Transcript Beers Criteria

Robyn Bryson, PharmD
Kerri Hagedorn, PharmD, BCPS
 Created
by Dr. Mark Beers in 1991
 Identified medications that could be
considered inappropriate in long-term
care facility patients 65 years and older
 Updated in 1997, 2003, and 2012
 Current list geared toward providers
caring for the elderly inpatient or
outpatient
 Main
objective is for the provider to review
this list when considering initiating
medications and consider alternatives if
available
 Centers
for Medicare and Medicaid
Services are using these recommendations
in assessing the quality of care rendered to
elderly patients
• Pharmacists participate in Medication Therapy
Management Services
 Includes
53 medications/medication
classes
• Inappropriate medications and medications to
avoid in elderly
• Potentially inappropriate medications/classes to
avoid in elderly with certain diseases and/or
syndromes that could be exacerbated by the
medication
• Medications to be used with caution in elderly
patients
 Update
for medications to avoid
• Addition of the following medications:
 Megestrol (Megace)
 Glyburide (DiaBeta, Glynase)
 Sliding-scale Insulin
 Update
for medications to use with
caution
• Addition of the following medications:
 Dabigatran (Pradaxa) and Prasugrel (Effient) due to
increased risk of bleeding if 75yo or older
 Update
for PIM and classes to avoid in
elderly with certain diseases/syndromes
that the medication could exacerbate
• Addition of the followings medications/classes
 Pioglitazone (Actos) and Rosiglitazone (Avandia) in
HF patients
 Acetylcholinesterase inhibitors with history of
syncope
 SSRIs with falls/fractures
 Adverse
reactions
that worsen current
disease states
 Current
 Adverse
 Current
reactions
that require treatment
or
hospitalization/office
visit
trials have
not proven efficacy in
elderly patients
trials have
proven increased
mortality risk


Primary purpose is to be
an educational tool and
quality measure
PIM affected by aging
were not included
• Medications requiring
renal dosing
• Drug-Drug interactions
• Therapeutic duplication


Palliative Care/Hospice
patients are not included
Non-English literature
was not included in
review
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Analgesics
Antidepressants
Antihistamines
Antihypertensives
Antiplatelet
Agents/Anticoagulants
Antipsychotics
Anxiolytics
Cardiac Drugs
Central Nervous System
Agents

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Chemotherapy
Diabetes Drugs
Gastrointestinal Drugs
Hormones
Hypnotics
Musculoskeletal Agents
NSAIDs
Respiratory Drugs
Stimulant Drugs
Urinary Drugs
 Meperidine
(Demerol)
• Neurotoxicity, Delirium, Cognitive Impairment,
Poor Oral Efficacy
 Pentazocine
(Talwin)
• Increased CNS effects
(Confusion/Hallucinations); Ceiling to analgesic
effect
 Tramadol
(Ultram)
• Decreases seizure threshold
 Safer
Alternatives
• Acetaminophen (Tylenol)
• Short-term NSAID
• Salicylates
• Topical Capsaicin
• Codeine
• Hydrocodone/APAP (Norco/Vicodin)
• Oxycodone/APAP (Percocet/Roxicet)
Is the patient allergic to any medications?

Bupropion (Wellbutrin)
• Decreases seizure threshold

Paroxetine (Paxil)
• Cause/Worsen Delirium, Worsen Constipation/Urinary
Retention/Cognitive Impairment

Mirtazapine (Remeron)
• SIADH

SSRIs
• SIADH, Psychomotor Impairment

Tricyclic Antidepressant
• Amitriptyline (Elavil) Clomipramine (Anafranil) Doxepin,
Imipramine (Tofranil) Trimipramine (Surmontil)
 Anticholinergic effects, Delirium, Sedation, Orthostatic
Hypotension, Cognitive Impairment, SIADH
 Anticholinergic
Antihistamines
• Brompheniramine, Carbinoxamine,
Chlorpheniramine, Clemastine, Cyproheptadine,
Dexbrompheniramine, Dexchlorpheniramine,
Diphenhydramine oral, Doxylamine,
Hydroxyzine, Promethazine, Triprolidine
 Loratadine
(Claritin)
• May worsen delirium, cognitive impairment,
constipation, or urinary retention
 Safer
Alternatives
• Cetirizine (Zyrtec)
• Fexofenadine (Allegra)
• Desloratadine (Clarinex)
• Levocetirizine (Xyzal)

