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Potentially Harmful Drugs in the Elderly: Beers List

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Potentially Harmful Drugs in the Elderly: Beers List −This Clinical Resource gives subscribers additional insight related to the Recommendations published in− March 2019 ~ Resource #350301 Potentially Harmful Drugs in the Elderly: Beers List In 1991, Dr. Mark Beers and colleagues published a methods paper describing the development of a consensus list of medicines considered to be inappropriate for long-term care facility residents.12 The “Beers list” is now in its sixth permutation.1 It is intended for use by clinicians in outpatient as well as inpatient settings (but not hospice or palliative care) to improve the care of patients 65 years of age and older.1 It includes medications that should generally be avoided in all elderly, used with caution, or used with caution or avoided in certain elderly.1 There is also a list of potentially harmful drug-drug interactions in seniors, as well as a list of medications that may need to be avoided or have their dosage reduced based on renal function.1 This information is not comprehensive; medications and interactions were chosen for inclusion based on potential harm in relation to benefit in the elderly, and availability of alternatives with a more favorable risk/benefit ratio.1 The criteria no longer address drugs to avoid in patients with seizures or insomnia because these concerns are not unique to the elderly.1 Another notable deletion is H2 blockers as a concern in dementia; evidence of cognitive impairment is weak, and long-term PPIs pose risks.1 Glimepiride has been added as a drug to avoid. Some drugs have been added with cautions (dextromethorphan/quinidine, trimethoprim/sulfamethoxazole), and some have had cautions added (rivaroxaban, tramadol, SNRIs). Notable drug interactions added include opioids plus benzodiazepines or gabapentenoids.1 Use of the Beers list has not been convincingly shown to reduce morbidity, mortality, or cost but is often used by organizations as quality measures. Use the list to identify red flags that might require intervention or close monitoring, not the final word on medication appropriateness.2 Medication use decisions must be individualized.2 If the decision is made to stop a potentially inappropriate medication, tapering may be needed (e.g., benzodiazepines, corticosteroids, acetylcholinesterase inhibitors, PPIs).2 The chart below summarizes the 2019 Beers list, potential therapeutic alternatives, and other considerations. Drugs categories include Analgesics, Antibiotics, Anticonvulsants, Antidepressants, Antigout, Antihistamines, Antihypertensives, Antiplatelets/Anticoagulants, Antipsychotics, Anxiolytics, Cardiac Drugs, Central Nervous System Agents (misc.), Diabetes Drugs, Gastrointestinal Drugs, Hormones, Hypnotics, Musculoskeletal Agents, NSAIDs, Respiratory Drugs, Urinary Drugs, Vasodilators. A = avoid in most elderly (does not apply to palliative care/hospice patients) C = use with caution in elderly H = High-risk meds in the elderly per CMS Quality Measure (CMS156v1). A Medicare Advantage and Part D display measure. Designated CMS high-risk meds based on 2012 Beers list. (Note: CMS high-risk med trimethobenzamide is no longer included on the Beers list.) --Information in table is from reference 1, unless otherwise specified.-- Drug or Drug Class Concern(s) Other Considerations (e.g., drug interactions, alternatives)b Analgesics (also see NSAIDs, below) Meperidine (A, H) (also see Neurotoxicity, delirium, poor Of special concern in patients with delirium, or at high risk of delirium. Opioids) efficacy (orally) Avoid combining with two or more other CNS-active drugs (fall risk). For alternatives for different types of pain, see our charts, Pharmacotherapy of Neuropathic Pain, Analgesics for Osteoarthritis, Treatment of Acute Low Back Pain, Treatment of Chronic Low Back Pain, Analgesics for Acute Pain More. Copyright © 2019 by Therapeutic Research Center 3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 pharmacist.therapeuticresearch.com ~ prescriber.therapeuticresearch.com ~ pharmacytech.therapeuticresearch.com ~ nursesletter.therapeuticresearch.com (Clinical Resource #350301: Page 2 of 22) Drug or Drug Class Concern(s) Other Considerations (e.g., drug interactions, alternatives)b Opioids in patient with a history Unsteady gait, psychomotor Acceptable for recent acute severe pain such as fracture or joint replacement. of falls or fractures; with impairment, syncope. gabapentinoids; or with Consider reducing other concomitant medication(s) that can cause falls. benzodiazepine With gabapentinoids, increased Employ fall-prevention strategies. risk of sedation, respiratory depression, and death. Avoid combining with two or more other CNS-active drugs (fall