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Robyn Bryson, PharmD Kerri Hagedorn, PharmD, BCPS.

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Presentation on theme: "Robyn Bryson, PharmD Kerri Hagedorn, PharmD, BCPS."— Presentation transcript:

1 Robyn Bryson, PharmD Kerri Hagedorn, PharmD, BCPS

2  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

3  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  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  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 Addition of the following medications:  Dabigatran (Pradaxa) and Prasugrel (Effient) due to increased risk of bleeding if 75yo or older

6  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

7  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

8  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

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

11  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  Bupropion (Wellbutrin) 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

13  Anticholinergic Antihistamines 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  Safer Alternatives Cetirizine (Zyrtec) Fexofenadine (Allegra) Desloratadine (Clarinex) Levocetirizine (Xyzal)

15  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  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  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

18  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)

19  Benzodiazepines should be used with caution when used for agitation/delirium or in patients with dementia/cognitive impairment  Meprobamate may cause dependence or sedation

20  Amiodarone 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

21  Acetylcholinesterase Inhibitors 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  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

23  Antispasmodics 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  Corticosteroids 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  Barbiturates 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  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  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

28  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  Nitrofurantoin 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

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

32  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

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


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