Evidence Based alternatives to beers potentially ...
EVIDENCE BASED ALTERNATIVES TO BEERS POTENTIALLY INAPPROPRIATE MEDICATIONS JANNA HAWTHORNE, PHARMD, MA ED PRIMARY CARE CLINICAL PHARMACIST BAPTIST HEALTH/PRACTICE 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 Identify evidence based alternatives to potentially inappropriate medications presented in the 2019 update of the American Geriatric Societys 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 POPULATION STATISTICS 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%) ADVERSE DRUG REACTIONS An appreciably harmful or unpleasant reaction resulting from an
intervention related 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 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 Anticholinergic Medications First Generation Antihistamines Brompheniramine Carbinoxamine Chlorpheniramine Clemastine Cyproheptadine Dexbrompheniramine Dexchlorpheniramine Dimenhydrinate Diphenhydramine Doxylamine Hydroxyzine Meclizine Promethazine Pyrilamine
Anticholinergic Medications Antiparkinsonian Agents Benztropine Trihexyphenidyl Alternatives Carbidopa/levodopa This recommendation also aligns with the 2017 Parkinsons Disease in Adults Guidelines published by the National Institute for Health and Care Excellence Antithrombotics Dipyridamole Alternatives Clopidogrel Aspirin/Dipyridamole
Cardiovascular Medications Peripheral Alpha-1 Blockers Doxazosin Prazosin Terazosin Central Alpha-Agonists Clonidine (1st line) Guanabenz Guanfacine Methyldopa Reserpine (>0.1 mg/day) Other Agents Nifedipine (IR formulation) Alternatives
Thiazide-type diuretics ACE-inhibitors ARBs Long acting dihydropyridine CCB These recommendations also align with the 2017 updated ACC/AHA guidelines 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 Studies have shown no difference on mortality with Flecainide rate vs. rhythm control so determination of approach Propafenone should be based on comorbidities and patient preference
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 If digoxin is initiated for either indication, Aldosterone
Antipsychotics First and Second Generation Chlorpromazine Thorazine Loxapine Olanzapine Perphenazine Thioridazine Trifluoperazine Haloperidol Alternatives Risperidone Quetiapine Pimavanserin* Endocrine Medications
Other Agents Estrogens, with or without progestins Other Agents Desiccated thyroid Alternatives Dyspareunia and vulvovaginitis Vaginal estrogens Vasomotor symptoms SSRI SNRI Gabapentin Alternatives Levothyroxine Endocrine Medications
Other Agents Alternatives Acute Pain Tramadol Morphine IR Oxycodone/APAP Meperidine Chronic Pain All of the above* For neuropathic pain: SNRI Gabapentin Capsaicin topical Pregabalin Lidocaine patch
Heart Failure Other Agents Non-dihydropyridine CCBs Other Agents NSAIDs & COX-2 inhibitors Other Agents Thiazolidinediones Other Agents Cilostazol Other Agents Dronedarone Syncope Other Agents Acetylcholinesterase Inhibitors Other Agents Non-selective peripheral alpha-1 blockers
Other Agents Tri-cyclic antidepressants Other Agents Antipsychotics Dementia & Delirium Other Agents Anticholinergics Other Agents Antipsychotics & Benzodiazepines Other Agents Corticosteroids Other Agents H-2 Receptor Antagonists Other Agents Meperidine Other Agents Z Drugs
Falls & Fractures Other Agents Anticonvulsants Other Agents Antipsychotics, Z Drugs, Benzodiazepines Other Agents Tricyclic Antidepressants Other Agents Opioids Parkinson Disease Other Agents Dopamine-receptor antagonist antiemetics Metoclopramide Prochlorperazine Promethazine
Other Agents All Antipsychotics GI Other Agents Aspirin >325 mg/day Non-COX 2 Selective NSAIDs Kidney/Urinary Tract Other Agents NSAIDs Urinary Incontinence Other Agents Estrogen oral and transdermal Peripheral alpha-1 blockers Lower Urinary Tract Symptoms Other Agents
Methyltestosterone Testosterone Megestrol Metoclopramide Mineral Oil Proton-Pump Inhibitors Desmopressin 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 Societys 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 QUESTIONS REFERENCES An Aging Nation: Projected Number of Children and Older Adults. United states Census Bureau. October 2018. https://www.census.gov/library/visualizations/2018/comm/historic-first.html. Accessed March 19, 2019. Charlesworth, C., Smit, E., Lee, D., Alramadhan, F. and Odden, M. (2015). Polypharmacy Among Adults Aged 65 Years
and Older in the United States: 19882010. 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, 356(9237), pp.1255-1259. Beijer, H. and de Claey, C. (2002) Hospitalizations caused by adverse drug reactions (ADR): a meta-analysis of observational studies. Pharm World Sci 24: 46-54. Pirmohamed, M., James, S., Meakin, S., Green, C., Scott, A., Walley, T. et al. (2004) Adverse drug reactions as cause of admission to hospital prospective analysis of 18,820 patients. BMJ 329: 15-19.
