Therapy During Pregnancy  Two thirds of pregnant patients take at least one medication; most take more  For pregnancy-related problems such as nausea, constipation, and preeclampsia  For chronic disorders such as hypertension, diabetes, and epilepsy  For infectious diseases or cancer  Drugs of abuse such as alcohol, cocaine, and heroin 3

4. Copyright © 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved. Drug Therapy During Pregnancy  Physiologic changes during pregnancy and their impact on drug disposition and dosing  Third trimester: Renal blood flow is doubled and renal excretion is accelerated  Tone and mobility of bowel decrease Prolongation of drug effects 4

5. Copyright © 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved. Drug Therapy During Pregnancy  Placental drug transfer  All drugs can cross the placenta  Some can cross more easily than others  Adverse reactions during pregnancy  Can adversely affect both pregnant patient and fetus  Some unique effects: Heparin causes osteoporosis Prostaglandins stimulate uterine contraction Certain pain relievers used during delivery can depress respiration in the neonate 5

6. Copyright © 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved. Drug Therapy During Pregnancy: Teratogenesis  Birth defects  Gross malformations Cleft palate, clubfoot, and hydrocephalus  Neurobehavioral and metabolic anomalies  Incidence and causes of congenital anomalies  Less than 1% of all birth defects caused by drugs  Identification of teratogens very difficult  As a result, only a few drugs are considered proven teratogens 6

7. Copyright © 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved. Teratogenesis  Minimizing the risk for teratogenesis  Pregnant patients should avoid unnecessary drug use (for example, alcohol, cocaine)  Responding to teratogen exposure  Identifying details of exposure  Ultrasound scans 7

8. Copyright © 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved. 8

9. FDA Pregnancy Risk Factors  A: Safest  B: More dangerous than A  C: More dangerous than A and B  D: More dangerous than A, B, and C  X: Most dangerous; known to cause fetal harm 9

10. Copyright © 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved. Drug Therapy During Breast-Feeding  Drugs can be excreted in breast milk, and effects can occur in the infant  How to decrease risk to the infant:  Take drugs immediately after breast-feeding  Avoid drugs that have long half-lives  Choose drugs that tend to be excluded from milk and that are least likely to affect the infant  Avoid drugs that are known to be hazardous 10

11. Copyright © 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved. Pediatric Patients  All patients younger than 16 years old  Pediatric patients respond differently to drugs than the rest of the population  More sensitive to drugs than other patients are  Show greater individual variation  Sensitivity due mainly to organ system immaturity  Increased risk for adverse drug reactions 11

12. Copyright © 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved. Pediatric Patients Less than 36 weeks’ gestational age Premature infants 36 to 40 weeks’ gestational age Full-term infants First 4 postnatal weeks Neonates Weeks 5 to 52 postnatal Infants 1 to 12 years old Children 12 to 16 years old Adolescents 12

13. Copyright © 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved. Pediatric Patients  Ongoing growth and development  Different age groups have different challenges  Two thirds of drugs used in pediatrics have never been tested in pediatric patients  Two laws:  Best Pharmaceuticals for Children Act (2002)  Pediatric Research Equity Act of 2003  These laws were permanently reauthorized as part of the FDA Safety and Innovation Act (FDASIA) of 2012 13

14. Copyright © 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved. 14

15. Copyright © 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved. Pharmacokinetics Neonates  Increased sensitivity  Absorption  Oral: Delayed gastric emptying time  Low gastric acidity results in increased absorpotion of acid labile drugs  IM slow, erratic  Transdermal ; more rapid  Distribution  BBB not fully developed Infants  Increased sensitivity  Absorption 15

16. Copyright © 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved. Case Study What should the nurse teach the orientees about young infants’ medication requirements related to the administration of fat-soluble medications and medications that bind to plasma proteins? 16

17. Copyright © 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved. Case Study Is there any information that the nurse should teach the new orientees about the administration of medications to young infants with regard to the blood-brain barrier? 17