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 Evidence Based alternatives to beers potentially inappropriate medications  Evidence Based alternatives to beers potentially inappropriate medications

Evidence Based alternatives to beers potentially inappropriate medications - PowerPoint Presentation

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Evidence Based alternatives to beers potentially inappropriate medications - PPT Presentation

Janna Hawthorne pharmd MA ed primary care clinical pharmacist baptist healthpractice plus No conflicts of interest to disclose Objectives Measure the burden of medications on patients 65 years of age and older including presence of adverse drug reactions ID: 774955

agents alternatives medications drug agents alternatives medications drug reactions adverse american control 2019 adults older patients disease doi 2018

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Slide1

Evidence Based alternatives to beers potentially inappropriate medications

Janna Hawthorne,

pharmd

, MA ed

primary care clinical pharmacist

baptist

health/practice plus

Slide2

No conflicts of interest to disclose

Slide3

Objectives:

Measure the burden of medications on patients 65 years of age and older, including presence of adverse drug reactions

Identify evidence based alternatives to potentially inappropriate medications presented in the 2019 update of the American Geriatric Society’s Beers Criteria

Evaluate the literature to determine evidence based alternatives for medications interacting with specific geriatric conditions

Discuss the available evidence for potentially inappropriate medications that do not have strict recommendations on alternatives for use

Slide4

Population statistics

Slide5

Medication burden for the aging population

Double in median number of Rx medications

Number of patients taking

>

5 meds tripled (12.8% to 39.0%)

Slide6

Adverse drug reactions

“An appreciably harmful or unpleasant reaction resulting from an interventionrelated to the intentional use of a medicinal product, which predicts hazard from future administration and warrants prevention or specific treatment, or alteration of the dosage regimen or withdrawal of the product”

(Edwards and

Aronson

, 2000)

Slide7

Adverse drug reactions in the aging population

Patients 65 years and older are being hospitalized twice as much as their younger counterparts due to ADR

ADR contribute to 6.5% of all hospital admissions, accounting for 4% of their overall bed capacity over a 6 month period

 highest incidence of their ADR being in older adults

ADR contribute to 10.7% of all admissions for elderly patients

A little over 2/3 of nursing home residents have experienced an ADR at least once over a 4 year period, with many having repeat events

60% of nursing home residents continue to experience ADRs

Slide8

Slide9

Slide10

First Generation Antihistamines Brompheniramine Carbinoxamine Chlorpheniramine Clemastine Cyproheptadine Dexbrompheniramine Dexchlorpheniramine Dimenhydrinate Diphenhydramine Doxylamine Hydroxyzine Meclizine Promethazine Pyrilamine Triprolidine

Alternatives Intranasal normal saline Second-generation antihistaminesCetirizineFexofenadineLoratadineLevocetirizineIntranasal steroidsFluticasoneBeclomethasoneBudesonideCiclesonideMometasoneTriamcinoloneFlunisolide

Anticholinergic Medications

Slide11

Anticholinergic Medications

Antiparkinsonian Agents Benztropine Trihexyphenidyl

Alternatives Carbidopa/levodopa

This recommendation also aligns with the

2017 Parkinson’s Disease in Adults Guidelines published by the National Institute for Health and Care Excellence

Antithrombotics Dipyridamole

Alternatives Clopidogrel Aspirin/Dipyridamole

Slide12

Cardiovascular Medications

Peripheral Alpha-1 Blockers Doxazosin Prazosin Terazosin

Alternatives Thiazide-type diuretics ACE-inhibitors ARBs Long acting dihydropyridine CCB

Central Alpha-Agonists

Clonidine (1st line) Guanabenz Guanfacine Methyldopa Reserpine (>0.1 mg/day)

Other Agents Nifedipine (IR formulation)

These recommendations also align with the 2017 updated ACC/AHA guidelines

Slide13

Cardiovascular Medications

Antiarrhythmic agents Disopyramide Dronedarone Amiodarone

Alternatives For atrial fibrillation have the option of either rate control or rhythm control: Rate control: Non-dihydropyridine CCB Beta-blockers Rhythm control: Dofetilide Flecainide Propafenone

Studies have shown no difference on mortality with rate vs. rhythm control so determination of approach should be based on comorbidities and patient preference

Slide14

Cardiovascular Medications

Other Agents Digoxin

Alternatives Atrial fibrillation rate control: Non-dihydropyridine CCB Beta-blockers Heart failure: ACE-Inhibitors ARBs ARB/Neprilysin Inhibitor Beta-blockers Aldosterone antagonists

If digoxin is initiated for either indication,

should avoid dosages > 0.125 mg daily

Slide15

CNS Medications

Antidepressants Amitriptyline Amoxapine Clomipramine Desipramine Doxepin (>6 mg/day) Imipramine Nortriptyline Paroxetine Protriptyline Trimipramine

Alternatives For depression: SSRI (except paroxetine) SNRI Bupropion For neuropathic pain: SNRI Gabapentin Capsaicin topical Pregabalin Lidocaine patch

Ergoloid

mesylates Isoxsuprine

Alternatives Acetylcholinesterase Inhibitors Memantine Vitamin E

Slide16

CNS Medications

Barbiturates Amobarbital Butabarbital Butalbital Mephobarbital Pentobarbital Phenobarbital Secobarbital

Alternatives Levetiracetam Lamotrigine

Other Agents

Meprobamate

Alternatives Buspirone SSRI SNRI

Slide17

Benzodiazepines Alprazolam Estazolam Lorazepam Oxazepam Temazepam Triazolam Chlordiazepoxide Clonazepam Clorazepate Diazepam Flurazepam Quazepam

