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Robyn Bryson, PharmD Kerri Hagedorn, PharmD, BCPS 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 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 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 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 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 Adverse reactions that worsen current disease states Current Adverse Current reactions that require treatment or hospitalization/office visit trials have not proven efficacy in elderly patients trials have proven increased mortality risk 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 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 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 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? 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 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 Safer Alternatives • Cetirizine (Zyrtec) • Fexofenadine (Allegra) • Desloratadine (Clarinex) • Levocetirizine (Xyzal) 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 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 • Orthostatic Hypotension (Persantine) 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 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) Benzodiazepines should be used with caution when used for agitation/delirium or in patients with dementia/cognitive impairment Meprobamate sedation may cause dependence or Amiodarone • QT prolongation, • Could worsen systolic HF Pulmonary toxicity, hypoor hyperthyroidism Antiarrhythmics or constipation shown to provide no additional efficacy Procainamide, Propafenone, Quinidine, Sotalol rhythm control for Afib outcome in AFib/HF Disopyramide (Norpace) • Anticholinergic SE Cilostazol (Pletal) • Could worsen HF Dronedarone (Multaq) • Shown to produce worse Digoxin • Doses >0.125 mg/day have • Dofetilide, Flecainide, Ibutilide, • Prefer rate control over Diltiazem & Verapamil Spironolactone • Hyperkalemia, caution if CrCl <30 ml/min Acetylcholinesterase Inhibitors Carbamazepine • SIADH • Donepezil (Aricept) • Orthostatic hypotension, bradycardia Anticonvulsants • Unsteady gait, psychomotor impairment, syncope, falls Dimenhydrinate & Meclizine • Cause/worsen delirium, worsen constipation/urinary retention, cognitive impairment 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 Antispasmodics • Cause/worsen delirium, • Belladonna alkaloids, Clidinium, Dicyclomine, Hyoscyamine, Propantheline, Scopolamine Worsen constipation, Cognitive impairment, Worsen Parkinson’s Dz • Anticholinergic SE, delirium H2 Blocker Delirium, Cognitive impairment, Worsen Parkinson’s Dz, Reduced clearance in elderly Worsen cognitive impairment Metoclopramide (Reglan) • Extrapyramidal SE, Tardive dyskinesia Mineral Oil • Aspiration Promethazine • Anticholinergic SE, • Cause/worsen delirium, Prochlorperazine Trimethobenzamide (Tigan) • Extrapyramidal SE, Poor efficacy 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 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 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 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 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 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 STOPP • Screening Tool of Older Persons’ potentially inappropriate Prescriptions START • Screening Tool to Alert doctors to Right Treatment Organized Provides by organ system 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 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. 2012 Apr;60(4):616-31. 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.