{"id":743,"date":"2026-01-20T15:42:41","date_gmt":"2026-01-20T12:42:41","guid":{"rendered":"https:\/\/tatd.org.tr\/geriatri\/?p=743"},"modified":"2026-01-20T15:42:42","modified_gmt":"2026-01-20T12:42:42","slug":"geriatrik-zehirlenmeler-risk-gruplari-ve-yonetim-ilkeleri","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/geriatri\/genel\/geriatrik-zehirlenmeler-risk-gruplari-ve-yonetim-ilkeleri\/","title":{"rendered":"Geriatrik Zehirlenmeler, Risk Gruplar\u0131 Ve Y\u00f6netim \u0130lkeleri"},"content":{"rendered":"\n

Yazar: Prof. Dr. \u00d6zg\u00fcr Karc\u0131o\u011flu<\/strong> Edit\u00f6r: Do\u00e7. Dr. Rana Di\u015fel<\/strong><\/p>\n\n\n\n

*Ekim 2024\u2019de yaz\u0131lan bu blog yaz\u0131s\u0131 teknik sorunlar nedeni ile Ocak 2026\u2019da yay\u0131nlanm\u0131\u015ft\u0131r.<\/p>\n\n\n\n

Ya\u015fl\u0131l\u0131k kavram\u0131 sadece takvim ya\u015f\u0131yla a\u00e7\u0131klanamayacak kadar karma\u015f\u0131k olsa da, \u201cgeriatrik hasta\u201d <\/em>grubu genellikle 65 ya\u015f \u00fczeri ki\u015fileri tan\u0131mlar. \u00dclkemizde ortalama ya\u015fam beklentisinin geli\u015fmi\u015f bat\u0131 \u00fclkelerinden daha d\u00fc\u015f\u00fck oldu\u011fundan hareketle ya\u015fl\u0131l\u0131k s\u0131n\u0131r\u0131n\u0131 55 olarak kabul edilmesi de savunulmaktad\u0131r. Bu konu ila\u00e7 metabolizmas\u0131 ve farmakokinetik ilkeleri a\u00e7\u0131s\u0131ndan \u00f6nemlidir \u00e7\u00fcnk\u00fc zehirlenme \u015fiddeti bu h\u00fccresel, enzimatik ve sistemik mekanizmalarla do\u011frudan ili\u015fkilidir.<\/p>\n\n\n\n

B\u00fct\u00fcn ya\u015fl\u0131lar ayn\u0131 de\u011fildir. <\/strong>\u2018Sa\u011fl\u0131kl\u0131 ya\u015fl\u0131\u2019 ve k\u0131r\u0131lgan veya \u201czay\u0131f ya\u015fl\u0131\u201d ayr\u0131m\u0131 bize bir\u00e7ok durumda yol g\u00f6sterecektir. Ki\u015fide sadece ya\u015f\u0131n ka\u00e7 oldu\u011fu de\u011fil, komorbiditeleri, at\u0131l\u0131m\/eliminasyon mekanizmalar\u0131n\u0131n \u00e7al\u0131\u015fmas\u0131, diyet durumu, polifarmasi gibi bir\u00e7ok etkenlerin hesaba kat\u0131lmas\u0131 zorunludur.<\/p>\n\n\n\n

Geriatrik zehirlenmeler<\/strong> di\u011fer ya\u015flara g\u00f6re daha fazla hastane yat\u0131\u015f\u0131, daha fazla \u00f6l\u00fcm ve sakatl\u0131k riski ile sonu\u00e7lan\u0131r. <\/em>Analjezikler, antidepresanlar, kardiyovask\u00fcler ila\u00e7lar, psikotroplar en \u00e7ok su\u00e7lananlardand\u0131r. \u00dclkemizde maalesef toplum tabanl\u0131 g\u00fcvenilir veriler \u00e7ok azd\u0131r.<\/p>\n\n\n\n

D\u00fcnyada intihar ve zehirlenme paternleri incelendi\u011finde 75 ya\u015f \u00fczeri erkeklerde art\u0131\u015f e\u011filiminin devam etti\u011fi bildirilmi\u015ftir (Choi 2022). Ya\u015fl\u0131lar\u0131n intihar nedenleri ve e\u011filimleri incelendi\u011finde komorbid hastal\u0131klar\u0131n ve bak\u0131mverenlerin \u00f6l\u00fcm\u00fcn\u00fcn, izolasyon duygusunun intihar ama\u00e7l\u0131 al\u0131mlarla do\u011frudan ili\u015fkili oldu\u011fu bir\u00e7ok \u00e7al\u0131\u015fmada ortaya konmu\u015ftur (Juurlink 2004). Gen\u00e7lerde intihar ama\u00e7l\u0131 al\u0131mlarda kad\u0131n olgular \u00f6n plandayken ya\u015fl\u0131larda kad\u0131n-erkek oranlar\u0131 e\u015fitlenmektedir (Geith 2024). Ya\u015fl\u0131lar\u0131n zehirlenmelerdeki oran\u0131 k\u00fclt\u00fcrel ve co\u011frafi etkenlerle yak\u0131ndan ili\u015fkilidir. \u00d6rne\u011fin Yemen\u2019de yak\u0131n zamanda yap\u0131lan bir \u00e7al\u0131\u015fmada 30 ya\u015f \u00fczerindeki zehirlenme olgular\u0131 ancak %12,4\u2019\u00fc olu\u015fturmaktad\u0131r (Al-Mahbashi 2024).<\/p>\n\n\n\n

Ya\u015fl\u0131da ila\u00e7 metabolizmas\u0131ndaki de\u011fi\u015fiklikler<\/strong><\/p>\n\n\n\n

