Pharmacotherapy and adherence to beers criteria (providers)

Pharmacotherapy and Adherence to Beers Criteria

Leonardo Rosario-Colón, Pharm.D., R.Ph., B.S.

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Objectives Goals and Objectives: The goal of this activity is

to help providers in all settings develop a better knowledge base on medication use in the elderly.

Upon completion of this activity, providers will be able to: Discuss the advantages and disadvantages of Beers

criteria for guiding drug therapy in the elderly. Use tools such as START/STOPP to choose the most

appropriate drug therapy in elderly patients.

MEDICATION USE IN THE ELDERLY

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Medication Use in the Elderly

Prescribing for older patients presents unique challenges: Premarketing drug trials often exclude geriatric

patients. Approved doses may not be appropriate for older

adults

Special caution because of age-related changes. Pharmacokinetics (absorption, distribution,

metabolism, and excretion) Pharmacodynamics (the physiologic effects of the

drug) Benzodiazepines and opioids

Rochon, Paula A (2016). Drug Prescribing for Older Adults. UpToDate. Available from: http://www.uptodate.com/contents/drug-prescribing-for-older-adults

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Medication Use in the Elderly (cont.)

Increased volume of distribution. Proportional increase in body fat relative to

skeletal muscle with aging. Diazepam

Decreased drug clearance. Natural decline in renal function with age,

even in the absence of renal disease. Prolong drug half-lives and lead to increased

plasma drug concentrations in older people. Lithium


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Medication Use in the Elderly (cont.)

Decline in hepatic function. Significant variability in drug metabolism. May lead to adverse drug reactions (ADRs)

when polypharmacy is a factor.


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Quality of Drug Prescribing Multiple factors contribute to the

appropriateness and overall quality of drug prescribing: Avoidance of inappropriate medications Appropriate use of indicated medications Monitoring for side effects and drug levels Avoidance of drug-drug interactions Involvement of the patient Integration of patient values


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Quality of Drug Prescribing (cont.)

Approximately 40% of patients over 60 years old take at least 5 medications.

Elderly patients account for about 25% of emergency department visits due to adverse drug events.

Avoidable adverse drug events (ADEs) are the serious consequences of inappropriate drug prescribing. Any new symptom should be considered drug-

related until proven otherwise.Goulding MR. Inappropriate medication prescribing for elderly ambulatory care patients. Arch Intern Med 2004;164:305-12.


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Inappropriate Medications Various criteria have been developed by

expert panels Assess the quality of prescribing practices and

medication use in older adult individuals. The most widely used criteria for inappropriate

medications are the Beers criteria. Other Tools:

STOPP/START Criteria Drug Burden Index FORTA (Fit FOR The Aged) List Among others…


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Impact of Inappropriate Drugs Several studies have identified that the use of drugs

identified as "inappropriate" is widespread in the United States, Canada, and Europe.

One study found that 43% of the sample used at least one medication that would be deemed potentially Nonsteroidal antiinflammatory drugs (NSAIDs) being the most

common.

Another study, using Medicare data, found that the point prevalence in each calendar month of potentially inappropriate medications used in adults ≥65 years was 34.2%.


BEERS CRITERIA

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Beers Criteria Originally created by Dr. Mark Beers (Geriatrician)

Published by the American Geriatrics Society in 1991 last updated in 2015

List of potentially inappropriate medications for use in older adults (≥65 years) effort to decrease the risk of adverse events

Intended for use in all ambulatory, acute, and institutionalized settings of care except hospice and palliative care

American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-46

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Beers Criteria (cont.) Some notable changes in the 2015 listings:

Removal of Loratadine from the list of medications with strong anticholinergic properties.

More liberal renal threshold (now creatinine clearance <30 rather than <60 mL/min) for withholding nitrofurantoin.

Avoidance of long-term proton pump inhibitors because of risk of Clostridium difficile infections and bone loss and fractures.

Stricter guidelines to avoid antipsychotics for behavioral problems unless other options have failed and the older adult is threatening harm to self or others.


