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Robyn Bryson, PharmD Kerri Hagedorn, PharmD, BCPS

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1 Robyn Bryson, PharmD Kerri Hagedorn, PharmD, BCPS
Beers Criteria Robyn Bryson, PharmD Kerri Hagedorn, PharmD, BCPS

2 Beers Criteria Created by Dr. Mark Beers in 1991
Identified medications that could be considered inappropriate in long-term care facility patients 65 years and older Updated in 1997, 2003, and 2012 Current list geared toward providers caring for the elderly inpatient or outpatient Upgrade panel used expertise in geriatric medicine, nursing, pharmacy practice, research, and quality measures along with reps from CMS, NCQA, and PQA NCQA = national committee for quality assurance PQA = pharmacy quality alliance

3 Beers Criteria, cont Main objective is for the provider to review this list when considering initiating medications and consider alternatives if available Centers for Medicare and Medicaid Services are using these recommendations in assessing the quality of care rendered to elderly patients Pharmacists participate in Medication Therapy Management Services

4 Beers Criteria 2012 Update Includes 53 medications/medication classes
Inappropriate medications and medications to avoid in elderly Potentially inappropriate medications/classes to avoid in elderly with certain diseases and/or syndromes that could be exacerbated by the medication Medications to be used with caution in elderly patients

5 Beers Criteria 2012 Update, cont
Update for medications to avoid Addition of the following medications: Megestrol (Megace) Glyburide (DiaBeta, Glynase) Sliding-scale Insulin Update for medications to use with caution Dabigatran (Pradaxa) and Prasugrel (Effient) due to increased risk of bleeding if 75yo or older

6 Beers Criteria 2012 Update, Cont
Update for PIM and classes to avoid in elderly with certain diseases/syndromes that the medication could exacerbate Addition of the followings medications/classes Pioglitazone (Actos) and Rosiglitazone (Avandia) in HF patients Acetylcholinesterase inhibitors with history of syncope SSRIs with falls/fractures Avandia is now part of a REMS program for md and pt enrollment New medication: Alogliptin and Pioglitazone (Oseni) AI: aricept, exelon, razadyne

7 How could a medication be inappropriate for an elderly patient?
Adverse reactions that worsen current disease states Adverse reactions that require treatment or hospitalization/office visit Current trials have not proven efficacy in elderly patients Current trials have proven increased mortality risk Increased healthcare cost Medications that cause orthostatic hypotension/falls/syncope which causes a fall that causes a hematoma or causes a fracture that requires surgery All antipsychotics may increase risk of stroke and death when used to treat behavioral symptoms in demented elderly pts Anticholinergic medications may cause unpleasant side effects and worsen dementia Some medications may lower seizure threshold (tramadol, bupropion, thiothixene) Some medications are not effective at higher doses in the elderly and higher doses increase the risk of adverse reactions

8 Drawbacks of Beers Criteria
Primary purpose is to be an educational tool and quality measure PIM affected by aging were not included Medications requiring renal dosing Drug-Drug interactions Therapeutic duplication Palliative Care/Hospice patients are not included Non-English literature was not included in review Not for disciplinary actions Palliative care/hospice need symptom control

9 Possible Inappropriate Medication Classes
Analgesics Antidepressants Antihistamines Antihypertensives Antiplatelet Agents/Anticoagulants Antipsychotics Anxiolytics Cardiac Drugs Central Nervous System Agents Chemotherapy Diabetes Drugs Gastrointestinal Drugs Hormones Hypnotics Musculoskeletal Agents NSAIDs Respiratory Drugs Stimulant Drugs Urinary Drugs

10 Analgesics Meperidine (Demerol) Pentazocine (Talwin) Tramadol (Ultram)
Neurotoxicity, Delirium, Cognitive Impairment, Poor Oral Efficacy Pentazocine (Talwin) Increased CNS effects (Confusion/Hallucinations); Ceiling to analgesic effect Tramadol (Ultram) Decreases seizure threshold

11 Is the patient allergic to any medications?
Analgesics Safer Alternatives Acetaminophen (Tylenol) Short-term NSAID Salicylates Topical Capsaicin Codeine Hydrocodone/APAP (Norco/Vicodin) Oxycodone/APAP (Percocet/Roxicet) Is the patient allergic to any medications?