    \n
  1. Karaci\u011fer: <\/strong>Ya\u015fl\u0131larda al\u0131nan ilac\u0131n \u201cilk ge\u00e7i\u015f\u201d (first-pass) etkisi hem karaci\u011fer kitlesinin azalmas\u0131, hem de perf\u00fczyon sorunlar\u0131 nedeniyle d\u00fc\u015fmektedir. Bu biyoyararlan\u0131m\u0131n, dolay\u0131s\u0131yla toksisite potansiyelinin art\u0131\u015f\u0131na yol a\u00e7ar.<\/li>\n\n\n\n
  2. Da\u011f\u0131l\u0131m hacmi (Vd) artar. <\/strong>Ya\u011f kitlesinin v\u00fccuda oran\u0131nda artma, kaslarda erime sonucunda Vd art\u0131\u015f\u0131 ortaya \u00e7\u0131kar. Lipofilik ila\u00e7larda Vd art\u0131\u015f\u0131, dolay\u0131s\u0131yla uzam\u0131\u015f yar\u0131lanma \u00f6mr\u00fc g\u00f6r\u00fcl\u00fcrken hidrofilik (suda \u00e7\u00f6z\u00fcnen) ila\u00e7larda Vd azal\u0131r, etki ve yar\u0131lanma s\u00fcresi d\u00fc\u015febilir.<\/li>\n\n\n\n
  3. Renal ekskresyon: <\/strong>Ya\u015fl\u0131lar\u0131n 2\/3\u2019\u00fcnde renal at\u0131l\u0131m %50\u2019ye kadar d\u00fc\u015fmektedir (Klotz, 2009). Bunun hipertansiyon, diyabet, koroner kalp hastal\u0131klar\u0131yla da ili\u015fkisi vard\u0131r.<\/li>\n\n\n\n
  4. Komorbiditeler ve polifarmasinin zararlar\u0131 <\/strong>da ila\u00e7 metabolizmas\u0131n\u0131 etkilemektedir.<\/li>\n<\/ol>\n\n\n\n

    Ya\u015fl\u0131larda polifarmasinin etkileri:<\/strong><\/p>\n\n\n\n

    Polifarmasi hasta taraf\u0131ndan \u00e7ok say\u0131da ilac\u0131n kullan\u0131lmas\u0131d\u0131r. Net bir say\u0131 vermek m\u00fcmk\u00fcn olmasa da genellikle 5 ila 10 aras\u0131nda oldu\u011fu s\u00f6ylenebilir. Belli bir hastal\u0131\u011f\u0131 olan subgruplarda ila\u00e7 kullan\u0131m\u0131 belirgin olarak artmaktad\u0131r.<\/p>\n\n\n\n

    Advers ila\u00e7 etkisi (A\u0130E) geli\u015fim riski di\u011fer hastal\u0131klardan ve ya\u015ftan ba\u011f\u0131ms\u0131z olarak kullan\u0131lan ila\u00e7 say\u0131s\u0131yla artmaktad\u0131r. Hastaneye yat\u0131\u015f oran\u0131 da ayn\u0131 \u015fekilde ila\u00e7 say\u0131s\u0131yla artar. Polifarmasi ki\u015finin fiziksel ve bili\u015fsel yeteneklerini belirgin \u015fekilde olumsuz etkiler. Hastaneye yat\u0131\u015flar\u0131n\u0131n %0,2 ila 16\u2019s\u0131n\u0131n A\u0130E\u2019lerle ili\u015fkili oldu\u011fu d\u00fc\u015f\u00fcn\u00fclmektedir. Vitamin K antagonistleri (warfarin), antiplateletler ve ins\u00fclin preparatlar\u0131 bunlar\u0131n \u00e7o\u011funu olu\u015ftumaktad\u0131r.<\/p>\n\n\n\n

    Ya\u015fl\u0131da ila\u00e7 a\u015f\u0131r\u0131 dozaj\u0131n\u0131n kolayla\u015fmas\u0131 ve zehirlenmelerin daha a\u011f\u0131r seyretmesinin nedenleri aras\u0131nda;<\/strong><\/p>\n\n\n\n

    -V\u00fccut ya\u011f oran\u0131 art\u0131p kas kitlesi azald\u0131\u011f\u0131ndan ila\u00e7 da\u011f\u0131l\u0131m hacmi artm\u0131\u015ft\u0131r.<\/p>\n\n\n\n

    – Tan\u0131l\u0131 b\u00f6brek hastal\u0131\u011f\u0131 olmasa bile b\u00f6breklerden ila\u00e7 at\u0131l\u0131m\u0131 azalm\u0131\u015ft\u0131r.<\/p>\n\n\n\n

    – Hepatik fonksiyonlar da azald\u0131\u011f\u0131ndan karaci\u011ferden eliminasyon uzam\u0131\u015ft\u0131r.<\/p>\n\n\n\n

    – \u0130la\u00e7 yar\u0131lanma \u00f6m\u00fcrleri uzam\u0131\u015f, ila\u00e7 kan konsantrasyonlar\u0131 da artm\u0131\u015ft\u0131r.<\/p>\n\n\n\n

    – Sonu\u00e7 olarak ayn\u0131 ila\u00e7 ayn\u0131 dozda ya\u015fl\u0131 ki\u015fiye verildi\u011finde bir gence g\u00f6re \u00e7ok daha y\u00fcksek oranda A\u0130E geli\u015fme olas\u0131l\u0131\u011f\u0131 bulunmaktad\u0131r.<\/p>\n\n\n\n

    \u0130la\u00e7-ila\u00e7 etkile\u015fimleri ve ya\u015fl\u0131lar: <\/strong>\u0130la\u00e7-ila\u00e7 etkile\u015fimleri t\u00fcm ya\u015flarda \u00f6nemli morbidite ve mortalite nedeni olmakla birlikte organ yetmezlikleri ve di\u011fer nedenlerle ya\u015fl\u0131lar bundan daha \u00e7ok etkilenmektedir. Gastrointestinal kanama ve d\u00fc\u015fmeler bu etkile\u015fimlerin en \u00f6nemli sonu\u00e7lar\u0131ndand\u0131r.<\/p>\n\n\n\n