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Designations of Quality of Evidence and Strength of Recommendations

Quality of Evidence High - evidence includes consistent results Moderate - evidence is sufficient to determine risks Low - evidence is insufficient to assess harms or risks

Strength of Recommendation Strong - benefits clearly outweigh harms Weak - benefits may not outweigh harms Insufficient - evidence inadequate to determine net

harms


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Potentially Inappropriate Medications (PIM)

Drugs Rationale Recommendation

Anticholinergics (1st Generation)DiphenhydramineHydroxyzinePromethazine

Risk of confusion, dry mouth and constipation

Avoid

AntiparkinsonBenztropineTrihexyphenidyl

Not recommended for prevention of extrapyramidal symptoms with antipsychotics

Avoid

AntispasmodicsDicyclomine

Highly anticholinergic Avoid

Anti-infectiveNitrofurantoin

Potential for pulmonary toxicity, hepatotoxicity and peripheral neuropathy

Avoid when CrCl < 30mL/min or long term use


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PIM - CardiovascularDrugs Rationale Recommendati

onPeripheral alpha-1 blockersTerazosin

High risk of orthostatic hypotension

Avoid use as antihypertensive

Central alpha blockersClonidineMethyldopa

High risk of adverse CNS effects, bradycardia and orthostatic hypotension

Avoid Clonidine as 1st lineAvoid others

Digoxin Use in atrial fibrillation: may increase mortality

Use in heart failure: higher doses not associated with additional benefit and may increase toxicity

Renal patients: adjust dose in stage 4-5 CKD

Avoid as 1st line

Avoid as 1st line

Avoid dosages > 0.125mg/d


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PIM – Cardiovascular cont.


Amiodarone Higher toxicities than other antiarrhythmics

Avoid as 1st line for atrial fibrillation unless patient has heart failure or substantial left ventricular hypertrophy


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PIM – Central Nervous System


Antidepressants (alone or in combination)AmitriptylineDoxepin > 6 mg/dImipramineNortriptylineParoxetine

Highly anticholinergic, sedating and cause orthostatic hypotension

Avoid

AntipsychoticsConventional and Atypical(see Mental Health PDL)

Increase risk of cerebrovascular accident and greater rate of cognitive decline and mortality in persons with dementia

Avoid except for schizophrenia, bipolar disorder, or short-term use as antiemetic during chemotherapy

BarbituratesButalbitalPhenobarbital

High rate of dependence, tolerance to sleep benefits, and greater risk of overdose

AvoidAmerican Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-

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PIM – CNS cont.Drugs Rationale Recommendati

onBenzodiazepines – Short / Intermediate ActingLorazepamTemazepam

Increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes

Avoid

Benzodiazepine – Long ActingClonazepamDiazepamFlurazepam

Increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes

May be appropriate for seizure disorders, rapid eye movement sleep disorder, severe generalized anxiety disorder, and periprocedural anesthesia

Non-benzodiazepine HypnoticsZolpidem

Increase risk of delirium, falls, and fractures. Minimal improvement in sleep latency and duration.

Avoid

Ergoloid mesylate Lack of efficacy Avoid


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PIM - EndocrineDrugs Rationale Recommendati

onAndrogensTestosterone

Potential for cardiac problems, contraindicated in prostate cancer

Avoid, unless indicated for confirmed hypogonadism with clinical symptoms

Estrogens with or without progestinsEstradiolEstradiol - NorethindroneEstropipate

Carcinogenic potential, lack of cardioprotective effect and cognitive protection

Avoid oral and topical patchVaginal use: acceptable at low dosages

Growth hormoneSomatropin

Impact on body composition is small and associated with edema, arthralgia, carpal tunnel syndrome, impaired fasting glucose

Avoid, except as hormone replacement after pituitary gland removalAmerican Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-

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PIM – Endocrine cont.Drugs Rationale Recommendati

onInsulin sliding scale Higher risk of

hypoglycemia without improvement in hyperglycemia management regardless of care setting

Avoid

Megestrol Minimal effect on weight; increases risk of thrombotic events and possibly death in older adults

Avoid


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PIM - Gastrointestinal Drugs Rationale Recommendati

onMetoclopramide Can cause

extrapyramidal effects, including tardive dyskinesia; risk may be greater in frail older adults

