POPULATION HEALTH:

GERIATRICSBEERS CRITERIA

APPLICATION

DR. MAK

CLINICAL PHARMACY REVIEW

2021

LEARNING OBJECTIVESAFTER REVIEW OF KEY CONCEPTS, STUDENTS WILL BE ABLE TO:

Recognize pharmacokinetic and pharmacodynamic changes in the aging process

§ Evaluate and make recommendations for medication regimens using the

2019 American Geriatrics Society Beers Criteria

Know how inappropriate use of medications can exacerbate geriatric syndromes Identify potentially inappropriate medications (PIMs) to be used with caution in older adults

Identify risks associated with clinically important drug–drug and drug-disease interactions in

elderly patients

Develop an alternative therapeutic plan for potentially inappropriate medications

AGE-RELATED PHARMACODYNAMIC CHANGES

• General trend of altered drug response or increased “sensitivity” in older adults

• Older adults are particularly sensitive to the CNS effects of drugs

• Decreased levels of the dopamine transporter

• Decreased number of dopaminergic neurons

• Decreased density of several types of dopamine receptors.

• Aging is associated with numerous changes in the CVS

• Orthostatic hypotension

• CCB

• BB

• Diuretics

• Increased risk of bleeding with Warfarin

WHEN WORKING UP AN ELDERLY PATIENT ….

• Match medications to conditions

• Always check kidney and liver functions

• Identify medications that may be inappropriate for an elderly patient

• Suggest alternatives

• If necessary, lower dose to prevent potential problems

• Identify drug to drug/disease interactions

• Make plans to minimize interactions if interacting drugs are essential

• Identify drug to nutrient interactions

• Collect dietary information from patients

• Recommend ways to minimize drug/nutrient interactions

• De-escalate intensity of regimen if frail

GERIATRIC SYNDROME

AMERICAN GERIATRIC SOCIETY (AGS) BEERS CRITERIA®

• Identify potentially inappropriate medications that should be avoided in older adults

• Reduce adverse drug events and drug related problems, also to improve medication selection and medication use in older adults

• Guide or tool to improve quality of, and overall cost of care for drug use in older patients

• Similar tools: • STOPP Screening Tool of Older Person’s Prescriptions

• START Screening Tool to Alert to Right Treatment

AGS BEERS CRITERIABENEFITS

• A starting point for a comprehensive process of identifying and improving medication appropriateness and safety; guide selection

• Educational for clinicians and patients

• Reduce ADRs

• Increased appreciation of special considerations that should be applied when prescribing for older adults

CHALLENGES

• Belief that uses of the listed drugs are universally appropriate

• Some health systems reinforced this perception, implementing quality improvement and decision support systems that implicitly consider any use of these medications to be problematic

• Some prior authorization programs built around the AGS Beers Criteria® have been misapplied by payors and/or misinterpreted by the prescribing clinician

SELECTED TABLES FROM AGS BEERS CRITERIA®

Table 2: Potentially Inappropriate Medication (PIM) Use in Older Adults

Table 3: Potentially Inappropriate Medication Use in Older Adults due to Drug-Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome

Table 4: Potentially Inappropriate Medication to be Used with Caution in Older Adults

Table 5: Potentially Clinically Important Drug-Drug Interactions that Should be Avoided in Older Adults

Table 6: Medications that Should be Avoided or Have Their Dosage Reduced with Varying Levels Kidney Function in Older Adults

Table 7: Drugs with Strong Anticholinergic Properties

BEERS CRITERIA TABLE 2: POTENTIALLY INAPPROPRIATE MEDICATION (PIM)USE IN OLDER ADULTS – 8 DRUG CATEGORIES

1. Anticholinergics

2. Anti-thrombotics

3. Anti-infectives

4. Cardiovascular

5. Central Nervous System

6. Endocrine

7. Gastrointestinal

8. Pain medications

WHY ARE PIMS PROBLEMATIC (DRUG CATEGORIES 1-4) IN OLDER ADULTS?

