Ehab E. Tuppo, DO, MPH, FACOI ACOI 2016 Annual Convention  I have no financial relationships to disclose

•  Beers MH, Ouslander JG, Rollingher I, et al in 1991  “Explicit Criteria for Determining Inappropriate Medication Use in Nursing Home Residents”

 In 2011 the updates were taken over by the American Geriatric Society

 Last update published in 2015  “American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults”, J Am Geriatr Soc 63:2227–2246, 2015  To identify potentially inappropriate medications that should be avoided in many older adults  These have been found to be associated with poor health outcomes, including confusion, falls, and mortality  To reduce adverse drug events and drug related problems, and to improve medication selection and medication use in older adults  Believing the Criteria judge all uses of the listed drugs to be universally inappropriate  Be-all and end-all of all potentially inappropriate medications that should be avoided  Older adults receiving palliative care or are in a hospice setting  Access to Criteria medications should not be excessively restricted by prior authorization and/or health plan coverage policies  Medications are potentially inappropriate, not definitively inappropriate • Unfavorable balance of benefits and harms for many older adults • Are there better alternatives? • May still be useful in certain situations  Understand why medications are included in the Criteria  Optimal application of Criteria involves offering safer non-pharmacologic and pharmacologic therapies  The Criteria should be a starting point for identifying and improving medication appropriateness and safety  Captures a small percentage of medication-related problems  Works best when used as a starting point to review and discuss a patient’s entire medication regimen  Addressing medication appropriateness, adherence, and adverse events  Use clinical common sense  The criteria are intended to support, not contradict, common sense and good clinical care Drugs Rationale Recommendation Alternatives

First-generation Highly anticholinergic, Avoid 2nd generation antihistamines reduced clearance with antihistimine hydroxyzine, meclizine, age, tolerance, (fexofenadine, promethazine, confusion, dry mouth, loratadine), diphenhydramine constipation intranasal steroids or normal saline Antiparkinsonian Not recommended for Avoid Carbidopa/levdopa agents EPS prevention with benztropine, trihexyphenidyl antipsychotics Antispasmodics Highly anticholinergic, Avoid atropine, belladonna effectiveness is alkaloids, dicyclomine, uncertain hycosamine, scopolamine Drugs Rationale Recommendation Alternatives Peripheral α-1 blockers High risk of orthostatic Avoid Diuretics, ACEI, doxazosin, prazosin, hypotension, better ARB, LA terazosin drugs available dihydropyridine CCB Central alpha blockers CNS effects, Avoid clonidine as clonidine, methyldopa, bradycardia, orthostatic first line, avoid the reserpine hypotension rest Digoxin In Afib:↑ mortality in Avoid as first line HF. ↓ renal clearance. In HF: Higher doses not beneficial Nifedipine (immediate Hypotension potential. Avoid Long acting release) Risk of myocardial dihydropyridine ischemia CCB Amiodarone ↑ toxicity than other Avoid as first line antiarrhythmics unless with HF or LVH Drugs Rationale Recommendation Alternatives

Antidepressants Highly anticholinergic, Avoid SSRI (except and neuropathic risk of orthostatic paroxetine), SNRI, pain (tertiary tricyclics) hypotension, sedating bupropion. amitriptyline, Neuropathic pain: imipramine, SNRI, capsaicin nortriptyline. cream, lidocaine, SSRI-paroxetine patch, pregabalin, gabapentin, Benzodiazepines ↑ sensitivity, ↓ Avoid Anxiety: SSRI, SNRI, short & intermediate metabolism, ↑ risk of bupropion acting-alprazolam, cognitive decline, falls, lorazepam, temazepam MVA, delirium Benzodiazepines REM sleep disorder, Avoid For epilepsy: long acting-clonazepam, ETOH & benzo lamotrigine, diazepam withdrawal, generalized levetiracetam anxiety disorder (Keppra) Drugs Rationale Recommendation Alternatives Barbiturates ↑ rate of physical Avoid butabarbital, butalbital, dependence, mephobarbital tolerance to sleep benefits, risk of overdose Nonbenzodiazepine, Similar to Avoid benzodiazepine benzodiazepines. ↑ receptor agonist hospitalizations & hypnotic ER visits. zolpidem, zaleplon Antipsychotics ↑ rate of cognitive Avoid in dementia & first (conventional) & decline & delirium unless second (atypical) mortality in those other options not generation with dementia. ↑ effective or patient CVA risk. is a danger to self or others (risperidone, quetiapine). Drugs Rationale Recommendation Alternatives