    \u00dclkemizden epidemiyolojik veriler:<\/strong> Samsun\u2019da 2005-2011 aras\u0131ndaki 7 y\u0131l i\u00e7inde ya\u015fl\u0131lar\u0131n akut zehirlenme nedeniyle acil klini\u011fine ba\u015fvurular\u0131n\u0131n incelendi\u011fi bir \u00e7al\u0131\u015fmada toplam 3106 hastan\u0131n, 126\u2019s\u0131 (%4,06) geriatrik ya\u015f grubunda (65-92 ya\u015f) idi (Kat\u0131 2013). Erkek\/kad\u0131n oran\u0131 1.1, ya\u015f ortalamas\u0131 73 olarak bulundu. Ya\u015fl\u0131 hastalar\u0131n yar\u0131dan fazlas\u0131nda akut zehirlenme nedeni ila\u00e7 zehirlenmesi iken, bu grupta di\u011fer zehirlenme nedenleri s\u0131ras\u0131yla; %27 karbon monoksit, %12,7 tar\u0131m ilac\u0131, %4,8 besin zehirlenmesi, %1,6 korozif madde zehirlenmesiydi. Ya\u015fl\u0131lardaki zehirlenmelerin b\u00fcy\u00fck \u00e7o\u011funlu\u011fu (%83.3) kaza kaynakl\u0131, %12,7\u2019si \u00f6zk\u0131y\u0131m kaynakl\u0131yd\u0131. \u00d6zk\u0131y\u0131m ama\u00e7l\u0131 al\u0131mlar\u0131n hemen t\u00fcm\u00fc be\u015feri ila\u00e7 ve tar\u0131m ilac\u0131 ile ger\u00e7ekle\u015fti.<\/p>\n\n\n\n

    Prezantasyon ve klinik seyirde ya\u015f\u0131n etkisi: <\/strong>Eski\u015fehir\u2019de yap\u0131lan bir tez \u00e7al\u0131\u015fmas\u0131nda acil servise gelen ya\u015fl\u0131 hastalarda ya\u015f artt\u0131k\u00e7a kullan\u0131lan ila\u00e7 say\u0131s\u0131 da anlaml\u0131 \u015fekilde artt\u0131\u011f\u0131 bildirildi (\u015een, 2012). Kad\u0131nlarda \u00e7oklu ila\u00e7 kullan\u0131m\u0131 daha yayg\u0131nd\u0131. Bak\u0131m yard\u0131mc\u0131s\u0131 olan hastalarda kullan\u0131lan ila\u00e7 say\u0131s\u0131 daha y\u00fcksekti. Ayr\u0131ca kullan\u0131lan ila\u00e7 say\u0131s\u0131 artt\u0131k\u00e7a acil laboratuar kullan\u0131m\u0131 artm\u0131\u015ft\u0131r.<\/p>\n\n\n\n

    Izmir\u2019de yapt\u0131\u011f\u0131m\u0131z uzmanl\u0131k tez \u00e7al\u0131\u015fmas\u0131ndan \u00fcretilen yay\u0131nda da belirtildi\u011fi gibi, antidepresan zehirlenmelerinde ya\u015f hastaneye yat\u0131\u015f oranlar\u0131 ve kal\u0131\u015f s\u00fcrelerini etkileyen ba\u011f\u0131ms\u0131z bir fakt\u00f6rd\u00fcr (Unverir P, 2006). Hekim \u00f6nerisine kar\u015f\u0131n kendi karar\u0131 ile hastaneden ayr\u0131lan (self-discharge) olgular\u0131 i\u00e7in de ya\u015f ba\u011f\u0131ms\u0131z ve g\u00fc\u00e7l\u00fc bir risk fakt\u00f6r\u00fcd\u00fcr (Vallersnes 2019).<\/p>\n\n\n\n

    \u0130la\u00e7 t\u00fcrleri ve miktar\u0131 ile ya\u015f ili\u015fkisi:<\/strong> Benzer \u015fekilde Townsend ve ark. \u0130ngiltere\u2019de 1985-1997 y\u0131llar\u0131 aras\u0131ndaki intihar ama\u00e7l\u0131 ila\u00e7 al\u0131mlar\u0131n\u0131 kapsayan geni\u015f \u00e7al\u0131\u015fmada; antidepresan ve sakinle\u015ftirici grubu ila\u00e7lar\u0131n daha \u00e7ok ya\u015fl\u0131larda, parasetamolun daha \u00e7ok gen\u00e7lerde zehirlenmelere yol a\u00e7t\u0131\u011f\u0131n\u0131 ortaya koymu\u015ftur (Townsend 2001).<\/p>\n\n\n\n

    \u00c7ok yak\u0131n d\u00f6nemde yap\u0131lan bir \u00e7al\u0131\u015fmada Geith ve ark. geriatrik olgularda suisidal ila\u00e7 zehirlenmelerinde al\u0131nan ajan miktar\u0131n\u0131n maksimum \u00f6nerilen dozun 13 kat\u0131 civar\u0131nda, gen\u00e7lerde ise 8,7 kat\u0131 kadar oldu\u011funu ortaya koymu\u015ftur (p<0.001) (Geith 2024). Yine bu \u00e7al\u0131\u015fmada ilgin\u00e7 \u015fekilde, zolpidem, zopiclone gibi antipsikotikler ve benzodiazepin grubu ile zehirlenmelerin ya\u015f ilerledik\u00e7e anlaml\u0131 \u015fekilde artt\u0131\u011f\u0131n\u0131, non-opioid analjeziklerin ise azald\u0131\u011f\u0131n\u0131 belirtmi\u015flerdir (Fig\u00fcr 1) (Geith 2024). \u0130ntihar ama\u00e7l\u0131 al\u0131mlarda antikoagulan ve kardiovaskuler ila\u00e7lar da ya\u015fl\u0131larca daha \u00e7ok se\u00e7ilmi\u015ftir.<\/p>\n\n\n\n

    \"\"<\/figure>\n\n\n\n

    Fig\u00fcr 1. \u0130ntihar ama\u00e7l\u0131 al\u0131mlarda ila\u00e7 t\u00fcrlerinin ya\u015f gruplar\u0131na da\u011f\u0131l\u0131m\u0131. Anlaml\u0131 farkl\u0131 olan ila\u00e7 t\u00fcrleri asterisk ile belirtilmi\u015ftir.<\/strong><\/p>\n\n\n\n

    *p <\/em>< 0.05; **p <\/em>< 0.01; ***p <\/em>< 0.001.<\/strong><\/p>\n\n\n\n

    Tablo 1<\/strong>\u2019de geriatrik olgularda kullan\u0131m\u0131 y\u00fcksek riskli olan ila\u00e7lar ve ilgili riskler \u00f6zetlenmi\u015ftir.<\/p>\n\n\n\n