Doxazosin (Cardura), Prazosin (Minipress),
Terazosin (Hytrin)
• Could cause orthostatic hypotension, urinary
incontinence

Clonidine (Catapres), Guanabenz, Guanfacine,
Methyldopa, Reserpine
• Could cause orthostatic hypotension, bradycardia, CNS
adverse effects

Short-acting Nifedipine
• Hypotension, Myocardial Ischemia

Triamterene
• Kidney injury

Vasodilators
• Increased syncope
 Aspirin
• Caution in patients >= 80yo
 Dabigatron (Pradaxa)
• Increased bleeding risk in patients >= 75yo
• Decreased efficacy in renal impairment
 Prasugrel (Effient)
• Increased bleeding risk
 Ticlopidine (Ticlid)
 Dipyridamole short-acting
• Orthostatic Hypotension
(Persantine)
 All
antipsychotics increase the risk of
stroke, death, and SIADH in demented
elderly patients requiring behavioral
treatment
 Chlorpromazine, Clozapine, Fluphenazine,
Olanzapine (Zyprexa), Perphenazine,
Thioridazine, Thiothixene (Navane),
Trifluoperazine
• May cause/worsen delirium, worsen constipation,
worsen cognitive impairment, worsen urinary
retention

Quetiapine (Seroquel)
or Clozapine (Clozaril)
are better options for
Parkinson’s disease

Less Anticholinergic
Options:
• Aripiprazole (Abilify)
• Asenapine (Saphris)
• Haloperidol
• Iloperidone
• Lurasidone (Latuda)
• Paliperidone (Invega)
• Quetiapine (Seroquel)
• Risperidone (Risperdal)
• Ziprasidone (Geodon)
 Benzodiazepines
should be used with
caution when used for agitation/delirium
or in patients with dementia/cognitive
impairment
 Meprobamate
sedation
may cause dependence or

Amiodarone

• QT prolongation,
• Could worsen systolic HF
Pulmonary toxicity, hypoor hyperthyroidism

Antiarrhythmics
or constipation

shown to provide no
additional efficacy
Procainamide, Propafenone,
Quinidine, Sotalol
rhythm control for Afib

outcome in AFib/HF


Disopyramide (Norpace)
• Anticholinergic SE
Cilostazol (Pletal)
• Could worsen HF
Dronedarone (Multaq)
• Shown to produce worse
Digoxin
• Doses >0.125 mg/day have
• Dofetilide, Flecainide, Ibutilide,
• Prefer rate control over
Diltiazem & Verapamil

Spironolactone
• Hyperkalemia, caution if
CrCl <30 ml/min
 Acetylcholinesterase
Inhibitors
 Carbamazepine
• SIADH
• Donepezil (Aricept)
• Orthostatic
hypotension,
bradycardia
 Anticonvulsants
• Unsteady gait,
psychomotor impairment,
syncope, falls
 Dimenhydrinate
&
Meclizine
• Cause/worsen delirium,
worsen
constipation/urinary
retention, cognitive
impairment
 Chlorpropamide
(Diabinese)
• Extended half-life, prolonged hypoglycemia, SIADH
 Glyburide
(Diabeta, Glynase)
• Prolonged hypoglycemia
 Sliding
Scale Insulin
• Poor efficacy, hypoglycemia
 Pioglitazone
(Actos)
• Caution in HF due to edema

Antispasmodics

• Cause/worsen delirium,
• Belladonna alkaloids, Clidinium,
Dicyclomine, Hyoscyamine,
Propantheline, Scopolamine
Worsen constipation,
Cognitive impairment,
Worsen Parkinson’s Dz
• Anticholinergic SE,
delirium