Avoid, unless for gastroparesis

Proton-pump inhibitorsOmeprazole

Risk if Clostridium difficile infection and bone loss and fractures

Avoid scheduled use for > 8 weeks unless for high-risk patients


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PIM – Pain Medication Drugs Rationale Recommendati

onMeperidine May have higher risk of

neurotoxicity, including delirium, than other opioids

Avoid, especially in individuals with CKD

Non-cyclooxygenase-selective NSAIDS, oral:Aspirin > 325 mg/dDiclofenacIbuprofenNabumetoneNaproxenSulindac

Increased risk of gastrointestinal bleeding for peptic ulcer disease in high risk groups

Avoid chronic use, unless other alternatives are not effective and patient can take gastroprotective agent (PPI or Misoprostol)

IndomethacinKetorolac

More likely to have CNS and kidney adverse effects

AvoidAmerican Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-

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PIM – Pain Medications cont.


Skeletal Muscle Relaxants –Cyclobenzaprine

Most are poorly tolerated by older adults, sedation, anticholinergic effects, and increase risk of fractures

Avoid


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PIM - Genitourinary


Desmopressin High risk of hyponatremia

Avoid for treatment of nocturia or nocturnal polyuria


STOPP/ START CRITERIA

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STOPPing/STARTing Medications in the Elderly

Beers Criteria does not address some medications that should be avoided in the elderly, drug interactions, duplications, and underprescribing

STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescritptions)

START (Screening Tool to Alert doctors to Right Treatment)

PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist’s Letter/Prescriber’s Letter. September 2011.

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Select Safer Alternatives

PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist’s Letter/Prescriber’s Letter. September 2011.

STOPP START

Colchicine AllopurinolSystemic corticosteroids DMARD (Rheumatoid Arthritis)

Acetaminophen, topicals (Osteoarthritis)Inhaled corticosteroids and/or bronchodilator (COPD)

Opioids Acetaminophen or NSAID (Mild/Moderate pain)

Non-selective Beta Blockers (COPD)

Atenolol (Cardioselective Beta Blockers)

Benzodiazepines Anxiety – low doseshorter acting (Lorazepam), SSRI or SNRISleep – Low dose Temazepam or Zolpidem

Glyburide Glimepiride or Glipizide

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Consider STARTing… Cardiovascular:

Metformin – patients with Type 2 Diabetes ACEI or ARB – heart failure, post-MI,

diabetic neuropathy Aspirin – prevention in diabetes with at

least one major cardiovascular risk factor Statin – patients with cardiovascular,

cerebrovascular, or peripheral vascular disease, and diabetes plus additional cardiovascular risk factor

Calcium and Vitamin D – patients with osteoporosisPL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist’s Letter/Prescriber’s Letter. September 2011.

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Summary and Recommendations Various criteria sets exist for identifying

medications that should not be prescribed, or should be prescribed with caution, in older adults.

ADEs result in four times as many hospitalizations in older, compared with younger, adults.

NSAIDS, atypical antipsychotic medications and Warfarin are the most common drugs involved in ADEs in the elderly.

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Summary and Recommendations (cont.)

A stepwise approach to prescribing for older adults should include: Periodic review of current drug therapy Discontinuing unnecessary medications Considering nonpharmacologic alternative

strategies Considering safer alternative medications Using the lowest possible effective dose Including all necessary beneficial

medications.

QUESTIONS?

Pre- and Post- Test1. According to Beers criteria, which of the

following is not a concern with using Proton Pump Inhibitors ?

a. Risk of Clostridium difficile infection.b. Risk of neurotoxicity.c. Risk of bone fractures.d. Risk of bone loss.

Pre- and Post- Test1. According to Beers criteria, which of the

following is not a concern with using Proton Pump Inhibitors ?

b. Risk of neurotoxicity.

Pre- and Post- Test2. A 66 y/o man who has a history of Type

2 Diabetes, smoker and hypertension. Based on given information and assuming no contraindications, what medications regimen will be best for this patient?

a. Glyburide, Aspirin and ACEI.b. Metformin, Statin and Clonidine.c. Glyburide, Aspirin and Doxazosin.d. Metformin, Statin, Aspirin, and ACEI.

Pre- and Post- Test2. A 66 y/o man who has a history of Type

2 Diabetes, smoker and hypertension. Based on given information and assuming no contraindications, what medications regimen will be best for this patient?

d. Metformin, Statin, Aspirin, and ACEI.

Healthcare

Pharmacotherapy and adherence to beers criteria (providers)