Androgens Contraindicated in Avoid unless for testosterone prostate ca, potential for confirmed cardiac problems hypogonadism with symptoms Estrogens Lack of cardio & cognitive Avoid unless vaginal For vasomotor with or without protection. Carcinogenic cream for symptoms-SSRI, progestins potential dyspareunia, UTIs & SNRI, bupropion (breast/endometrial) other vaginal symptoms Growth Edema, gynecomastia, Avoid unless needed hormone arthralgia, impaired for replacement after fasting glucose pituitary gland removal Drugs Rationale Recommendation Alternatives

Insulin (sliding ↑ risk of hypoglycemia Avoid unless in use scale) with titration of basal insulin Sulfonylureas– ↑ risk of hypoglycemia. Avoid Short acting-glipizide. Long acting Risk of SIADH with Metformin chlorpropamide, Chlorporpamide glyburide Magestrol Minimal weight effect. ↑ Avoid risk of thrombotic events & death Drugs Rationale Recommendation Alternatives Metoclopr ↑ risk of EPS including Avoid unless for gastroparesis amide tardive dyskinesia Reglan Proton Risk of C-difficile Avoid use for >8 weeks unless Pump infection, bone loss & high risk (corticosteroids & Inhibitors fractures NSAIDS), Barrett’s esophagitis or need for maintenance Mineral Risk of aspiration Avoid oil (oral) Drugs Rationale Recommendation Alternatives

Meperidine Not effective in Avoid Mod-severe pain and demerol commonly used doses. ↑ chronic pain-tramadol, risk of neurotoxicity morphine, oycodone. (delirium) than other opiods Non-cyclooxygenase- ↑ risk of GI bleed/PUD Avoid chronic use selective NSAIDS (PPI don’t eliminate unless alternatives Ibuprofen, meloxicam, risk) esp. with are not effective naproxen, asa, increasing age etodolac, sulindac NSAIDS- Most side effects of Avoid Mild-mod pain- Indomethacin, NSAIDS. ↑ risk of CNS acetaminophen, ketorolac effects & kidney damage ibuprofen, naproxen. Skeletal Muscle ↑ risk of anticholinergic Avoid Mild-mod pain- relaxants effects, sedation, acetaminophen, cyclobenzaprine, fractures ibuprofen, naproxen. metaxalone, orphenadrine Drug Interacting drug Risk recommendation ACEIs Amiloride/triamterene ↑ risk of hyperkalemia Avoid unless hypokalemia with ACEI Anticholinergic Anticholinergic ↑ risk of cognitive decline Avoid Antidepressants ≥2 CNS-active drugs ↑ risk of falls Avoid ≥3 CNS active drugs Antipsychotics ≥2 CNS-active drugs ↑ risk of falls Avoid ≥3 CNS active drugs Corticosteroids NSAIDS ↑ risk of PUD/GI bleed Avoid or use GI protection Lithium ACEIs, loop diuretics ↑ risk of lithium toxicity Avoid. Monitor Li levels Warfarin Amiodarone, NSAIDS ↑ risk of bleeding Avoid. Monitor INR Peripheral α-1 Loop diuretics ↑ risk of UI in older women Avoid unless needed blockers Opioid receptor ≥2 CNS-active drugs ↑ risk of falls Avoid ≥3 CNS active drugs agonists Benzodiazepines ≥2 CNS-active drugs ↑ risk of falls and fractures Avoid ≥3 CNS active drugs or hypnotics  Potentially inappropriate medications  Use common sense (clinical)  Use the Criteria as a starting point for full review of the patient’s medications  Alternatives exist  Pharmacological and non-pharmacological  Watch for drug-drug interactions