H2 Blocker

Delirium, Cognitive
impairment, Worsen
Parkinson’s Dz, Reduced
clearance in elderly
Worsen cognitive
impairment
Metoclopramide
(Reglan)
• Extrapyramidal SE, Tardive
dyskinesia

Mineral Oil
• Aspiration
Promethazine
• Anticholinergic SE,
• Cause/worsen delirium,
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Prochlorperazine
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Trimethobenzamide
(Tigan)
• Extrapyramidal SE, Poor
efficacy

Corticosteroids
• Cause/worsen delirium

Estrogen
• Breast/Endometrial cancer, Worsen incontinence, No
cardioprotective properties, No cognitive protection

Growth Hormone
• Edema, Arthralgia, Carpal tunnel, Gynecomastia, Insulin
resistance

Megestrol
• Thrombosis, Death, Lack of efficacy for weight gain

Testosterone/Methyltestosterone
• Prostatic hyperplasia, Cardiac events

Desiccated Thyroid
• Cardiac SE
 Barbiturates
• Dependence, Tolerance, Delirium, Possible overdose
 Benzodiazepines
• Cognitive impairment, Delirium, Unsteady gait,
Syncope, Falls, Accidents, Fractures
 Chloral Hydrate
• Tolerance, Delirium, Possible overdose
 Eszopiclone (Lunesta), Zaleplon (Sonata),
Zolpidem (Ambien)
• Cognitive impairment, Delirium, Unsteady gait,
Syncope, Falls, MVA, Fractures, Little benefit
 Muscle
Relaxants
• Carisoprodol,
Chlorzoxazone,
Cyclobenzaprine,
Metaxalone,
Methocarbamol,
Orphenadrine
• Anticholinergic SE,
Sedation, Fractures,
Delirium, Cognitive
impairment
 Benztropine,
Tizanidine (Zanaflex),
Trihexyphenidyl
• Delirium, Worsen
cognitive impairment,
Worsen constipation,
Worsen urinary
retention
 Cause
GI bleeding or peptic ulcer
 Cause renal injury in advanced renal
disease
 Caution in CHF due to edema SE
 Indomethacin
• Causes more SE than other NSAIDs
 Aspirin
• Max daily dose of 325 mg
 Inhaled
Anticholinergic
• Tiotropium (Spiriva),
Ipratropium
• Urinary retention
 Phenylepherine,
Pseudoephedrine,
Theophylline
• CNS stimulant
 Atropine
or
Homatropine
• Anticholinergic SE,
Delirium, Worsen
constipation, Worsen
cognitive impairment
 Amphetamine
&
Methylphenidate
• CNS stimulation
 Nitrofurantoin
• Pulmonary toxicity, Minimal efficacy if CrCl <60
ml/min
 Urinary
Antimuscarinics
• Darifenacin (Enablex), Oxybutynin (Ditropan),
Trospium (Sanctura), Tolterodine (Detrol)
• Cause/worsen delirium, Worsen constipation,
Cognitive impairment
 STOPP
• Screening Tool of Older Persons’ potentially
inappropriate Prescriptions
 START
• Screening Tool to Alert doctors to Right
Treatment
 Organized
 Provides
by organ system
the “START” options initially
• Example: START ACEI or ARB for HF, post-MI, or
in diabetic nephropathy
 Then
provides the “STOPP” treatments
• Example: STOPP beta-blockers in COPD or
diabetic patients
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
American Geriatrics Society updated Beers Criteria
for potentially inappropriate medication use in
older adults. American Geriatrics Society 2012
Beers Criteria Update Expert Panel. J Am Geriatr
Soc. 2012 Apr;60(4):616-31.
PL Detail-Document, Potentially Harmful Drugs in the
Elderly: Beers List. Pharmacist’s Letter/Prescriber’s
Letter. June 2012.
PL Detail-Document, STARTing and STOPPing
Medications in the Elderly. Pharmacist’s
Letter/Prescriber’s Letter. September 2011.