    Tablo 1. Ya\u015fl\u0131larda kolayl\u0131kla doz a\u015f\u0131m\u0131na yol a\u00e7an ila\u00e7lar ve ilgili riskler.<\/strong><\/p>\n\n\n\n

    \u0130la\u00e7<\/strong><\/td>Risk<\/strong><\/td>A\u00e7\u0131klama<\/strong><\/td><\/tr>
    Analjezikler (opioid)<\/strong><\/td>Solunum depresyonu, bilin\u00e7 bask\u0131lanmas\u0131, kab\u0131zl\u0131k<\/td>Akut ve kronik a\u011fr\u0131 kontrol\u00fcnde fentanil, morfin, oksikodon kullan\u0131larak, dikkatli doz ayarlamas\u0131 ile sonu\u00e7 al\u0131nabilir. Di\u011fer opioid t\u00fcrevlerinde daha y\u00fcksek risk vard\u0131r.<\/td><\/tr>
    Antipsikotikler<\/strong><\/td>\u00d6l\u00fcm<\/td>Demans durumundaki davran\u0131\u015fsal sorunlar\u0131n kontrol\u00fc i\u00e7in verildi\u011finde risk y\u00fcksektir. Di\u011fer durumlarda yarar\u0131 daha fazlad\u0131r.<\/td><\/tr>
    Benzodiazepinler<\/strong><\/td>D\u00fc\u015fme, bilin\u00e7 bozuklu\u011fu<\/td>D\u00fc\u015fme riski ve k\u0131r\u0131klarda belirgin art\u0131\u015f.<\/td><\/tr>
    Kemoterapi ajanlar\u0131<\/strong><\/td>Kemik ili\u011fi depresyonu (n\u00f6tropeni, anemi, karaci\u011fer hasar\u0131, kardiyotoksisite)<\/td>Endikasyonu kesin olarak ortaya konmu\u015f olan ila\u00e7lar, hastan\u0131n organ yetmezlikleri ile beklenen toksisite d\u00fc\u015f\u00fcn\u00fclerek verilmelidir.<\/td><\/tr>
    Antihistaminikler (1. Ku\u015fak)<\/strong><\/td>Uyku hali, odaklanamama, idrar retansiyonu<\/td>Uyku ilac\u0131 olarak verildi\u011finde antikolinerjik etkileri \u00f6nemli bir dezavantajd\u0131r. Uzam\u0131\u015f sedasyon, ara\u00e7 kullanmada risk art\u0131\u015f\u0131 vard\u0131r.<\/td><\/tr>
    Antikoagulan ila\u00e7lar: warfarin<\/strong><\/td>Mide veya intrakranial kanama, aort veya beyinde anevrizma kanamas\u0131<\/td>PT ve INR izlemi iyi yap\u0131ld\u0131\u011f\u0131nda yarar\u0131 risklerinden daha fazlad\u0131r.<\/td><\/tr>
    \u0130nsulin<\/strong><\/td>Kan \u015fekerinde d\u00fc\u015fme (hipoglisemi)<\/td>\u00d6\u011f\u00fcn atlama durumunda hemen her zaman hipoglisemik atak g\u00f6r\u00fcl\u00fcr. Gastroenterit, i\u015ftahs\u0131zl\u0131k gibi durumlarda da risk y\u00fcksektir.<\/td><\/tr>
    Oral antidiabetik<\/strong><\/td>Hipoglisemi<\/td>Ya\u015fl\u0131 hastalarda hipoglisemi riski y\u00fcksektir.<\/td><\/tr>
    Digoksin<\/strong><\/td>Bili\u015fsel bozukluk, aritmiler, atrioventrik\u00fcler blok<\/td>Atrial aritmilerde h\u0131z kontrol\u00fcnde etkinli\u011fi d\u00fc\u015f\u00fck ve sistolik kalp yetmezli\u011finde tedavide alt s\u0131ralarda yeri olmas\u0131na ra\u011fmen gere\u011finden \u00e7ok kullan\u0131lmaktad\u0131r.<\/td><\/tr>
    Kinolon grubu antibiyotikler<\/strong><\/td>Tendon r\u00fcpt\u00fcr\u00fc, diare, aritmiler, myastenia gravis<\/td>Kortikosterioidler ile kombine kullan\u0131mda tendon r\u00fcpt\u00fcr\u00fc riski artar.<\/td><\/tr>
    Trimetoprim-sulfametoksazol <\/strong><\/strong><\/td>Hiperkalemi, sulfonilure ile birlikte ise hipoglisemi<\/td>Warfarin ile kombinasyonda INR y\u00fcksekli\u011fi olabilir.<\/td><\/tr><\/tbody><\/table><\/div><\/figure>\n\n\n\n

    Uygun olmayan ila\u00e7 re\u00e7eteleme (UOIR)<\/strong><\/p>\n\n\n\n

    Geni\u015f bir \u00e7al\u0131\u015fmada her 5 ya\u015fl\u0131dan birinin en az bir ila\u00e7la ilgili olarak UOIR ma\u011fduru oldu\u011fu, en fazla yanl\u0131\u015f kullan\u0131lan ila\u00e7lar\u0131n ise benzodiazepinler ve nonsteroid antiinflamatuarlar oldu\u011fu ortaya konmu\u015ftur.<\/p>\n\n\n\n

    UOIR durumunu anlamak i\u00e7in bir\u00e7ok kriterler belirlenmi\u015ftir. Bunlar i\u00e7inde ne \u00e7ok kullan\u0131lan ve kabul g\u00f6reni Beers Kriterleridir (BK). Amerikan Geriatri Derne\u011fi (AGS) 2015\u2019te BK uyar\u0131nca hekimlerin ila\u00e7 re\u00e7etelerinde uygun olmama potansiyeli ortaya konmakta, bununla kal\u0131nmay\u0131p uygun se\u00e7enekler de \u00fcretilmektedir (American Geriatrics Society 2015). Bu \u015fekilde daha g\u00fcvenli ve etkin ila\u00e7 kullan\u0131m\u0131 sa\u011flanmaya \u00e7al\u0131\u015f\u0131lmaktad\u0131r.<\/p>\n\n\n\n