12 Antidepressants Bupropion (Wellbutrin) Paroxetine (Paxil)
Decreases seizure threshold Paroxetine (Paxil) Cause/Worsen Delirium, Worsen Constipation/Urinary Retention/Cognitive Impairment Mirtazapine (Remeron) SIADH SSRIs SIADH, Psychomotor Impairment Tricyclic Antidepressant Amitriptyline (Elavil) Clomipramine (Anafranil) Doxepin, Imipramine (Tofranil) Trimipramine (Surmontil) Anticholinergic effects, Delirium, Sedation, Orthostatic Hypotension, Cognitive Impairment, SIADH Syndrome of inappropriate antidiuretic hormone secretion causes euvolemic hyponatremia (correct with lasix and hypertonic saline IV)

13 Antihistamines Anticholinergic Antihistamines Loratadine (Claritin)
Brompheniramine, Carbinoxamine, Chlorpheniramine, Clemastine, Cyproheptadine, Dexbrompheniramine, Dexchlorpheniramine, Diphenhydramine oral, Doxylamine, Hydroxyzine, Promethazine, Triprolidine Loratadine (Claritin) May worsen delirium, cognitive impairment, constipation, or urinary retention

14 Antihistamines Safer Alternatives Cetirizine (Zyrtec)
Fexofenadine (Allegra) Desloratadine (Clarinex) Levocetirizine (Xyzal)

15 Antihypertensives Doxazosin (Cardura), Prazosin (Minipress), Terazosin (Hytrin) Could cause orthostatic hypotension, urinary incontinence Clonidine (Catapres), Guanabenz, Guanfacine, Methyldopa, Reserpine Could cause orthostatic hypotension, bradycardia, CNS adverse effects Short-acting Nifedipine Hypotension, Myocardial Ischemia Triamterene Kidney injury Vasodilators Increased syncope

16 Antiplatelet Agents & Anticoagulants
Aspirin Caution in patients >= 80yo Dabigatron (Pradaxa) Increased bleeding risk in patients >= 75yo Decreased efficacy in renal impairment Prasugrel (Effient) Increased bleeding risk Ticlopidine (Ticlid) Dipyridamole short-acting (Persantine) Orthostatic Hypotension

17 Antipsychotics All antipsychotics increase the risk of stroke, death, and SIADH in demented elderly patients requiring behavioral treatment Chlorpromazine, Clozapine, Fluphenazine, Olanzapine (Zyprexa), Perphenazine, Thioridazine, Thiothixene (Navane), Trifluoperazine May cause/worsen delirium, worsen constipation, worsen cognitive impairment, worsen urinary retention Clozapine requires close monitoring of WBC and ANC due to agranulocytosis

18 Antipsychotics Quetiapine (Seroquel) or Clozapine (Clozaril) are better options for Parkinson’s disease Less Anticholinergic Options: Aripiprazole (Abilify) Asenapine (Saphris) Haloperidol Iloperidone Lurasidone (Latuda) Paliperidone (Invega) Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon) Atypical antipsychotics carry unwanted side effects (weight gain, diabetes, etc)

19 Anxiolytics Benzodiazepines should be used with caution when used for agitation/delirium or in patients with dementia/cognitive impairment Meprobamate may cause dependence or sedation Benzos are okay for severe anxiety, seizures, REM sleep d/o, benzo/ETOH withdrawal, EOL or perioperative anesthesia Alternative: SSRI, SNRI, Buspirone

20 Cardiac Medications Amiodarone Antiarrhythmics Dronedarone (Multaq)
QT prolongation, Pulmonary toxicity, hypo- or hyperthyroidism Antiarrhythmics Dofetilide, Flecainide, Ibutilide, Procainamide, Propafenone, Quinidine, Sotalol Prefer rate control over rhythm control for Afib Dronedarone (Multaq) Shown to produce worse outcome in AFib/HF Disopyramide (Norpace) Anticholinergic SE Diltiazem & Verapamil Could worsen systolic HF or constipation Digoxin Doses >0.125 mg/day have shown to provide no additional efficacy Cilostazol (Pletal) Could worsen HF Spironolactone Hyperkalemia, caution if CrCl <30 ml/min Dig-monitor for renal impairment HF-recommend using ACEI, ARB, Diuretic, BB (titrated)

21 CNS Agents Acetylcholinesterase Inhibitors Anticonvulsants
Donepezil (Aricept) Orthostatic hypotension, bradycardia Anticonvulsants Unsteady gait, psychomotor impairment, syncope, falls Carbamazepine SIADH Dimenhydrinate & Meclizine Cause/worsen delirium, worsen constipation/urinary retention, cognitive impairment

