Geri-PARDY! (2015 Beers Criteria) Pharmacology Edition

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1 Geri-PARDY! Pharmacology Edition (2015 Beers Criteria) Aurelio Muyot, MD, AGSF, FACP Assistant Professor College of Osteopathic Medicine Touro University Nevada

2 Objectives Review the 2015 Beers Criteria for Potentially Inappropriate Medications (PIM) What s new in 2015 Criteria How to use it to choose the appropriate medication(s)

3 Beers Criteria or as we know it Beers List History First list of potentially inappropriate medications was developed in 1991 for nursing home residents Revisions in 1997 and 2003 now includes all setting of geriatric care Update in 2012 was now under the auspices of the American Geriatrics Society Most recent update was in 2015

4 American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 63(11), Nov 2015,

5 What s New in the 2015 Criteria 1. Drug classes A. Anti-arrhythmics in atrial fibrillation Can be used as first line now with some caveats Example: Recommends to avoid disopyramide due to anticholinergic side effects B. Avoid proton pump inhibitors use beyond 8 weeks due to association with C. difficile infection, bone loss, and fractures C. Avoid non-benzodiazepine, benzodiazepine receptor agonist hypnotics due to minimal efficacy in insomnia and potential for harm

6 What s New in the 2015 Criteria 2. Drugs and disease/syndromes A. Avoid non-benzodiazepine, benzodiazepine receptor agonist hypnotics in patient with dementia/cognitive impairment B. Avoid opioids in patients with a history of falls or fractures C. Avoid anti-psychotics as first-line treatment for delirium

7 What s New in the 2015 Criteria 3. Specific drugs A. Nitrofurantoin can be used in patients with CrCl 30 ml/min. (previously 60 ml/min.), but long term use is not recommended due to toxicity B. Avoid desmopressin as treatment for nocturia/nocturnal polyuria due to high risk of hyponatremia

8 What s New in the 2015 Criteria 4. Addition of Drug-Drug Interactions Category Taking 3 or more CNS-active drugs ACE and K sparing diuretics 5. Addition of Dose Adjustment based on kidney function Direct-acting oral anticoagulants (DOAC) H2 blockers Uric acid lowering agents

9 How to Use the Guide

10 Applying the 2015 Beers Criteria Think of the AGS 2015 Beers Criteria as a warning light that should prompt close review and monitoring of the medication. Medications are listed as potentially inappropriate, not definitely inappropriate There are caveats to the recommendations and rationale, as well as guidance Recommendations may not be applicable to all sites or clinical situations

11 Potentially Inappropriate Medication Drugs to avoid with this disease Proceed with Caution Drug-Drug Interactions Kidney Function and Drugs Anti- Cholinergic Drugs

12 100 The largest medical school in Nevada What is the College of Osteopathic Medicine at Touro University Nevada?

13 Potentially Inappropriate Medication Drugs to avoid with this disease Proceed with Caution Drug-Drug Interactions Kidney Function and Drugs Anti- Cholinergic Drugs

14 100 Drug often found in over the counter (OTC) sleep aids What is diphenhydramine?

15 First Generation Anti-histamines and Older Patients Clearance is reduced with advanced age Tolerance develops when used a hypnotic Anti-cholinergic side effects Confusion Dry mouth Constipation, etc. Diphenhydramine may be appropriate as treatment for acute allergic reaction

16 200 Class of anti-hypertensives associated with a high risk of CNS side effects What are central alpha blockers? Other side effects include bradycardia, orthostatic hypotension

17 300 Older anti-thrombotic not recommended in oral-short acting form What is dipyridamole? May cause orthostatic hypotension

18 400 Anti-parkisonian agent with significant anti-cholinergic side effects What is trihexyphenidyl?

19 500 Antibiotic for urinary infection not recommended for long term use What is nitrofurantoin? Potential for pulmonary toxicity, hepatotoxicity, and peripheral neuropathy

20 100 GI motility drug to avoid with Parkinson disease What is metoclopramide?

