What's the Best Brew for Grandma? 2012 Beers List Update

What's the Best Brew for Grandma? 2012 Beers List Update

Hospitalist Best PracticeJ Rush Pierce Jr, MD, MPH

June 20, 2012

Disclosures

• I am member and serve on Emergency Preparedness Special Interest Group for the American Geriatrics Society, who played a major role in the 2012 Beers update

• 5% of my salary supported by Donald W Reynolds Foundation for education of hospital care of the elderly

Agenda

• Background of Beers list (rationale, history, methodology of update)

• Focused review of update• Usefulness and limitations• Relevance to hospital medicine/resources

What the Beers list is not

Beers list - background

• 1991 – for use in NH’s• 1997 – update for

elderly in all settings• 1999 – adopted by CMS

for NH regulation• 2003 – update; adopted

by Medicare D, HEDIS, NCQA

• 2012 – evidence-based update

Case Q1

82 y/o white man admitted with CAP, now ready to go home after completion of CAP rx.

PMHx: diabetes, HTN, painful diabetic neuropathy Home meds : glyburide, lovastatin, clonidine, ASA,

amitriptyline, pantoprazole

Q1 How many of these meds are on the Beers list?Q2 What will you send the patient home on?

Case Q2

77 y/o woman with dementia has recurrent UTI’s and nausea. Urology suggests long-term suppressive therapy. Recent organisms have been sensitive to nitrofurantoin and Bactrim.

Q1 What is best choice for urinary suppression?Q2 What drug is best choice for nausea?

Criticisms of previous Beers list iterations

• Not evidence-based• Many drugs on list were infrequently used• Unstructured• Uncertain relevance to clinical practice

– Many studies settings show that 20 – 30% of patients on Beers list meds

– Inconsistent assoc with ADE in epidemiologic studies

NEISS-CADES• Setting: 53 US hospitals• Patients: 5077 pts > 64 years adm to hospital for

ADE• Findings:

– Half of hospitalizations were for pts >79 yrs old– Two-thirds due to warfarin (33.3%), insulins (13.9%),

oral antiplatelet agents (13.3%), and oral hypoglycemic agents (10.7%).

– Beers medications were implicated in 6.6% of hospitalizations for ADE, half of these digoxin

Source: NEJM 2011;365:2002

2012 Beers Update

• Evidence-based approach by American Geriatric Society

• Incorporate exceptions• Divide into three categories (Drugs to avoid,

Drug-disease/syndrome interactions, Drugs to use with caution)

• Publish grade of evidence and strength of recommendation

Evidence grade and strength of recommendations

• Grade of evidence – High (>1 RCT or multiple consistent high quality

observational studies) – Moderate (1 RCT, or multiple consistent lower quality

observational studies)– Low (important study design flaws, inconsistent

findings among studies)• Strength of recommendations

– Strong (risk/burden clearly > benefit)– Weak (benefits finely balanced with risk/burden)– Insufficient (insufficient evidence to determine)

Anticholinergics

Source: JAGS 2012;60:616

Antibiotics


Cardiovascular drugs


Cardiovasc drugs (contd)


Psych drugs


Psych drugs (contd)


Endocrine drugs


Pain


Drug – disease/synd interactions





Drugs to use with caution


Beers criteria and outpt studies

• Chang et al (Pharmacotherpy 2005;25:831)– Setting: Taiwan– Patients: 550 older pts seen in outpt clinic– Findings: ADE OR = 15

• Budnitz et al (Ann Intern Med 2007;147:755)– Setting: Brazil– Patients: 186 older outpts– Findings: ADE OR = 2.3

Beers criteria and hosp studies

• Onder et al (Eur J Clin Pharmacol 2005;61:453)– Setting: Italy– Patients: 5,152 older pts adm to hosp– Findings: No assoc Beers list and ADE, LOS or

mortality• LaRoche et al (Brit J Clin Pharm 2007;63:177)

– Setting: France– Patients: 2,018 pts > 70 adm to hosp– Findings: more ADR in pts on Beers list meds, but no

diff in ADR attributable to Beers meds

Beers and hospital studies• Franceschi M, et al (Drug Safety 2008;31:545)

– Setting: Italy– Patients: 1,756 older pts adm to hospital– Findings:

• 4.4% of hospitalizations related to ADE that was definitely or possibly avoidable

• 1/5 of these (<1% or adms) had received an inappropriate med• Budnitz et al (Ann Intern Med 2007;147:755)

– Setting: US– Patients: 177,504 older pts seen in ED– Findings:

• No association between Beers meds and ADE

BEERS vs STOPP (Hamilton. Arch Intern Med 2011; 171:1013)

• STOPP = Screening Tool of Older Persons’ potentially inappropriate Prescriptions

• Setting: Ireland• Patients: 600 pts > 64 years adm to hosp• Findings:

– ADE 26%– 2/3 ADE causal or contributory to adm– OR ADE 1.84 (95% CI = 1.51 – 2.26) with STOPP,

1.27 (95% CI = 0.94 – 1.72) with Beers

Source: Arch Intern Med 2011;171:1013



Source:http://www.bgs.org.uk/powerpoint/aut10/Mahony_inappropriate_prescribing.pdf



http://www.americangeriatrics.org/files/documents/annual_meeting/2012/handouts/friday/Joseph_Hanlon.pdf

Case Q1

82 y/o white man admitted with CAP, now ready to go home after completion of CAP rx.

PMHx: diabetes, HTN, painful diabetic neuropathy Home meds : glyburide, lovastatin, clonidine, ASA,

amitriptyline, pantoprazole

Q1 How many of these meds are on the Beers list?Q2 What will you send the patient home on?

Case Q2

77 y/o woman with dementia has recurrent UTI’s and nausea. Urology suggests long-term suppressive therapy. Recent organisms have been sensitive to nitrofurantoin and Bactrim.

Q1 What is best choice for urinary suppression?Q2 What drug is best choice for nausea?

Beers and Relevance to Hospital Medicine

• Education/resources (google AGS)• Avoid starting Beers/STOPP meds in hospital

– Phenergan, benzos• If Beers/STOPP meds started in hospital, consider

stopping before go home– Antipsychotics, opiates, zolpidem, ?loop diuretics for

edema not due to CHF or cirrhosis• For patients on Beers/STOPP meds on admission,

consider communicating with PCP• Redo admission order set; clinical decision support

Documents

What's the Best Brew for Grandma? 2012 Beers List Update