1. Anticholinergics: ADRs related to reduced clearance and exaggerated toxicities

1st gen antihistamines, antispasmodics, antiparkinsonian agents

2. Which antithrombotic agent causes orthostatic hypotension and increase fall risk?

dipyridamole

3. Which antibiotic when used long term or in patients with CrCl < 30 mL/min increases

hepatotoxicity, pulmonary toxicity, or peripheral neuropathy? nitrofurantoin

4. CNS

• Which BP agents are more associated with orthostatic hypotension than others?

• Peripheral and central alpha blockers

• Which BP agent is associated with higher risk of CNS effects?

• Central alpha blockers (e.g. clonidine, methyldopa, guanfacine, guanabenz, reserpine)

WHY ARE PIMS PROBLEMATIC (DRUG CATEGORIES 5-8) IN OLDER ADULTS?5. Drugs causing CNS side effects:

antidepressants, antipsychotics, benzodiazepines, Z drugs

6. Endocrine medications• Drugs associated with hypoglycemia:

• insulins, chlorpropamide, glyburide, glimepiride• Cardiac problems or increasing cancer risk

• Testosterone, estrogen

7. GI• What do we worry about with metoclopramide use for an older patient? EPS• What are the problems associated with long term use of PPIs?

• C.difficile, bone loss and fracture

8. Pain medicationsMeperidine, NSAIDs, muscle relaxants (what are the problems with these)

SL (MALE), 75Y

Active Problems Active Medications in Chart

- Acid reflux- ACS s/p PCI- Anxiety- Benign prostatic hypertrophy- Chronic back pain- Constipation d/t opioid therapy- COPD- Dementia- Depression- T2DM- Heart Failure- Hypertension- Hyperlipidemia- Insomnia- Left BKA with phantom pain- Peripheral vascular disease

1. Sitagliptin 25mg daily 2. Losartan 100mg daily3. Aspirin 81mg daily 4. Atorvastatin 40mg daily 5. Breo Ellipta® 100-25 mcg/INH 6. Buspirone 15mg BID 7. Cyclobenzaprine 10mg TID PRN 8. Cilostazol 100mg BID 9. Diazepam 10mg TID10. Donepezil 10mg daily 11. Doxepin 10mg qHS PRN12. Gabapentin 300mg TID13. Gemfibrozil 600mg BID 14. Glyburide 10mg BID 15. Lantus® 100 unit/ml 18U Q12H

16. Magnesium citrate 1.745g/30ml PRN17. Metformin 850mg TID18. Norco® 10-325mg q4h PRN19. Omeprazole 40mg daily20. Prasugrel 10mg daily21. Pioglitazone 30mg daily22. Proair® HFA 1-2 puffs q4-6h PRN23. Temazepam 15mg qHS PRN24. Terazosin 2mg qHS25. Tradjenta® 5mg daily26. Tramadol ER 100mg qHS27. Nifedipine IR 30mg TID28. Zoloft® 100mg daily29. Zolpidem 10mg qHS30. Naproxen 220mg BID PRN

WHAT ARE THE INDICATIONS FOR EACH MEDICATION?Condition Treatment

1. Acid reflux

2. ACS s/p PCI, PVD

3. Anxiety

4. Benign prostatic hypertrophy

5. Chronic back/phantom pain

6. Constipation d/t opioid Rx

7. COPD

8. Dementia

9. Depression

10. T2DM

11. Heart failure/Hypertension

12. Hyperlipidemia

13. Insomnia

Condition Treatment

1. Acid reflux omeprazole

2. ACS s/p PCI, PVD aspirin, cilostazol, prasugrel

3. Anxiety diazepam, temazepam, buspirone

4. Benign prostatic hypertrophy terazosin

5. Chronic back/phantom pain cyclobenzaprine, Norco®, tramadol ER, gabapentin, naprosyn

6. Constipation d/t opioid Rx magnesium citrate

7. COPD Breo Ellipta®, Proair HFA®

8. Dementia donepezil

9. Depression Zoloft®

10. T2DM sitagliptin, glyburide, Lantus®, metformin, Tradjenta®, pioglitazone

11. Heart failure/Hypertension losartan

12. Hyperlipidemia atorvastatin, gemfibrozil

13. Insomnia doxepin, temazepam, zolpidem

TEAM EXERCISE

What Medications may be a PIM? (Table 2)