    ABD\u2019de bak\u0131mevlerindeki ya\u015fl\u0131lar \u00fczerinde yap\u0131lan \u00e7al\u0131\u015fmada 6 geriatrik sendroma potansiyel olarak katk\u0131da bulunan 513 ila\u00e7tan olu\u015fan bir liste ortaya \u00e7\u0131kar\u0131ld\u0131: bili\u015fsel bozukluk, deliryum, d\u00fc\u015fmeler, i\u015ftahs\u0131zl\u0131k \/ kilo kayb\u0131, idrar inkontinans\u0131 ve depresyon (Saraf 2016). Antiepileptikler t\u00fcm sendromlarla ili\u015fkilendirilirken, antipsikotikler, antidepresanlar, antiparkinsonizm ve opioid agonistleri 5 geriatrik sendromla ili\u015fkilendirildi. \u00c7ok say\u0131da ila\u00e7 kullan\u0131m\u0131 en fazla d\u00fc\u015fme riski ile ili\u015fkiliydi.<\/p>\n\n\n\n

    GZ olgular\u0131 s\u0131kl\u0131kla demans ve konf\u00fczyon ile yanl\u0131\u015f al\u0131mlar, \u00fcr\u00fcn\u00fcn uygunsuz kullan\u0131m\u0131, depolama sorunlar\u0131 (ila\u00e7lar\u0131 yanl\u0131\u015f kutulara koymak gibi), farkl\u0131 yoldan ila\u00e7 al\u0131m\u0131 (kulak damlas\u0131n\u0131 g\u00f6ze damlatmak gibi) ve yanl\u0131\u015f ki\u015finin ilac\u0131 almas\u0131ndan kaynaklanmaktad\u0131r. Ya\u015fl\u0131larda depresyon da olduk\u00e7a s\u0131kt\u0131r ve suisidal al\u0131mlar da \u00f6nemli orandad\u0131r. Suisidlerin ba\u015far\u0131ya ula\u015fma oran\u0131 da bu ya\u015f grubunda daha y\u00fcksektir.<\/p>\n\n\n\n

    A\u0130E\u2019lerin s\u0131kl\u0131\u011f\u0131n\u0131n ya\u015fla do\u011frudan ili\u015fkili oldu\u011fu geni\u015f bir \u0130sve\u00e7 \u00e7al\u0131\u015fmas\u0131nda ortaya konmu\u015ftur (Hakkarainen 2009). T\u00fcm A\u0130E\u2019ler 18-44 ya\u015f aral\u0131\u011f\u0131nda %5.9 aral\u0131\u011f\u0131nda g\u00f6r\u00fcl\u00fcrken 65 ya\u015f \u00fczerinde %22.2\u2019ye \u00e7\u0131kmaktad\u0131r. Spesifik zehirlenmelerle ilgili olarak da ya\u015fl\u0131l\u0131kla advers olay g\u00f6r\u00fclme s\u0131kl\u0131\u011f\u0131 artabilmektedir. \u00d6rne\u011fin benzodiazepin kullanan ya\u015fl\u0131larda d\u00fc\u015fme riskinin ve k\u0131r\u0131k olu\u015fma s\u0131kl\u0131\u011f\u0131n\u0131n anlaml\u0131 \u015fekilde artt\u0131\u011f\u0131 bildirilmi\u015ftir. Woolcott ve ark. meta analiz sonu\u00e7lar\u0131na g\u00f6re sedatif hipnotikler, antidepresanlar ve benzodiazepinler ile ya\u015fl\u0131larda d\u00fc\u015fme riskinin di\u011fer fakt\u00f6rlerden ba\u011f\u0131ms\u0131z olarak etkilendi\u011fini ortaya koymu\u015flard\u0131r (Woolcott 2009). Di\u011fer ila\u00e7larda belirgin bir fark bulunmam\u0131\u015ft\u0131r.<\/p>\n\n\n\n

    \u0130ran\u2019da 2008 y\u0131l\u0131nda GZ olgular\u0131n\u0131n (60 ya\u015f ve \u00fczeri) incelenmesi sonucunda erkeklerin %70 ile daha b\u00fcy\u00fck bir oranda zehirlendi\u011fi, suisidal al\u0131mlar\u0131n 1\/3 oran\u0131nda oldu\u011fu belirtilmi\u015ftir (Karbakhsh 2008). Zehirlenme \u015fiddet indeksi (PSS) %17 olguda \u015fiddetli grupta bulunmu\u015ftur. Olgular\u0131n %5.4\u2019\u00fc asemptomatik iken %11.7 GZ olgusu \u00f6l\u00fcmle sonu\u00e7lanm\u0131\u015ft\u0131r. Opioidler \u00f6l\u00fcmc\u00fcl olgularda en s\u0131k saptanan ajan grubudur. Al\u0131mlar %80 olguda oral yolla, %4 inhalasyon, %3 kadar da b\u00f6cek sokmas\u0131 ve hayvan \u0131s\u0131r\u0131klar\u0131 gibi yollarla olmu\u015ftur.<\/p>\n\n\n\n

    Ya\u015fl\u0131larda \u00f6nlenebilir A\u0130E\u2019leri inceleyen bir Almanya \u00e7al\u0131\u015fmas\u0131nda d\u00fc\u015f\u00fck doz aspirin rejiminin \u00f6nlenebilir A\u0130E\u2019ler i\u00e7inde \u00f6nemli bir pay\u0131 oldu\u011fu g\u00f6r\u00fclm\u00fc\u015ft\u00fcr (Schmiedl 2018). \u00d6zellikle 80 ya\u015f \u00fczerinde \u00e7ok dikkatli kullan\u0131lmas\u0131 gerekti\u011fi vurgulanm\u0131\u015ft\u0131r. \u0130la\u00e7 ba\u015flama ve sonland\u0131rmada komorbiditeleri de g\u00f6z \u00f6n\u00fcnde tutan belli kriterlerle davran\u0131lmas\u0131n\u0131n A\u0130E\u2019leri minimize edece\u011fi a\u00e7\u0131kt\u0131r. STOPP\/START kriterleri bu konuda en fazla kullan\u0131lanlardand\u0131r.<\/p>\n\n\n\n

