Evidence Based alternatives to beers potentially ...

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

Triprolidine Alternatives Intranasal normal saline Second-generation antihistamines Cetirizine Fexofenadine Loratadine Levocetirizine Intranasal steroids Fluticasone Beclomethasone Budesonide Ciclesonide Mometasone Triamcinolone Flunisolide

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

should avoid dosages > 0.125 mg daily antagonists CNS Medications Antidepressants Amitriptyline Amoxapine Clomipramine Desipramine Doxepin (>6 mg/day) Imipramine Nortriptyline Paroxetine Protriptyline Trimipramine Ergoloid mesylates

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

Vitamin E CNS Medications Barbiturates Amobarbital Butabarbital Butalbital Mephobarbital Pentobarbital Phenobarbital Secobarbital Other Agents Meprobamate Alternatives Levetiracetam Lamotrigine

Alternatives Buspirone SSRI SNRI CNS Medications Benzodiazepines Alprazolam Estazolam Lorazepam Oxazepam Temazepam Triazolam Chlordiazepoxide Clonazepam Clorazepate

Diazepam Flurazepam Quazepam Z Drugs Eszopiclone Zaleplon Zolpidem Alternatives Buspirone SSRI SNRI Alternatives Sleep hygiene Melatonin CNS Medications

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

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 Pain Medications Non-selective

NSAIDs Aspirin (>325 mg/ day) Diclofenac Diflunisal Etodolac Fenoprofen Ibuprofen Indomethacin Ketoprofen Ketorolac Meclofenamate Mefenamic acid Meloxicam Nabumetone Naproxen Oxaprozin Piroxicam Sulindac

Tolmetin Skeletal Muscle Relaxants Carisoprodol Chlorzoxazone Cyclobenzaprine Metaxalone Methocarbamol Orphenadrine Alternatives Celecoxib Acetaminophen Salsalate Pain 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

Strongly anticholinergic drugs Questionable Alternatives Other Agents Growth Hormone Antispasmodics Atropine (excludes ophthalmic) Belladonna alkaloids Clidinium-chlordiazepoxide Dicyclomine (excludes ophthalmic) Hyoscyamine Methoscopolamine Propantheline Scopolamine Nitrofurantoin Androgens

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

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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:

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