Geriatric drug therapy: who are the stakeholders? (Pharmacology and Older People)

The impact of drug therapy in the elderly is profound, affecting more than just the patient consuming the medication. It also has an impact on all segments of society, including the pharmaceutical industry, the federal government, health professionals, and other caregivers.

The perspective of each of these groups may be quite different, but each is equally important. Whether the main concern is the development of new drugs, the design of prescription reimbursement programs, drug prescribing, providing care for individuals consuming medications, or knowing how to take a medication properly, each of these groups is an important stakeholder in the drug therapy of the elderly.

This article will look at some of the significant implications of drug therapy in each of these groups to provide the reader with insight into this important topic.

PHARMACEUTICAL MANUFACTURERS

The pharmaceutical industry must look at geriatric medication use from a broad perspective, ranging from clinical considerations to policy making and reimbursement issues. In addition to the obvious concern about whether a drug product being developed will be safe and effective in the elderly, the company must be concerned about whether the drug will receive the approval of the Food and Drug Administration and whether the company will make a profit in an increasingly competitive market.

Perhaps the single most influential factor resulting in the increasing complexity of drug therapy in the elderly is the recent development of a large number of new drugs and drug classes.

While a considerable number of prescription and nonprescription drugs were available prior to the early 1970s, the selection was relatively small compared to today's vast pharmacotherapeutic armamentarium. At that time drugs were available for treatment of infection, high blood pressure, and depression, but product selection was nothing like it is today. It was not as complex, nor was it as beneficial to the patient.

Most of the important drug classes commonly used in the elderly today were developed in the past 25 years. Histamine receptor blockers like cimetidine (Tagamet), ranitidine (Zantac), and famotidine (Pepcid) for the prevention and cure of peptic ulcer disease have all but eliminated gastric ulcer surgery, which (while seeming quite barbaric now) was a common intervention for resistant ulcers before the availability of this class of drugs.

Beta adrenergic receptor blocking drugs such as propranolol (Inderal), atenolol (Tenormin), and almost a dozen others have proven very effective in treating angina, hypertension, and a variety of other conditions. Calcium channel blockers like diltiazem (Cardizem), verapamil (Isoptin), and nifedipine (Procardia) effectively treat angina, high blood pressure, and cardiac arrhythmias. Cephalosporin antibiotics like cephalexin (Keflex), a large number of other second, third, and fourth generation drugs within the class, and a host of other entirely new classes of antibiotics are now available to treat a wide variety of infections. In many cases, these drugs allow for the treatment of serious infections that would have previously required hospitalization.

New classes of antidepressants such as the selective serotonin reuptake inhibitors (SSRIs), including sertraline (Zoloft), paroxetine (Paxil), and fluoxetine (Prozac), have made possible more effective treatment of depression, a condition that has recently been recognized as very common in the elderly. Drugs to lower cholesterol such as the HMG-CoA Reductase Inhibitors lovastatin (Mevacor) and pravastatin (Pravachol) have made it possible to prevent the complications of chronically elevated cholesterol in many patients. Countless heart attacks have been prevented in elderly patients because of the availability of these drugs.

In recent years a number of unique "breakthrough" drugs have been developed to treat conditions for which effective treatment was previously unavailable. Recent breakthrough drugs include dornase alpha (Pulmozyme) for cystic fibrosis, and clozapine (Clozaril) for schizophrenia.

The amazing thing about all this drug development is that in spite of the tremendous advances recently made, we have only just begun to see the benefits that will spring from the profound increase in scientific knowledge that, in many instances, has enabled scientists to understand precisely how the human body functions on a genetic and even a molecular level.

One of the first steps in developing a new drug, and perhaps the most difficult, is to define the specific biochemical abnormality that causes a specific disease process. From that point, scientists can develop a pharmacologic intervention to control or even reverse the process. For example, for a long time scientists were aware that the prostate gland grew as age advanced, with a high …