    Spesifik ila\u00e7 etkileri:<\/strong><\/p>\n\n\n\n

      \n
    1. Digitoksin, gliburid ve spironolakton <\/strong>\u00f6nlenebilir A\u0130E ile en yak\u0131ndan ili\u015fkili bulunmu\u015ftur.<\/li>\n\n\n\n
    2. Aspirin<\/strong> ve di\u011fer salisilatlara ba\u011fl\u0131 zehirlenme bulgular\u0131, pulmoner \u00f6dem, asit-baz bozukluklar\u0131 ve n\u00f6rolojik bulgular ya\u015fl\u0131larda s\u0131k g\u00f6r\u00fcl\u00fcr ve ba\u015fka nedenlere ba\u011flan\u0131p atlan\u0131r. Gen\u00e7lere g\u00f6re daha d\u00fc\u015f\u00fck salisilat d\u00fczeylerinde hemodiyaliz gerekli olabilir.<\/li>\n\n\n\n
    3. Antihipertansiflere<\/strong> ba\u011fl\u0131 kardiyak iletim sorunlar\u0131 daha s\u0131k g\u00f6r\u00fcl\u00fcr, \u00f6zellikle beta bloker ve kalsiyum kanal blokerleri <\/strong>kullan\u0131m\u0131nda dikkatli olunmal\u0131d\u0131r. Renal ve\/veya hepatik i\u015flevlerinde bozulma olan ya\u015fl\u0131larda beta bloker toksisitesi<\/strong> h\u0131zla ortaya \u00e7\u0131kabilir. Verapamil ve diltiazem<\/strong> ile hem uyku hali ve n\u00f6bet gibi n\u00f6rolojik bulgular, hem de atrioventrik\u00fcler blok ve bradikardi gibi disritmiler ya\u015fl\u0131larda daha s\u0131k g\u00f6r\u00fcl\u00fcr.<\/li>\n\n\n\n
    4. Nitratlar<\/strong> d\u00fc\u015f\u00fck dozlarda miyokard infarkt\u00fcs\u00fc ve akci\u011fer \u00f6demine neden olabilir. Bunun nedeni azalm\u0131\u015f organ kan ak\u0131mlar\u0131d\u0131r. Ayr\u0131ca ya\u015fl\u0131larda komorbiditeler nedeniyle methemoglobinemi<\/strong> bulgular\u0131 da daha d\u00fc\u015f\u00fck d\u00fczeylerde nitrat kullan\u0131m\u0131yla ortaya \u00e7\u0131kacakt\u0131r.<\/li>\n\n\n\n
    5. Anjiotensin d\u00f6n\u00fc\u015ft\u00fcr\u00fcc\u00fc enzim inhibit\u00f6r\u00fc (ACEI) <\/strong>kullanan ya\u015fl\u0131larda b\u00f6brek i\u015flevleri yak\u0131n izlenmelidir. Hipovolemi s\u0131k g\u00f6r\u00fcld\u00fc\u011f\u00fcnden b\u00f6brekte dengeler h\u0131zla bozulabilir.<\/li>\n\n\n\n
    6. Sulfonilure<\/strong> ya\u015fl\u0131larda kolayca hipoglisemiye neden olurlar.<\/li>\n\n\n\n
    7. Teofiline<\/strong> ba\u011fl\u0131 n\u00f6bet\/status epileptikus ve ta\u015fiaritmiler de ilac\u0131n g\u00f6rece d\u00fc\u015f\u00fck konsantrasyonlarda s\u0131k g\u00f6r\u00fcl\u00fcr.<\/li>\n\n\n\n
    8. Salisilat, lityum ve teofilin <\/strong>ile uzun d\u00f6nemli tedavi alanlarda bulgular normal g\u00f6r\u00fcnen kan d\u00fczeylerinde bile akut entoksikasyondan daha ciddi olabilir.<\/li>\n\n\n\n
    9. Eski ku\u015fak antipsikotikler, (fenotiazinler, tioksantinler ve butirofenonlar)<\/strong> \u00f6zellikle \u00f6nceden hastal\u0131\u011f\u0131 olan ya\u015fl\u0131larda kolayl\u0131kla kardiovaskuler toksisiteye yol a\u00e7abilirler. Tioridazin ve mezoridazin<\/strong> ile ventrik\u00fcler aritmiler ve kalp bloklar\u0131 g\u00f6r\u00fclebilir.<\/li>\n\n\n\n
    10. Siklik antidepresanlar <\/strong>ya\u015fl\u0131larda terap\u00f6tik d\u00fczeyde bile zehirlenmeye yol a\u00e7abilir, \u00f6zellikle sedatif hipnotiklerle kombine doz a\u015f\u0131mlar\u0131 <\/strong>ciddi sonu\u00e7lar do\u011furur.<\/li>\n\n\n\n
    11. Benzodiazepinler a\u015f\u0131r\u0131 sedasyona yol a\u00e7arak <\/strong>ya\u015fl\u0131larda d\u00fc\u015fme riski ve travmalar\u0131 anlaml\u0131 \u015fekilde art\u0131r\u0131r.<\/li>\n\n\n\n
    12. Domperidon ve eritromisin <\/strong>gibi ajan kullananlarda gastrointestinal motilite artaca\u011f\u0131ndan ila\u00e7 etkileri azalabilir.<\/li>\n<\/ol>\n\n\n\n

      \u00d6nleme:<\/strong><\/p>\n\n\n\n

      GZ\u2019den korunma \u00f6nlemleri \u00f6ncelikle kaza ile al\u0131mlara y\u00f6nelmelidir. Bunlar ila\u00e7 k\u00f6t\u00fcye kullan\u0131m\u0131 ve suisidlerden daha olumlu sonu\u00e7 verecektir. Bir\u00e7ok yazar GZ\u2019lerin \u00f6nlenmesi i\u00e7in \u00e7ok boyutlu bir eylem plan\u0131n\u0131n y\u00fcr\u00fct\u00fclmesini \u00f6nermi\u015ftir. Bunun bir oda\u011f\u0131 primer \u00f6nleme, yani potansiyel toksik doz maruziyetinin \u00f6nlenmesi, ki\u015fisel e\u015fiklerin a\u015f\u0131lmas\u0131n\u0131 engelleme olacakt\u0131r. Di\u011fer ba\u015fl\u0131k ise toksik al\u0131m ger\u00e7ekle\u015ftikten sonra onun sonu\u00e7lar\u0131n\u0131 en aza indirgeme olacakt\u0131r.<\/p>\n\n\n\n