SL (MALE), 75Y

Active Problems Active Medications in Chart

- Acid reflux- ACS s/p PCI- Anxiety- Benign prostatic hypertrophy- Chronic back pain- Constipation d/t opioid therapy- COPD- Dementia- Depression- T2DM- Heart Failure- Hypertension- Hyperlipidemia- Insomnia- Left BKA with phantom pain- Peripheral vascular disease

1. Sitagliptin 50mg daily 2. Losartan 100mg daily3. Aspirin 81mg daily 4. Atorvastatin 40mg daily 5. Breo Ellipta® 100-25 mcg/INH 6. Buspirone 15mg BID 7. *Cyclobenzaprine 10mg TID PRN 8. Cilostazol 100mg BID 9. *Diazepam 10mg TID10. Donepezil 10mg daily 11. Doxepin 10mg qHS PRN12. Gabapentin 300mg TID13. Gemfibrozil 600mg BID 14. *Glyburide 10mg BID 15. Lantus® SoloStar 100 unit/ml 18U Q12H

16. Magnesium citrate 1.745g/30ml17. Metformin 850mg TID18. *Norco® 10-325mg q4h PRN19. *Omeprazole 40mg daily20. Prasugrel 10mg daily21. Pioglitazone 30mg daily22. Proair® HFA 1-2 puffs q4-6h PRN23. *Temazepam 15mg qHS PRN24. Terazosin 2mg qHS25. Tradjenta® 5mg daily26. Tramadol ER 100mg qHS27. *Nifedipine IR 30mg TID28. Zoloft® 100mg daily29. *Zolpidem 10mg qHS30. *Naproxen 220mg BID PRN

* PIM medications

WHAT ARE POTENTIAL DRUG-DISEASE OR DRUG-SYNDROME INTERACTIONS THAT MAY EXACERBATE THE DISEASE OR GERIATRIC SYNDROME IN SL?

WHAT GERIATRIC SYNDROMES DOES SL HAVE?

Heart Failure

Dementia or Cognitive Impairment

Benign Prostatic Hypertrophy

DRUG TO AVOID• Pioglitazone

• Antidepressants, antipsychotics, benzodiazepines, Z drugs

• Anticholinergics: 1st gen antihistamines, antispasmodics, antiparkinsonian agents

DISEASE /SYNDROME

Beers criteria table 3

Potentially Inappropriate Medications:to be Used with Caution in SL

Beers Criteria Table 4: Potentially Inappropriate Medication to be Used with Caution in Older Adults

• ASA

• Prasugrel

• SSRIs: sertraline

• TCAs: diazepam, temazepam, doxepin

• Tramadol

WHAT ARE POTENTIAL DRUG INTERACTIONS FOR SL?Pharmacodynamic interactions

Additive or counteractive effects• Gabapentin and Norco

• BZDs and Norco

• Multiple BZDs

• Multiple CNS-active medications (Antidepressants, BZDs, Z-drugs, opioids)

Pharmacokinetic interactions

Absorption, distribution, metabolic effects• Gemfibrozil and atorvastatin

• Gemfibrozil with cilostazol, diazepam, doxepin, omeprazole

• Gemfibrozil with glyburide

Beers Criteria Table 5: Potentially Clinically Important Drug-Drug Interactions that Should be Avoided in Older Adults

WHAT MEDICATIONS SHOULD SL AVOID OR HAVE DOSAGE REDUCED IF HIS KIDNEY FUNCTION IS IMPAIRED?

• Gabapentin, dose adjust when CrCl < 60 mL/min

• Metformin, dose adjust when eGFR < 45, D/c when < 30

• Tramadol, dosee adjust when CrCl < 30 mL/min

Beers Criteria: Table 6: Medications to avoid or dose reduced with kidney function in older adults

HOW MANY MEDICATIONS IN SL’S LIST HAS STRONG ANTICHOLINERGIC PROPERTIES?

