PHAR 840 Van Geriatrics

Van – Geriatrics Thursday, February 13, 2025 12:42 PM Beers Criteria • Primary target audience: practicing clinicians ○ Do not automatically defer to colleague → use Criteria as tool to stimulate dialogue between clinicians ○ When stopping meds → taper down slowly rather than abrupt stop (withdrawal reaction) ○ Variety of health care professionals play important role in addressing management • Intended for adults ≥ 65 y/o in all ambulatory, acute, and institutionalized setting of care, EXCEPT hospice and end-of-life care settings • Main Criteria of 2023 Update ○ Potentially Inappropriate Medication (PIM) Use in Older Adults ○ Drug-Disease or Drug-Syndrome Interactions that May Exacerbate the Disease or Syndrome ○ Drugs To Be Used with Caution in Older Adults ○ Potentially Clinically Important Drug-Drug Interactions that Should Be Avoided in Older Adults ○ Medications that Should Be Avoided or Have Their Dosage Reduced with Varying Levels of Kidney Function in Older Adults 2023 AGS Beers Criteria 1) Potentially Inappropriate Medication (PIM) Use in Older Adults 2) Drug-Disease or Drug-Syndrome Interactions that May Exacerbate the Disease or Syndrome Diseases/High-Risk Medications 1st-Generation Antihistamines • • • • • Brompheniramine Chlorpheniramine Diphenhydramine (oral) Hydroxyzine Meclizine Rationale → AVOID due to: • Highly anticholinergic • Clearance ↓ w/ age • Tolerance develops Recommendation/Alternative • Intranasal saline • 2nd generation antihistamines Diphenhydramine in acute tx of severe allergic reaction may be appropriate • Cetirizine • Fexofenadine • Loratadine • Intranasal steroid • Beclomethasone • Fluticasone • OTC Aspirin • For primary prevention of CV disease • Risk of major bleeding • Lack of net benefit + potential net harm for primary prevention • AVOID initiating aspiring for primary prevention of CV disease • Consider deprescribing aspirin (already taking for primary prevention) Warfarin • Tx of nonvalvular atrial fibrillation or VTE • Higher risks or major bleeding • Similar or lower effectiveness • AVOID starting warfarin as initial therapy unless alternative options are contraindicated • Older adults using warfarin long-term → reasonable to continue if: • Well-controlled INRs • No adverse effects • Preferred choice: DOACs (for anticoagulation for most people w/ these conditions) • 1) Apixaban • 2) Rivaroxaban • 3) Warfarin Rivaroxaban • Long-term tx of nonvalvular atrial fibrillation or VTE • Higher risk of major bleeding + GI bleeding than other • AVOID long-term tx of atrial fibrillation or VTE in favor of safer DOACs (apixaban better) anticoagulant alternatives • May be reasonable in special situations • Ex: when once daily dosing necessary to facilitate medication adherence ○ Rivaroxaban – once daily dosing ○ Apixaban – twice daily dosing Non-Selective Peripheral α1-Blocker • Tx of HTN ○ Doxazosin ○ Prazosin ○ Terazosin → AVOID use as antihypertensive • High risk of orthostatic hypotension + associated harms Central α-Agonists • Tx of HTN ○ Clonidine • Adverse CNS effects • Bradycardia • Orthostatic hypotension • • • • Thiazide-type diuretic ACEi ARB Long-acting dihydropyridine CCB • Felodipine • Nifedipine ER • Amlodipine • In African-Americans • Thiazide-type diuretic • CCB ○ Guanfacine → AVOID clonidine as 1st-line tx for HTN → AVOID other central α-agonists for tx of HTN Barbiturates • Phenobarbital → AVOID due to: • High rate of physical dependency • For epilepsy → other anticonvulsants • Lamotrigine • Levetiracetam Estrogens w/ or w/o progestins (oral or patch) Carcinogenic potential Lack of cardioprotective effect + cognitive protection • Tx of dyspareunia + vulvovaginitis • Vaginal estrogen formulations • Vasomotor symptoms • SSRI • SNRI • Gabapentin → DO NOT initiate systemic estrogen → Consider deprescribing if already using Sulfonylureas • Both short and long-acting ○ Short: Glipizide ○ Long: Glimepiride ○ Long: Glyburide • Higher risk of CV events, all-cause mortality, and HYPOglycemia • ↑ risk of CV death + ischemic stroke • Long-acting higher risk of prolonged HYPOglycemia than short-acting • AVOID sulfonylureas as 1st or 2nd line monotherapy or add-on PPIs • • • • • Risk of: • C. diff. • Pneumonia • GI malignancies • Bone loss • Fractures • AVOID scheduled use for > 8 weeks unless for: • High-risk patients (oral corticosteroids or chronic NSAID use) • Erosive esophagitis • Barret's esophagitis • Pathologic hypersecretory condition • Demonstrated need for maintenance tx • If not for any of the above → deprescribe OR • Decrease to lower dose • Stop and use on-demand • Monitor at 4-12 weeks Metoclopramide • Extrapyramidal effects + tardive dyskinesia • Risk greater in frail older adults + w/ prolonged exposure • AVOID unless gastroparesis w/ duration of use NOT to exceed 12 weeks • Except in rare cases Skeletal Muscle Relaxants • Carisoprodol • Cyclobenzaprine • Most poorly tolerated • Anticholinergic adverse effects • Sedation • ↑ risk of fractures • Questionable effectiveness at doses tolerated → AVOID • Acute, Mild, or Moderate Pain • Acetaminophen • Non-acetylated salicylate ○ Salsalate • Propionic acid derivatives ○ Ibuprofen ○ Naproxen → IF no HF, eGFR > 30 mL/min and given w/ PPI for gastroprotection if used for > 7 days Esomeprazole Lansoprazole Omeprazole Pantoprazole • Dose not apply to skeletal muscle relaxants used for spasticity management • Baclofen • Tizanidine therapy • If used → choose short-acting agents 3) Drugs To Be Used w/ Caution in Older Adults Diseases/High-Risk Medications Rationale Recommendation/Alternative Dabigatran • Long-term tx of nonvalvular atrial fibrillation or VTE • Compared to warfarin • Use caution in selecting this medication over other DOACs for long-term tx of • ↑ risk of GI bleeding nonvalvular atrial fibrillation or VTE • Compared to apixaban • ↑ risk of GI bleeding + major bleeding Prasugrel Ticagrelor • ↑ risk of major bleeding compared to clopidogrel • Use caution (especially in adults ≥ 75 y/o) • If prasugrel used → consider lower dose (5 mg) for those ≥ 75 y/o Bactrim (trimethoprim/sulfamethoxazole) • ↑ risk of hyperkalemia concurrent use w/: • ACEi • ARB • ARNI (Entresto) • +in presence of ↓ CrCl • Use w/ caution in patients on ACEi, ARB, or ARNI, and decreased CrCl Sodium-Glucose Cotransporter-2 (SLGT2) inhibitors • Canagliflozin • Dapagliflozin • Empagliflozin • ↑ risk of urogenital infections • Diabetic ketoacidosis • Use w/ caution • Monitor patients for urogenital infections + ketoacidosis 4) Clinically Important DDIs Diseases/High-Risk Medications Rationale Opioids + BZDs • ↑ risk of overdose and adverse events Recommendation/Alternative • AVOID Opioids + gabapentin/pregabalin • ↑ risk of severe sedation related adverse events • AVOID • Respiratory depression • Exceptions • Death • Transitioning from opioid to gabapentin or pregabalin • Reducing opioid dose • Caution should be used in all circumstances Phenytoin + TMP-SMX • Phenytoin toxicity • AVOID Theophylline + Ciprofloxacin • Theophylline toxicity • AVOID Warfarin + Amiodarone Warfarin + Ciprofloxacin • PK interactions Warfarin + Macrolides • Excluding azithromycin Warfarin + TMP-SMX Warfarin + SSRIs • PD interactions • ↑ bleeding • AVOID when possible • If used together → monitor INR closely 5) Medications that Should Be Avoided or Have Their Dosage Reduced w/ Decreased Kidney Function Diseases/High-Risk Medications Rationale Recommendation/Alternative Ciprofloxacin • ↑ risk of CNS effects + tendon rupture • CrCl < 30 mL/min → dose reduction TMP-SMX • ↑ risk of worsening renal function + hyperkalemia • CrCl 15-29 mL/min → dose reduction • Especially w/ concurrent use of ACEi, ARB, or ARNI • CrCl < 15 mL/min → AVOID Nitrofurantoin (Macrobid) • Potential for toxicity w/ long-term use • Pulmonary • Hepatoxicity • Peripheral neuropathy • CrCl < 30 mL/min → AVOID Chronic Insomnia Management in Older Adults Diseases/High-Risk Medications Benzodiazepines • Short + Immediate-Acting ○ Alprazolam ○ Lorazepam ○ Oxazepam ○ Temazepam ○ Triazolam • Long-Acting ○ Chlordiazepoxide ○ Diazepam Rationale • Risk of abuse, misuse, and addiction • ↑ sensitivity to BZDs + ↓ metabolism of long-acting agents • ALL BZDs • ↑ risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes • Except in certain disease states Recommendation/Alternative • AVOID • Deprescribe if only used for insomnia • Sleep Onset Insomnia (SOI) • Ramelteon (Rozerem) ○ Indenofuran melatonin receptor agonist ○ For sleep latency ○ DDI – strong CYP1A2 inhibitor (fluvoxamine) ○ Take within 30 mins of bedtime ○ Avoid around high-fat meal ○ AE: headache, somnolence, nasopharyngitis ○ Lack of withdrawal effects + rebound insomnia ○ Lack of abuse potential • Melatonin ○ Hormone ○ For sleep latency ○ Safety concerns ▪ Potential for residual daytime sedation + prolonged duration of action ○ AVOID controlled-release products ○ Immediate release should be used ▪ 1 to 2 mg (up to 6 mg) administered 1 hour before bedtime • Sleep Maintenance Insomnia • Doxepin (Silenor) ○ Take 30 minutes before bedtime ○ Do not take within 3 hours of a meal ○ C/I: untreated narrow-angle glaucoma, severe urinary retention ○ No reports of memory impairment or cognitive disorders Non-benzodiazepine, Benzodiazepine Receptor Agonist Hypnotics (Z-drugs) • Eszopiclone • Zaleplon • Zolpidem • • • • Delirium, falls, fractures ↑ ER visits/hospitalization Motor vehicle crashes Minimal improvement in sleep latency + duration • AVOID • Deprescribe if only used for insomnia • Taper down slowly then stop • Offer behavioral sleeping advice • Consider CBT if available • Monitor every 1-2 weeks for duration of tapering • If relapse: ○ Consider maintaining current BZRA dose for 1-2 weeks, then continue to taper at slow rate • Recommendations • See above Geriatric Syndromes Discussion • Frailty • A person who has 3 of below components is considered frail: ○ Decreased muscle mass and strength ○ Unintentional weight loss ○ Exhaustion ○ Slowed motor performance (walking speed) ○ Low physical activity level • Fall • Not a normal part of aging and can be prevented • Risk Factors • Falls + AGS Beers Criteria Diseases/High-Risk Medications • Anticholinergics • Antidepressants • (TCAs, SSRIs, SNRIs) • Antiepileptics • Antipsychotics • Benzodiazepines • Non-benzodiazepine, BZRA hypnotics • (eszopiclone, zaleplon, zolpidem) • Opioids Rationale • • • • Recommendation/Alternative Ataxia Impaired psychomotor function Syncope Additional falls • AVOID unless safer alternatives not available • AVOID antileptics • Except for seizure + mood disorders • AVOID opioids • Except for severe acute pain • If one drug must be used → consider ↓ use of other CNS active ○ Recent fractures medications (that increase risk of falls and fractures) ○ Joint replacements Role of Pharmacist in Fall Prevention • In collab w/ other health care professionals: • Screen patients using standardized protocol to determine fall risk • Review and optimize medication therapy • Recommend vitamin D supplementation (when appropriate) ○ AGS recommends at least 1,000 international units (IU)/d with calcium in older adults ≥ 65 years old to reduce risk of fractures and falls • Educate patients and caregivers about ways to prevent fall