      Ya\u015fl\u0131larda yayg\u0131n \u00f6l\u00fcm nedeni olan doz a\u015f\u0131m\u0131 ve zehirlenmelere kar\u015f\u0131 kamu sa\u011fl\u0131\u011f\u0131 \u00f6nlemlerinin al\u0131nmas\u0131, risk de\u011ferlendirmeleri \u00f6nerilmi\u015ftir. Bili\u015fsel problemleri olan ki\u015filerin ila\u00e7lar\u0131 yanl\u0131\u015fl\u0131kla veya farkl\u0131 dozda almas\u0131n\u0131 \u00f6nlemek i\u00e7in kilitli ila\u00e7 kutusu kapaklar\u0131, sadece g\u00fcnl\u00fck dozu vermek gibi \u00f6nlemler yararl\u0131d\u0131r. \u0130la\u00e7 paketlemesinde kolay okunur ve tan\u0131n\u0131rl\u0131k art\u0131r\u0131lmal\u0131d\u0131r. Bili\u015fsel problemi olan ya\u015fl\u0131lar\u0131n ila\u00e7 i\u00e7eri\u011fi ve dozaj\u0131n\u0131 anlamas\u0131nda \u00f6zel yard\u0131m gereklidir. Suisidal al\u0131mlar\u0131 azaltmak i\u00e7in depresyonun daha etkin ve erken tedavisi \u00f6nemli yarar sa\u011flar.<\/p>\n\n\n\n

      Yara temizli\u011finde kullan\u0131lan sol\u00fcsyonlar\u0131 daha az toksik hale getirecek \u00fcretim \u00f6nlemleri al\u0131nabilir. Yeni tan\u0131 alm\u0131\u015f ya\u015fl\u0131 bir maj\u00f6r depresyon olgusuna 100 tablet i\u00e7eren bir kutu trisiklik antidepresan vermek do\u011frudan tehlikelidir.<\/p>\n\n\n\n

      Y\u00fcksek riskli ila\u00e7 kullan\u0131m\u0131 k\u0131s\u0131tlanmal\u0131, zorunlu olmad\u0131k\u00e7a ila\u00e7 verilmemelidir. Dozlar da etkiyi sa\u011flayan en d\u00fc\u015f\u00fck miktarla s\u0131n\u0131rl\u0131 olmal\u0131d\u0131r. Ya\u015fl\u0131larda dozaj hatalar\u0131 ve yanl\u0131\u015f ila\u00e7 verilmesi gibi sorunlar da s\u0131k g\u00f6r\u00fclmektedir. Taburculukta kontrol listeleri bunu \u00f6nlemek i\u00e7in kullan\u0131labilir. Bak\u0131mevi, huzurevi \u00e7al\u0131\u015fanlar\u0131 konuyla ilgili \u00f6zel e\u011fitim almal\u0131d\u0131r. Fig\u00fcr 2\u2019deki gibi tehlike bildirici i\u015faretler ya\u015fl\u0131lara uyarlanarak kullan\u0131labilir.<\/p>\n\n\n\n

      \"\"<\/figure>\n\n\n\n

      Fig\u00fcr 2.<\/strong> Pittsburgh\u2019da \u00e7ocuklara ilac\u0131n tehlikeli oldu\u011funu anlatmak i\u00e7in kutulara konan g\u00f6r\u00fcnt\u00fc.<\/p>\n\n\n\n

      Ya\u015fl\u0131larda deliryumu<\/strong> \u00f6nlemek i\u00e7in antipsikotik kullan\u0131m\u0131nda dikkatli olunmal\u0131, polifarmasi \u00f6nlenmeli, erken mobilizasyon ile fiziksel aktivite art\u0131r\u0131lmal\u0131, \u00e7evre modifikasyonlar\u0131 d\u00fc\u015f\u00fcn\u00fclmeli, farmakolojik olmayan uyku destekleri sa\u011flanmal\u0131, a\u011fr\u0131 tedavisi yap\u0131lmal\u0131d\u0131r.<\/p>\n\n\n\n

      GZ\u2019de y\u00f6netim ve tedavi ilkeleri:<\/strong><\/p>\n\n\n\n

      Ya\u015fl\u0131lar\u0131n de\u011ferlendirilmesinde<\/strong> temel olarak genel ilkeler ge\u00e7erlidir. Rutinde al\u0131nan \u00f6yk\u00fc, yap\u0131lan muayene ve incelemeler yetersiz kalabilmektedir. \u0130\u015flevsellik kay\u0131plar\u0131, bili\u015fsel durum, sosyal destek, polifarmasi varl\u0131\u011f\u0131 sorgulanmal\u0131d\u0131r. Kendisi ve yak\u0131nlar\u0131ndan \u00f6yk\u00fc al\u0131m\u0131nda odaklanmal\u0131 ve daha \u0131srarl\u0131 olunmal\u0131d\u0131r.<\/p>\n\n\n\n

      Hemodiyaliz ve hemoperf\u00fczyon<\/strong> daha d\u00fc\u015f\u00fck doz e\u015fiklerinde gerekli olabilir. Nonsteroid antiinflamatuar ajan doz a\u015f\u0131m\u0131 gibi g\u00f6rece benign durumlarda bile renal i\u015flevler bozulduysa hemodiyaliz d\u00fc\u015f\u00fcn\u00fclmelidir.<\/p>\n\n\n\n