Active Problems Active Medications in Chart

- Acid reflux- ACS s/p PCI- Anxiety- Benign prostatic hypertrophy- Chronic back pain- Constipation d/t opioid therapy- COPD- Dementia- Depression- T2DM- Heart Failure- Hypertension- Hyperlipidemia- Insomnia- Left BKA with phantom pain- Peripheral vascular disease

1. Sitagliptin 50mg daily 2. Losartan 100mg daily3. Aspirin 81mg daily 4. Atorvastatin 40mg daily 5. Breo Ellipta® 100-25 mcg/INH 6. Buspirone 15mg BID 7. Cyclobenzaprine 10mg TID PRN *8. Cilostazol 100mg BID 9. Diazepam 10mg TID10. Donepezil 10mg daily 11. Doxepin 10mg qHS PRN *12. Gabapentin 300mg TID13. Gemfibrozil 600mg BID 14. Glyburide 10mg BID 15. Lantus SoloStar® 100 unit/ml 18U Q12H

16. Magnesium citrate 1.745g/30ml17. Metformin 850mg TID18. Norco® 10-325mg q4h PRN19. Omeprazole 40mg daily20. Prasugrel 10mg daily21. Pioglitazone 30mg daily22. Proair® HFA 1-2 puffs q4-6h PRN23. Temazepam 15mg qHS PRN24. Terazosin 2mg qHS25. Tradjenta® 5mg daily26. Tramadol ER 100mg qHS27. Nifedipine IR 30mg TID28. Zoloft® 100mg daily29. Zolpidem 10mg qHS30. Naproxen 220mg BID PRN

Beers Criteria: Table 7

WHAT ARE THERAPEUTIC OPTIONS TO BEERS DRUGS FOR SL?(TEAM EXERCISE)

• Anxiolytics: diazepam, temazepam

• Dc temazepam, diazepam PRN, alternatives: buspirone, SSRI, SNRI if appropriate

• Chronic pain: cyclobenzaprine, Norco, tramadol ER, gabapentin, naproxen

• DC cyclobenzaprine, Norco PRN, switch tramadol from ER to IR, naproxen PRN, keep gabapentin for now; refer to pain management

• T2DM: sitagliptin, glyburide, Lantus, metformin, Tradjenta®, pioglitazone

• DC sitagliptin (duplicate with Tradjenta), switch glyburide to glipizide if postprandial levels need improvement, possibly increase Lantus dose, check kidney function for metformin, DC pioglitazone

• Insomnia: doxepin, temazepam, zolpidem

• Avoid concomitant CNS depressive agents, try melatonin and non-Rx interventions, evaluate for sleep apnea

APPLICATION OF KEY PRINCIPLES FOR CLINICIANS (1)

Think of the AGS Beers Criteria® as a warning light

•Why is the patient taking the drug; is it truly needed?

• Are there safer and/or more effective alternatives?

• Does my patient have any particular characteristic that increase or mitigate risk of this medication?

• Keep in mind that there are situations in which use of Beers medications is justified and appropriate

APPLICATION OF KEY PRINCIPLES FOR CLINICIANS (2)

• Actively inquire about symptoms that could be adverse drug effects, and assess whether these could be related to medications

• Don’t let the AGS Beers® Criteria distract you from closely attending to other medications not addressed by the criteria. These include

• Other high-risk medications (e.g. anticoagulants, hypoglycemics)

• Medication adherence

• Unnecessary medication use

• Underuse of medications

• And more (!)

REFERENCE• Pharmacotherapy: A Pathophysiologic Approach, 11th edition: Chapter e-22,

Geriatrics: The Aging Process in Humans and Its Effects on Physiology. Krista L. Donohoe; Elvin T. Price; Tracey L. Gendron; Tricia W. Slattum, 2021 McGraw Hill.

• O’Mahony D, O’Sullivan D, Byrne S et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age and Ageing 2015; 44: 213–218, doi: 10.1093/ageing/afu145

• 2019 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 Soc. 2019;67(4):674-694. doi:10.1111/jgs.15767