Alternatives Buspirone SSRI SNRI

CNS Medications

“Z Drugs”

Eszopiclone Zaleplon Zolpidem

Alternatives Sleep hygiene Melatonin

Slide18

Antipsychotics First and Second Generation Chlorpromazine Thorazine Loxapine Olanzapine Perphenazine Thioridazine Trifluoperazine Haloperidol

Alternatives Risperidone Quetiapine Pimavanserin*

CNS Medications

Slide19

Endocrine Medications

Other Agents Estrogens, with or without progestins

Alternatives Dyspareunia and vulvovaginitis Vaginal estrogens Vasomotor symptoms SSRI SNRI Gabapentin

Other Agents

Desiccated thyroid

Alternatives Levothyroxine

Slide20

Endocrine Medications

Diabetes Agents Sulfonylureas Chlorpropamide Glimepiride Glyburide Sliding Scale Insulin

Alternatives Oral agents Glipizide Metformin Basal-bolus insulin regimens Insulin glargine Insulin detemir Insulin degludec Insulin NPH

Slide21

Pain Medications

Non-selective NSAIDsSkeletal Muscle Relaxants Aspirin (>325 mg/day) Diclofenac Diflunisal Etodolac Fenoprofen Ibuprofen Indomethacin Ketoprofen Ketorolac Meclofenamate Mefenamic acid Meloxicam Nabumetone Naproxen Oxaprozin Piroxicam Sulindac Tolmetin Carisoprodol Chlorzoxazone Cyclobenzaprine Metaxalone Methocarbamol Orphenadrine

Alternatives Celecoxib Acetaminophen Salsalate

Slide22

Pain Medications

Other Agents Meperidine

Alternatives Acute Pain Tramadol Morphine IR Oxycodone/APAP Chronic Pain All of the above* For neuropathic pain: SNRI Gabapentin Capsaicin topical Pregabalin Lidocaine patch

Slide23

Other Agents Cilostazol

Heart Failure

Other Agents Non-dihydropyridine CCBs

Other Agents NSAIDs & COX-2 inhibitors

Other Agents Dronedarone

Other Agents

Thiazolidinediones

Slide24

Other Agents Antipsychotics

Syncope

Other Agents Acetylcholinesterase Inhibitors

Other Agents Non-selective peripheral alpha-1 blockers

Other Agents

Tri-cyclic antidepressants

Slide25

Other Agents H-2 Receptor Antagonists

Other Agents Anticholinergics

Other Agents Antipsychotics & Benzodiazepines

Other Agents Meperidine

Other Agents Corticosteroids

Dementia & Delirium

Other Agents

“Z Drugs”

Slide26

Other AgentsOpioids

Falls & Fractures

Other Agents Anticonvulsants

Other AgentsAntipsychotics, “Z Drugs”, Benzodiazepines

Other Agents

Tricyclic Antidepressants

Slide27

Parkinson Disease

Other AgentsDopamine-receptor antagonist antiemetics Metoclopramide Prochlorperazine Promethazine

Other Agents

All Antipsychotics

Slide28

Other AgentsAspirin >325 mg/dayNon-COX 2 Selective NSAIDs

GI

Other AgentsNSAIDs

Kidney/Urinary Tract

Slide29

Other Agents Estrogen oral and transdermalPeripheral alpha-1 blockers

Urinary Incontinence

Other AgentsStrongly anticholinergic drugs

Lower Urinary Tract Symptoms

Slide30

Other Agents Antispasmodics Atropine (excludes ophthalmic) Belladonna alkaloids Clidinium-chlordiazepoxide Dicyclomine (excludes ophthalmic) Hyoscyamine Methoscopolamine Propantheline Scopolamine Growth Hormone Megestrol Metoclopramide Mineral Oil Nitrofurantoin Proton-Pump Inhibitors Androgens Methyltestosterone Testosterone Desmopressin

Questionable Alternatives

Slide31

Conclusions

Patients 65 years of age and older have a significant medication burden, that seems to be increasing with time and advancements in western medicine

The medication burden for these older adults can result in significant adverse drug reactions

The 2019 update of the American Geriatric Society’s Beers Criteria introduces a significant amount of medications that are potentially inappropriate for use,

BUT

there are evidence based alternatives that can be implemented to maintain disease control

There are a significant number of alternatives that can be implemented within drug-disease interaction scenarios to avoid development of adverse drug reactions

While there are not alternatives to every medication presented in the Beers Criteria, outside literature can be evaluated to determine best appropriate options for the clinical picture and patient presented

Slide32

questions

Slide33

References

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United states Census Bureau

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Charlesworth, C., Smit, E., Lee, D.,

Alramadhan

, F. and

Odden

, M. (2015). Polypharmacy Among Adults Aged 65 Years and Older in the United States: 1988–2010. 

The Journals of Gerontology Series A: Biological Sciences and Medical Sciences

, 70(8), pp.989-995.

Edwards, I. and Aronson, J. (2000). Adverse drug reactions: definitions, diagnosis, and management. 

The Lancet

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Beijer

, H. and de

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Cooper, J. (1996) Probable adverse drug reactions in a rural geriatric nursing home population: a four-year study.

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Slide34

References

American Geriatrics Society Beers Criteria Update Expert Panel.  American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am

Geriatr

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ePub

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National Institute for Health and Care Excellence (2017)

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Slide35

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