      Emilimi \u00f6nleme stratejilerinde <\/strong>genel anlamda farkl\u0131l\u0131k yoksa da \u00f6rne\u011fin katartik<\/strong> uygulamas\u0131 kolayca s\u0131v\u0131-elektrolit anormalli\u011fine yol a\u00e7abilece\u011finden dikkatli olunmal\u0131d\u0131r. Magnezyum i\u00e7erenler hipermagnezemiye neden olabilir.<\/p>\n\n\n\n

      Multipl doz aktif k\u00f6m\u00fcr <\/strong>ya\u015fl\u0131larda gastrointestinal motilite azalmas\u0131ndan dolay\u0131 dikkatli uygulanmal\u0131d\u0131r. Kronik konstipasyon \u00f6yk\u00fcs\u00fc olanlarda bu uygulamadan ka\u00e7\u0131n\u0131lmas\u0131 uygun olabilir.<\/p>\n\n\n\n

      \u0130drarla at\u0131l\u0131m\u0131 art\u0131rma stratejilerinde <\/strong>\u00f6nceki di\u00fcretik kullan\u0131m\u0131 sonucu var olabilecek hipokalemi nedeniyle dikkatli olunmal\u0131d\u0131r.Bu olgularda idrar alkalinizasyonu<\/strong> ile at\u0131l\u0131m\u0131 art\u0131rma kontrendikedir.Bu ve benzeri durumlarda s\u0131v\u0131-elektrolit durumunun yak\u0131n izlemi \u00f6nemlidir.<\/p>\n\n\n\n

      Antidot uygulamalar\u0131nda<\/strong> genel ilkeler ge\u00e7erli ise de baz\u0131 dozaj de\u011fi\u015fiklikleri s\u00f6z konusu olabilir. \u00d6rne\u011fin digoksin Fab antikorlar\u0131 konjestif kalp yetmezli\u011fi bulgular\u0131n\u0131 tetikleyebilir.
      <\/strong><\/p>\n\n\n\n

       Kaynaklar<\/strong><\/p>\n\n\n\n

        \n
      1. Choi NG, Marti CN. Intent disclosure in late-life suicide: Age group differences in correlates and associations with suicide means. Front Psychol. 2022 Oct 5;13:949333. doi: 10.3389\/fpsyg.2022.949333. PMID: 36275279; PMCID: PMC9580761.<\/li>\n\n\n\n
      2. Juurlink DN, Herrmann N, Szalai JP, Kopp A, Redelmeier DA (2004) Medical illness and the risk of suicide in the elderly. Arch Intern Med 164(11):1179\u20131184<\/li>\n\n\n\n
      3. Geith S, Lumpe M, Schurr J, et al. Clinical course and demographic insights into suicide by self-poisoning: patterns of substance use and socio-economic factors. Soc Psychiatry Psychiatr Epidemiol. 2024 Sep 24. doi: 10.1007\/s00127-024-02750-x.<\/li>\n\n\n\n
      4. Al-Mahbashi HM, Howilah AA. A cross-sectional study examining the pattern of acute poisoning among patients admitted to a governmental hospitals in Sana’a City, Yemen. Toxicol Rep. 2024 Aug 2;13:101704. doi: 10.1016\/j.toxrep.2024.101704.<\/li>\n\n\n\n
      5. Klotz U. (2009) Pharmacokinetics and drug metabolism in the elderly, Drug Metabolism Reviews, 41:2, 67-76.<\/li>\n\n\n\n
      6. C. Kat\u0131\u00a0et al.<\/em>, “Evaluation of Acute Poisonings in Geriatric Patients Attended to a University Emergency Clinic,”\u00a0Turkish Journal of Geriatrics<\/em>, 2013; 16 (3) 286-291<\/li>\n\n\n\n
      7. \u015een SE. Acil Servise Ba\u015fvuran Ya\u015fli Hastalarin \u00c7oklu \u0130la\u00e7 Kullaniminin Hastalarin Klinik S\u00fcre\u00e7lerine Etkisi. Tipta Uzmanlik Tezi. Eski\u015fehir Osmangazi \u00dcniversitesi Tip Fak\u00fcltesi Acil T\u0131p Anabilim Dal\u0131, Eski\u015fehir, 2012<\/li>\n\n\n\n
      8. P Unverir, R Atilla, O Karcioglu,<\/strong> H Topacoglu, Y Demiral, Y Tuncok. <\/a>A retrospective analysis of antidepressant poisonings in the emergency department: eleven-year experience.<\/strong> Hum Exp Toxicol 2006, 25 (10): 605-612.<\/li>\n\n\n\n
      9. Vallersnes<\/a>, O.M., Jacobsen, D., Ekeberg, \u00d8.\u00a0et al.<\/em>\u00a0Mortality and repeated poisoning after self-discharge during treatment for acute poisoning by substances of abuse: a prospective observational cohort study.\u00a0BMC Emerg Med<\/em>\u00a019<\/strong>, 5 (2019). https:\/\/doi.org\/10.1186\/s12873-018-0219-9<\/a><\/li>\n\n\n\n
      10. Townsend E, Hawton K, Harriss L, Bale E, Bond A. Substances used in deliberate self-poisoning 1985-1997: trends and associations with age, gender, repetition and suicide intent. Soc Psychiatry Psychiatr Epidemiol. 2001 May;36(5):228-34. doi: 10.1007\/s001270170053. PMID: 11515700.<\/li>\n\n\n\n
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        Pharmacovigilance Centers (NRPC) (2018) Preventable ADRs leading to hospitalization \u2014 results of a long-term prospective safety study with 6,427 ADR cases focusing on elderly patients, Exp Opin Drug Saf, 17:2, 125-137.<\/p>\n","protected":false},"excerpt":{"rendered":"

        Yazar: Prof. Dr. \u00d6zg\u00fcr Karc\u0131o\u011flu Edit\u00f6r: Do\u00e7. Dr. Rana Di\u015fel *Ekim 2024\u2019de yaz\u0131lan bu blog yaz\u0131s\u0131 teknik sorunlar nedeni ile Ocak 2026\u2019da…<\/p>\n","protected":false},"author":1509,"featured_media":746,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[1],"tags":[],"class_list":["post-743","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-genel"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/743","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/users\/1509"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/comments?post=743"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/743\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media\/746"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media?parent=743"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/categories?post=743"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/tags?post=743"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}