Kongkaew, C., Noyce, P. and Ashcroft, D. (2008) Hospital admissions associated with adverse drug reactions: a systematic review of prospective observational studies. Ann Pharmacother 42: 1017-1025. Cooper, J. (1996) Probable adverse drug reactions in a rural geriatric nursing home population: a four-year study. J Am Geriatr Soc 44: 194-197. Dilles, T., Vander Stichele, R., Van Bortel, L. and Elseviers, M. (2013) The development and test of an intervention to improve ADR screening in nursing homes. J Am Med Dir Assoc 14: 371-376. 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 Soc. 2019; 00:1-21. doi.org/10.1111/jgs.15767. ePub ahead of
print. https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.15767 (accessed 2019 Mar 19). Hanlon, J., Semla, T. and Schmader, K. (2015). Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug-Disease Interactions in the Elderly Quality Measures. Journal of the American Geriatrics Society, 63(12), pp.e8-18. National Institute for Health and Care Excellence (2017) Parkinsons disease in adults (NICE Guideline 71). Available at https://www.nice.org.uk/guidance/ng71 [Accessed 08 March 2019]. Whelton, P., Carey, R., Aronow W., et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guidelines for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: a Report of the American College of Cardiology/ American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018; 71: e127-248.
Frankel G, Kamrul R, Kosar L, Jensen B. Rate versus rhythm control in atrial fibrillation. Can Fam Physician. 2013;59(2):161-8. Yancy, C., Jessup, M., Bozkurt, B., Butler, J., Casey, D., Colvin, M., Drazner, M., Filippatos, G., Fonarow, G., Givertz, M., Hollenberg, S., Lindenfeld, J., Masoudi, F., McBride, P., Peterson, P., Stevenson, L. and Westlake, C. (2017). 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation, 136(6). Ambrosy, A., Pang, P. and Gheorghiade, M. (2019). Digoxin for Worsening Chronic Heart Failure. Wade AG, Ford I, Crawford G, et al. Efficacy of prolonged release melatonin in insomnia patients aged 5580 years: quality of sleep and next-day alertness outcomes. Current Medical Research and Opinion. 2007;23(10):2597-2605. doi:10.1185/030079907x233098.
Cummings, J., Isaacson, S., Mills, R., et al. Pimavanserin for patients with Parkinsons disease psychosis: a randomized, placebocontrolled phase 3 trial. Lancet 2014;383:533-540. REFERENCES Coutinho J, Field JB, Sule AA. Armour Thyroid Rage - A Dangerous Mixture. Cureus. 2018;10(4):e2523. Published 2018 Apr 24. doi:10.7759/cureus.2523 Carbone LD, Johnson KC, Robbins J, et al. Antiepileptic drug use, falls, fractures, and BMD in postmenopausal women: findings from the women's health initiative (WHI). J Bone Miner Res. 2009;25(4):873-81. Poirier A-A, Aube B, Cote M, Morin N, Di Paolo T, Soulet D. Gastrointestinal dysfunctions in Parkinson's Disease:
symptoms and treatments. Hindawi Publishing Corporation. October 2016:01-23. doi:10.1155/2016/6762528. Colgan, R. and Williams, M. Diagnosis and Treatment of Acute Uncomplicated Cystitis. Amer Family Physician 2011; 84(7):771-776 Enweluzo C, Aziz F. Gastroparesis: a review of current and emerging treatment options. Clin Exp Gastroenterol. 2013;6:161-5. Published 2013 Sep 5. doi:10.2147/CEG.S50236 Andersson KE, Van Kerrebroeck P. Pharmacotherapy for Nocturia. Curr Urol Rep. 2018;19(1):8. Published 2018 Feb 9. doi:10.1007/s11934-018-0750-y
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