START, STOPP, Beers Oh My! Navigating the World of Geriatric Pharmacy Jessica DiLeo, PharmD Kate Murphy, PharmD OBJECTIVES Identify pharmacodynamic and pharmacokinetic parameters that may influence treatment options among geriatric patients Identify and review common references for optimizing medication use in the elderly Conduct a patient chart review and identify factors which may influence and/or contribute to potentially inappropriate treatment options among geriatrics Review pertinent counseling points for common Beers List, STOPP, and START criteria medications as it applies to geriatric patients BACKGROUND 1
What is Geriatrics? Geriatrics refers to the medical care of the elderly Who is elderly? Difficult to define and resource dependent Typically defined as those aged 60 to 65 years and older Why is Geriatrics important? Physiologic changes among older adults Polypharmacy Potentially inappropriate medications (PIMs) Misuse vs. Under use Medications to avoid Adverse Drug Reactions (ADRs) 25% of ER visits related to ADRs are for elderly patients Drug-Drug Interactions (DDIs) Physiologic Changes in the Elderly PROCESS PHYSIOLOGIC CHANGE CLINICAL SIGNIFICANCE Absorption Decreased gastric acid production (increased gastric ph) Decreased gastric emptying Decreased GI motility Decreased GI blood flow Decreased absorptive surface area Possible reduction of tablet dissolution Possible reduction in solubility Increase exposure time in stomach Distribution Decreased total body mass (lean) Increased body fat Decreased total body water Decreased plasma albumin Altered protein binding Influence dosing weight Alter the onset and duration of water-soluable and highly-tissue bound drugs May delay onset of action among lipophilic drugs 2
Physiologic Changes in the Elderly PROCESS PHYSIOLOGIC CHANGE CLINICAL SIGNIFICANCE Metabolism Excretion Tissue Sensitivity Reduced liver mass Reduced blood flow to liver Reduced Phase I metabolism Reduced enzyme activity Reduced renal blood flow Reduced glomerular filtration Reduced function of tubular secretion Alterations in receptor numbers and affinity Alterations in second messanger function s Alterations in cellular and nuclear responses Decreased first passmetabolism Decreased renal elimination Variable sensitivity to drugs Could result in ADE, therapy failure, or insignificant responses Physiologic Changes in the Elderly PHYSIOLOGIC CHANGE Cognitive function may decrease over time Bone loss CLINICAL SIGNIFICANCE May impair understanding and adherence to medication regimen Increase fall risk Increased fracture Gait may slow and balance may worsen May increase fall and fracture risk Polypharmacy What is polypharmacy? Various defined Refers to the use of multiple medications Why is it a concern? Multiple provides Prescribing cascades Increase risk for DDIs and ADRs Inappropriate dosing and prescribing 3
QUESTION #1 Which of the following factors can influence medication dosing among the elderly? a) delayed gastric emptying b) declining kidney and liver function c) co-morbidities d) reduced and/or increased sensitivity to certain medications e) all of the above Introduction to Geriatric References Beers Criteria START Criteria STOPP Criteria Canadian Criteria Consider these tools, not rules 2012 AGS BEERS Criteria for Potentially Inappropriate Medication Use in Older Adults List of potentially inappropriate medications (PIMs) for elderly Advantages Quick and easy reference for problem drugs Recent data (2012 update) Disadvantages Limited scope Limited evidence, inconclusive 4
START/STOPP Criteria Screening Tool to Alert Doctors to the Right Treatment (START) Screening Tool of Older People s potentially inappropriate Prescriptions (STOPP) Advantages Recommendations for medications that are often omitted with therapeutic alternatives Recent data More patient-centric Disadvantages Limited evidence that outcomes are affected by its use QUESTION #2 Which of the following references can be used to identify potentially inappropriate medication use in the elderly? a) Beers list b) START/STOPP Criteria c) JNC-8 d) A and B e) all of the above What is the concern? Fall Risk Hypoglycemia Hypotension Dizziness Sedation Constipation Urinary Retention Cognitive Impairment Toxicity 5
Anticholinergics Constipation/Urinary Retention Oral Corticosteroids complications Limit treatment to exacerbations (<3 months) Beta Blockers Consider cardio-selective beta blockers if necessary Tricyclic Antidepressants Cognitive impairment Alpha blockers Avoid for treatment of HTN Consider 5-alpha reductase inhibitors as alternatives for treatment of BPH Tamsulosin has less ADEs Alpha agonists Avoid (exception with hypertensive emergencies) 6
Benzodiazepines Cognitive impairment Re-evaluate need for therapy frequently Consider shorter acting benzodiazepines Antihistamines Constipation Urinary retention If treatment for allergies needed: Reserve for PRN use Consider second generation over first generation Consider nasal corticosteroids instead CASE PRESENTATION AB is a 69 year-old female PMH: COPD, Type 2 Diabetes, dyslipidemia, HTN, and HF C/O recent episodes of falling within past 30 days. Dizziness bothers her the most when she gets out of bed in the morning and middle of the night Medication List: Atorvastatin 10mg qam Carvedilol 6.25mg BID Diazepam 10mg BID PRN (typically takes qhs) Lisinopril 40mg qam Metformin 500mg BID Spiriva qday Symbicort 160/4.5mcg, 2 inhalations BID 7
QUESTION #3 Which of the medications on AB s chart may increase her fall risk? a) lisinopril b) diazepam c) atorvastatin d) A and B e) all of the above QUESTION #4 Which of the following counseling points would be appropriate to help AB minimize her fall risk? a) Recommend patient take offending medication(s) at bedtime b) Discuss with patient and provider need for continued use of diazepam c) Recommend patient move slowly and have a grasp on a steady object when changing positions (i.e. sitting to standing) d) B and C e) all of the above 8
Rules of Thumb Consider physiologic changes in geriatric patients Evaluate and treat every patient individually Many elderly patients may take these medications, not all require intervention or recommendations to avoid Screen for adverse events at each interaction Counsel patients thoroughly REFERENCES Beers M, Ouslander J, Rollingher I, et al. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991; 151: 1825-32. Beyth R, Shorr R. Principles of drugt therapy in older patients: rational drug prescribing. Clin Geriatr Med 2002; 18: 577-592. Fick D, Cooper J, Wade W, et al. Updating the Beers Criteria for potentially inappropriate medication use in older adults. Arch Intern Med 2003; 163: 2716-24. Fick D, Waller J, Maclean J, et al. Potentially inappropriate medication use in a Medicare managed care population: association with higher costs and utilization. J Managed Care Pharm 2001; 7: 40 7-13. Goulding M. Inappropriate medication prescribing for elderly ambulatory care patients. Arch Intern Med 2004; 164: 305-312. Gu Q, Dillon C, Burt V. Prescription Drug Use Continues to Increase: US Prescription Drug Data for 2007-2008. NCHS Data Brief; 42. Available at http://www.cdc.gov/nchs/data/databriefsdb42.pdf. Accessed on January 27, 2015 Potentially Harmful Drugs in the Elderly: Beers List. Available at http://pharmacistsletter.therapeuticresearch.com/pl/articledd.aspx?cs=faculty&s=pl&pt=6&fpt=3 1&dd=280610&pb=PL&searchid=50198915#CHART4413. Accessed on January 6, 2015. Reuben D, Herr K, Pacala J, et al. Geriatrics at Your Fingertips. 16 th ed. American Geriatrics Society; 2014. STARTing and STOPPing Medications in the Elderly. Available at http://pharmacistsletter.therapeuticresearch.com/pl/articledd.aspx?pt=2&dd=270906&fromce=092011. Accessed on January 6, 2015. 9