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
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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
Slide2No conflicts of interest to disclose
Slide3Objectives:
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
Slide4Population statistics
Slide5Medication burden for the aging population
Double in median number of Rx medications
Number of patients taking
>
5 meds tripled (12.8% to 39.0%)
Slide6Adverse 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)
Slide7Adverse 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
Slide8Slide9Slide10First 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
Slide11Anticholinergic 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
Slide12Cardiovascular 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
Slide13Cardiovascular 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
Slide14Cardiovascular 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
Slide15CNS 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
Slide16CNS Medications
Barbiturates Amobarbital Butabarbital Butalbital Mephobarbital Pentobarbital Phenobarbital Secobarbital
Alternatives Levetiracetam Lamotrigine
Other Agents
Meprobamate
Alternatives Buspirone SSRI SNRI
Slide17Benzodiazepines 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
Slide18Antipsychotics First and Second Generation Chlorpromazine Thorazine Loxapine Olanzapine Perphenazine Thioridazine Trifluoperazine Haloperidol
Alternatives Risperidone Quetiapine Pimavanserin*
CNS Medications
Slide19Endocrine 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
Slide20Endocrine 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
Slide21Pain 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
Slide22Pain 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
Slide23Other Agents Cilostazol
Heart Failure
Other Agents Non-dihydropyridine CCBs
Other Agents NSAIDs & COX-2 inhibitors
Other Agents Dronedarone
Other Agents
Thiazolidinediones
Slide24Other Agents Antipsychotics
Syncope
Other Agents Acetylcholinesterase Inhibitors
Other Agents Non-selective peripheral alpha-1 blockers
Other Agents
Tri-cyclic antidepressants
Slide25Other Agents H-2 Receptor Antagonists
Other Agents Anticholinergics
Other Agents Antipsychotics & Benzodiazepines
Other Agents Meperidine
Other Agents Corticosteroids
Dementia & Delirium
Other Agents
“Z Drugs”
Slide26Other AgentsOpioids
Falls & Fractures
Other Agents Anticonvulsants
Other AgentsAntipsychotics, “Z Drugs”, Benzodiazepines
Other Agents
Tricyclic Antidepressants
Slide27Parkinson Disease
Other AgentsDopamine-receptor antagonist antiemetics Metoclopramide Prochlorperazine Promethazine
Other Agents
All Antipsychotics
Slide28Other AgentsAspirin >325 mg/dayNon-COX 2 Selective NSAIDs
GI
Other AgentsNSAIDs
Kidney/Urinary Tract
Slide29Other Agents Estrogen oral and transdermalPeripheral alpha-1 blockers
Urinary Incontinence
Other AgentsStrongly anticholinergic drugs
Lower Urinary Tract Symptoms
Slide30Other 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
Slide31Conclusions
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
Slide32questions
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