risk). Overdose risk with Avoid with gabapentinoids except when transitioning off opioids. Can use benzodiazepines. combo with caution for an opioid-sparing effect. Adjust dose for renal function. For alternatives for different types of pain, see our charts, Pharmacotherapy of Neuropathic Pain, Analgesics for Osteoarthritis, Treatment of Acute Low Back Pain, Treatment of Chronic Low Back Pain, Analgesics for Acute Pain. Tramadol (Ultram, etc) (C) SIADH. Check sodium when Renal impairment: avoid extended-release product. Reduce dose of starting or changing dose. immediate-release product. Renal impairment (CrCl <30 For alternatives for different types of pain, see our charts, mL/min): increased risk of CNS Pharmacotherapy of Neuropathic Pain, Analgesics for Osteoarthritis, adverse effects. Treatment of Acute Low Back Pain, Treatment of Chronic Low Back Pain, Analgesics for Acute Pain. Antibiotics Ciprofloxacin in patient taking Risk of theophylline toxicity. Avoid use of ciprofloxacin with theophylline. theophylline, or warfarin, or in patients with CrCl <30 Increased bleeding risk with If ciprofloxacin and warfarin must be used together, monitor INR. mL/min. warfarin. CNS effects (seizures, confusion) Dose reduction generally required for CrCl<30 mL/min. in renal impairment. Macrolides (excluding Increased bleeding risk If a macrolide other than azithromycin must be used with warfarin, monitor azithromycin) with warfarin INR. More. Copyright © 2019 by Therapeutic Research Center 3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 pharmacist.therapeuticresearch.com ~ prescriber.therapeuticresearch.com ~ pharmacytech.therapeuticresearch.com ~ nursesletter.therapeuticresearch.com (Clinical Resource #350301: Page 3 of 22) Drug or Drug Class Concern(s) Other Considerations (e.g., drug interactions, alternatives)b Nitrofurantoin in patients with Pulmonary toxicity, peripheral Cohort data suggest nitrofurantoin can be effective and have minimal risk in CrCl <30 mL/min (A), or for neuropathy, hepatotoxicity, moderate renal impairment.14 chronic use (A, H) especially with chronic use. Trimethoprim/sulfamethoxazole Phenytoin toxicity. Avoid use of trimethoprim/sulfamethoxazole with phenytoin. in patients taking phenytoin or warfarin, or with renal Bleeding risk with warfarin. If trimethoprim/sulfamethoxazole and warfarin must be used together, insufficiency (especially with monitor INR. ACEI or ARB) Renal insufficiency: hyperkalemia Reduce dose for CrCl 15 to 29 mL/min. Avoid if CrCl <15 mL/min. (especially with ACEI or ARB), worsening renal function. Use with ACEI or ARB with caution in patients with renal insufficiency.1 Check potassium after four or five days, or hold ACEI or ARB.18 Anticonvulsants Anticonvulsants in patient with Unsteady gait, psychomotor For new-onset seizures, “newer” agents preferred (e.g., lamotrigine, history of fall or fracture, impairment, syncope. levetiracetam).5 Also see our chart, Comparison of Antiepileptic Drugs. except for seizure or mood 5 disorder (also see individual Consider bone protection (e.g., bisphosphonate). agents for additional, agent- Consider reducing other concomitant medication(s) that can cause falls. specific concerns) Employ fall-prevention strategies. Avoid combining with two or more other CNS-active drugs (fall risk). Alternatives for neuropathic pain may include SNRIs, gabapentin, pregabalin, capsaicin, or lidocaine patch (U.S.), depending on etiology and comorbidities. For more help choosing, see our chart, Pharmacotherapy of Neuropathic Pain. Carbamazepine (C) (also see SIADH. Check sodium when For alternative anticonvulsants, see our chart, Comparison of Antiepileptic Anticonvulsants) starting or changing dose. Drugs. Gabapentin in patient with Increased risk of central nervous Reduce dose in renal impairment. CrCl <60 mL/min., or with system adverse effects in renal opioids (also see impairment. For alternative anticonvulsants, see our chart, Comparison of Antiepileptic Anticonvulsants) Drugs. With opioids, increased risk of Continued… sedation, respiratory depression, Avoid with opioids except when transitioning off opioids. Can use combo More. Copyright © 2019 by Therapeutic Research Center 3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 pharmacist.therapeuticresearch.com ~ prescriber.therapeuticresearch.com ~ pharmacytech.therapeuticresearch.com ~ nursesletter.therapeuticresearch.com (Clinical Resource #350301: Page 4 of 22) Drug or Drug Class Concern(s) Other Considerations (e.g., drug interactions, alternatives)b Gabapentin, and death. with caution for an opioid-sparing effect. continued Alternatives for neuropathic pain may include SNRIs, pregabalin, capsaicin, or lidocaine patch (U.S.), depending on etiology and comorbidities. For more help choosing, see our chart, Pharmacotherapy of
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