Zusammenfassung
Gebrechliche alte Menschen gelten als besonders gefährdet, eine unerwünschte Arzneimittelwirkung zu erleiden. Empirische Studien belegen die erhöhte Rate unerwünschter Arzneimittelwirkungen. Ob „frailty“ per se den Arzneimittelmetabolismus beeinträchtigt oder führend die zugrunde liegenden Organalterungsprozesse und die Multimorbidität, kann nach aktueller Datenlage nicht sicher beantwortet werden. Herz-Kreislauf-Erkrankungen weisen eine erhebliche Verflechtung mit „frailty“ auf. So gibt es eine überproportionale syndromale Interdependenz zwischen Herzinsuffizienz und „frailty“, und die typischen Alterungsprozesse des Sinusknotens können als „heartbeat frailty“ interpretiert werden. Die geriatrietypische Multimorbidität beinhaltet häufig einen Cluster chronischer Herz-Kreislauf-Erkrankungen, was oftmals auch bedarfsgerecht zur Multimedikation mit Einsatz mehrerer kardiovaskulärer Medikamente führt. Neuere Definitionen der „Polypharmazie“ bewerten weniger die Zahl der Medikamente als deren Angemessenheit. Eine praxisorientierte Bewertungshilfe bieten unter anderem die Fit-fOR-The-Aged(FORTA)-Liste, die PRISCUS‑2.0‑Liste sowie die „Cochrane Library Special Collection on deprescribing“. Bei der Behandlung der arteriellen Hypertonie wurden in den letzten Jahren die Zielwerte auch für ältere Menschen immer niedriger angesetzt. Bei gebrechlichen alten Menschen hingegen geben die Leitlinien keinen starren Blutdruckzielkorridor vor, die Verträglichkeit ist hier das Entscheidende. Bei der Einleitung einer antihypertensiven Therapie kann bei gebrechlichen Personen – abweichend vom Regelfall einer Zweifachkombination – eine Monotherapie erwogen werden. In der OPTIMISE-Studie führte das Absetzen eines Blutdruckmedikaments nicht zu einer besseren Verträglichkeit der medikamentösen Therapie. In Bezug auf die Nutzen-Risiko-Bewertung von neuen oralen Antikoagulanzien im Vergleich zu Vitamin-K-Antagonisten in der Antikoagulation bei gebrechlichen alten Menschen mit Vorhofflimmern kommen aktuelle Studien zu unterschiedlichen Ergebnissen. Ein „shared decision-making“ wird empfohlen, was gerade bei betagten Personen die Adhärenz verbessern könnte.
Abstract
The frail and elderly are considered to be at particular risk of suffering an adverse drug reaction. Empirical studies confirm the increased rate of adverse drug reactions. Whether frailty per se impairs drug metabolism or the underlying organ ageing processes and multimorbidity cannot be answered with certainty based on current data. Cardiovascular diseases exhibit a considerable interdependence with frailty. For example, there is a disproportionate syndromal interdependence between heart failure and frailty, and the typical ageing processes of the sinus node can be interpreted as heartbeat frailty. Multimorbidity in the elderly often includes a cluster of chronic cardiovascular diseases, often leading to the use of several cardiovascular medications as required. More recent definitions of polypharmacy assess the appropriateness of drugs rather than their number. The Fit-fOR-The-Aged (FORTA) list, the PRISCUS 2.0 list and the “Cochrane Library Special Collection on deprescribing”, for example, offer a practice-oriented assessment aid. In the treatment of arterial hypertension, the target values for older people have also been set ever lower in recent years. In the case of frail elderly people, on the other hand, the guidelines do not specify a strict blood pressure target corridor; tolerability is the crucial factor here. When initiating antihypertensive therapy in frail individuals, one can consider monotherapy—in a departure from the standard case of dual combination therapy. The OPTIMISE study showed that discontinuation of one blood pressure medication did not lead to better tolerability of the drug therapy. Current studies come to differing conclusions regarding the risk–benefit assessment of new oral anticoagulants compared to vitamin K antagonists in the anticoagulation of frail elderly people with atrial fibrillation. Shared decision-making, which could improve adherence particularly in older people, is recommended.
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U. Müller-Werdan gibt an, dass sie in den letzten Jahren Vortragshonorare erhalten hat von Assistenz3, Bayer, Bristol Myers Squibb, Daiichi Sankyo, Novartis, Paul-Martini-Stiftung, Pfizer, ThermoFisher und Schäfer Events.
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Müller-Werdan, U. Arzneimitteltherapie von arterieller Hypertonie und Vorhofflimmern bei gebrechlichen Patienten. Innere Medizin (2024). https://doi.org/10.1007/s00108-024-01681-8
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DOI: https://doi.org/10.1007/s00108-024-01681-8
Schlüsselwörter
- Frailty-Syndrom
- „Frailty“/Pharmakokinetik
- Polypharmazie
- Hypertonie/Blutdruckzielwert
- Neue orale Antikoagulanzien