22 Diabetes Medications Chlorpropamide (Diabinese)
Extended half-life, prolonged hypoglycemia, SIADH Glyburide (Diabeta, Glynase) Prolonged hypoglycemia Sliding Scale Insulin Poor efficacy, hypoglycemia Pioglitazone (Actos) Caution in HF due to edema Avoid Glucotrol XL Use basal insulin, rapid-acting mealtime insulin, premixed insulin 1-2X/day

23 GI Medications Antispasmodics H2 Blocker Metoclopramide (Reglan)
Belladonna alkaloids, Clidinium, Dicyclomine, Hyoscyamine, Propantheline, Scopolamine Anticholinergic SE, delirium H2 Blocker Cause/worsen delirium, Worsen cognitive impairment Metoclopramide (Reglan) Extrapyramidal SE, Tardive dyskinesia Mineral Oil Aspiration Prochlorperazine Cause/worsen delirium, Worsen constipation, Cognitive impairment, Worsen Parkinson’s Dz Promethazine Anticholinergic SE, Delirium, Cognitive impairment, Worsen Parkinson’s Dz, Reduced clearance in elderly Trimethobenzamide (Tigan) Extrapyramidal SE, Poor efficacy

24 Hormones Corticosteroids Estrogen Growth Hormone Megestrol
Cause/worsen delirium Estrogen Breast/Endometrial cancer, Worsen incontinence, No cardioprotective properties, No cognitive protection Growth Hormone Edema, Arthralgia, Carpal tunnel, Gynecomastia, Insulin resistance Megestrol Thrombosis, Death, Lack of efficacy for weight gain Testosterone/Methyltestosterone Prostatic hyperplasia, Cardiac events Desiccated Thyroid Cardiac SE

25 Hypnotics Barbiturates Benzodiazepines Chloral Hydrate
Dependence, Tolerance, Delirium, Possible overdose Benzodiazepines Cognitive impairment, Delirium, Unsteady gait, Syncope, Falls, Accidents, Fractures Chloral Hydrate Tolerance, Delirium, Possible overdose Eszopiclone (Lunesta), Zaleplon (Sonata), Zolpidem (Ambien) Cognitive impairment, Delirium, Unsteady gait, Syncope, Falls, MVA, Fractures, Little benefit

26 Musculoskeletal Medications
Muscle Relaxants Carisoprodol, Chlorzoxazone, Cyclobenzaprine, Metaxalone, Methocarbamol, Orphenadrine Anticholinergic SE, Sedation, Fractures, Delirium, Cognitive impairment Benztropine, Tizanidine (Zanaflex), Trihexyphenidyl Delirium, Worsen cognitive impairment, Worsen constipation, Worsen urinary retention

27 NSAIDs Cause GI bleeding or peptic ulcer
Cause renal injury in advanced renal disease Caution in CHF due to edema SE Indomethacin Causes more SE than other NSAIDs Aspirin Max daily dose of 325 mg Recommend—hydrocodone/APAP, oxycodone/APAP, codeine, celecoxib (except in HF), duloxetine, venlafaxine, pregabalin, gabapentin, topical analgesics, lidocaine patches Avoid ketorolac and indomethacin If NSAIDs are used then recommend to use a GI protectant (misoprostol/PPI)

28 Respiratory & Miscellaneous Medications
Inhaled Anticholinergic Tiotropium (Spiriva), Ipratropium Urinary retention Phenylepherine, Pseudoephedrine, Theophylline CNS stimulant Atropine or Homatropine Anticholinergic SE, Delirium, Worsen constipation, Worsen cognitive impairment Amphetamine & Methylphenidate CNS stimulation

29 Urinary Medications Nitrofurantoin Urinary Antimuscarinics
Pulmonary toxicity, Minimal efficacy if CrCl <60 ml/min Urinary Antimuscarinics Darifenacin (Enablex), Oxybutynin (Ditropan), Trospium (Sanctura), Tolterodine (Detrol) Cause/worsen delirium, Worsen constipation, Cognitive impairment

30 STARTing and STOPPing Criteria

Screening Tool of Older Persons’ potentially inappropriate Prescriptions START Screening Tool to Alert doctors to Right Treatment

32 START and STOPP Organized by organ system
Provides the “START” options initially Example: START ACEI or ARB for HF, post-MI, or in diabetic nephropathy Then provides the “STOPP” treatments Example: STOPP beta-blockers in COPD or diabetic patients BB in COPD: bronchospasm BB in DM: masks hypoglycemia

33 References American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc Apr;60(4): PL Detail-Document, Potentially Harmful Drugs in the Elderly: Beers List. Pharmacist’s Letter/Prescriber’s Letter. June 2012. PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist’s Letter/Prescriber’s Letter. September 2011.

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