21 200 Analgesic class to avoid in heart failure patient What are NSAID or COX-2 inhibitors?

22 300 Drug class associated with increased risk of stroke and mortality in persons with dementia What are antipsychotics?

23 Dementia-related Behavioral Problems Look for triggers Physiologic Environmental Medical or psychologic Non-pharmacologic interventions should be attempted first Pharmacologic treatment only if nonpharmacologic measures have failed and older adult is threatening harm to self or others

24 400 True or False: Nonbenzodiazepine hypnotics are safer to use in older persons who fall vs. benzodiazepines What is False? Can cause ataxia, impaired psychomotor function, syncope, additional falls

25 500 Oral and transdermal forms not recommended in women with urinary incontinence What is estrogen? Aggravates incontinence. Intravaginal estrogen may help with GU symptoms.

26 100 Commonly recommended OTC for primary prevention of CV events What is aspirin? Lack of evidence of benefit vs. risk in adults 80

27 200 Direct oral anticoagulant with antidote, use with caution in adults 75 or CrCl < 30 ml/min. What is dabigatran?

28 300 Anti-seizure medication that may cause or exacerbate SIADH What is carbamazepine or oxcarbazepine? Also has an antidiuretic effect

29 400 Antidepressant classes associated with SIADH (name at least 2/3) What are SSRIs, SNRIs, or TCAs?

30 500 What electrolyte should you monitor when your patient is on an antipsychotic? What is sodium? Thought to be due to either stimulating ADH release or by enhancing activity of ADH in the kidneys

31 100 Electrolyte abnormality risk when combining ACEI and triamterene What is hyperkalemia?

32 200 Risk of this geriatric syndrome increases when combining zoldipem with 2 CNS-active drugs What is falls? Also increases fracture risk.

33 300 CNS side effect when combining meclizine with oxybutynin What is cognitive decline? Both are anti-cholinergic.

34 400 Urinary side effect in women when combining alpha-1 blocker and loop diuretic What is urinary incontinence?

35 500 Increased risk of this side effect when combining warfarin with amiodarone What is bleeding? Amiodarone inhibits the enzymes that metabolize warfarin

36 100 Non-mineralocorticoid diuretic to avoid when CrCl <30 ml/min. due to hyperkalemia risk What is/are triamterene and amiloride?

37 200 Uric acid lowering drug that is no longer effective when CrCl 30 ml/min. What is probenecid?

38 300 Reduction of dose recommended with this class of GI medication when CrCl <50 ml/min. What are H2 blockers? Can cause mental status changes.

39 400 Avoid this adjuvant medication for chronic pain when CrCl < 30 ml/min. What is duloxetine? Increases GI side effects.

40 500 Direct oral thrombin inhibitor to avoid when CrCl <30 ml/min. What is dabigatran?

41 100 Antiarrhythmic with strong anticholinergic property What is disopyramide?

42 200 OTC sleep medication with strong anticholinergic property What is diphenhydramine?

43 300 Antidepressant class with strong anticholinergic properties What are tricyclics?

44 400 Antiemetic with strong anticholinergic property What is prochloroperazine or promethazine?

45 500 Muscle relaxant (s) with strong anticholinergic properties What is cyclobenzaprine or orphenadine?

47 Category: Person

48 Who s picture is this?

49 Who is Dr. Mark Beers?

50 Questions?

1/21/2016 UPDATE ON THE AMERICAN GERIATRICS SOCIETY 2015 BEERS CRITERIA DISCLOSURE OBJECTIVES AGING GOALS BEERS CRITERIA

1/21/2016 UPDATE ON THE AMERICAN GERIATRICS SOCIETY 2015 BEERS CRITERIA DISCLOSURE OBJECTIVES AGING GOALS BEERS CRITERIA UPDATE ON THE AMERICAN GERIATRICS SOCIETY 2015 BEERS CRITERIA DISCLOSURE I have no financial conflict of interest to disclose. Lacey Charbonneau, Pharm.D. PGY-1 Community Practice Resident Baptist Medical