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Detail-Document #230907 −This Detail-Document accompanies the related article published in−

PHARMACIST’S LETTER / PRESCRIBER’S LETTER September 2007 ~ Volume 23 ~ Number 230907

Potentially Harmful in the Elderly: List and More (B=Beers list ; C=Canadian list drug) Drug Concern Alternative Treatment (Toradol) GI bleeding.5 Mild : APAP, short-acting NSAID (e.g., (B); long-term use (C) ) Meperidinea Not effective at (Demerol) (B); long- commonly used oral Moderate or severe pain: , term use (C) doses; , /APAP (Vicodin, etc), falls, factures, (OxyContin, etc), oxycodone/APAP (Percocet, etc), dependency, patch (Duragesic)19 withdrawal5,15 (Talwin) More CNS effects Topicals (, arthritis): (B); long-term use (C) (e.g., confusion, (Lidoderm), (Zostrix, etc) ) than other ; ceiling to effect5 Propoxyphene (e.g., No better than Darvon, etc) (B) acetaminophen, but has AE5 (Elavil) AE, without active ( (B, C), , urinary [Pamelor], [Norpramin])15 (Sinequan, etc) (B), retention or (for )19 incontinence, SSRI15 (Tofranil)(C) , (Wellbutrin) (for cardiac patient)19 , falls5,15 (Remeron) (for insomnia or )19 Neuropathic pain: topicals (lidocaine [Lidoderm], capsaicin [Zostrix, etc]) Bupropion May cause seizure5 Tricyclic without active metabolites (Nortriptyline (Wellbutrin), [Pamelor], desipramine [Norpramin])15 disorder (B) Trazodone (for insomnia)19 SSRI15 Mirtazapine (Remeron) (for insomnia or anorexia)19 (Prozac) Long half-life; SSRI with shorter half-life (e.g., used daily (B) agitation, insomnia, [Lexapro], [Zoloft]) anorexia5 Tricyclic for Fall risk; urinary SSRI, with pressure monitoring15 in patient retention; worsening with postural , , BPH, block15 glaucoma, (C)

More. . . Copyright © 2007 by Therapeutic Research Center ’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 www.pharmacistsletter.com ~ www.prescribersletter.com (Detail-Document #230907: Page 2 of 12) Drug Concern Alternative Treatment Antidepressants, cont. Tricyclic in patient or with little anticholinergic or - with incontinence5 blocking effect (e.g., [Celexa]), bupropion incontinence or [Wellbutrin]) bladder outflow obstruction (B) SSRIs in patient with May cause or worsen Tricyclic without active metabolites (Nortriptyline SIADH (B) SIADH5 [Pamelor], desipramine [Norpramin])15 Trazodone (for insomnia)19 Bupropion (Wellbutrin) (for cardiac patient)19 Mirtazapine (Remeron) (for insomnia or )19 SSRI in patient on Enhanced SSRI side Avoid combination. If switching from MAOI to MAOI (C) effects15 another antidepressant, ensure a 14-day washout. If switching from another antidepressant to an MAOI, minimum washout is 2 weeks for drug without long half-life and 5 weeks for drug with long half-life (e.g., fluoxetine).30 Antihistamines, anticholinergic Anticholinergic AE, (Zyrtec), (Allegra), (B): retention, (Claritin), Chlorpheniramine (Chlor- confusion, sedation5 (Clarinex), (Xyzal), low- Trimeton, etc), diphenhydramine19,26 (Periactin), (Polaramine), (, etc), (Vistaril, Atarax), (Phenergan, etc) Antihypertensives Alpha-blockers Hypotension, dry mouth, , ACE inhibitor, beta-blocker, ( [Cardura], incontinence5 channel blocker22 [Minipress], [Hytrin])(B) (Catapres) , CNS Thiazide, ACE inhibitor, beta-blocker, (B) AE5 blocker22 Ethacrynic Hypotension; fluid, electrolyte (Lasix), (Bumex) (Edecrin) (B) imbalances5 (B) Orthostatic hypotension, Thiazide, ACE inhibitor, beta-blocker, depression5 calcium channel blocker22 ; depression5 Thiazide, ACE inhibitor, beta-blocker, (Aldomet) (B) calcium channel blocker22 , short- Hypotension, constipation5 Another calcium or long- acting (Procardia, acting nifedipine Adalat) (B)

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(Detail-Document #230907: Page 3 of 12) Drug Concern Alternative Treatment Antihypertensives, cont. >0.25mg Depression, impotence, Thiazide, ACE inhibitor, beta-blocker, (B, C) sedation, orthostatic calcium channel blocker22 hypotension, extrapyramidal effects5,15

Thiazide in patient May precipitate attack15 ACE inhibitor, beta-blocker, calcium with gout (C) channel blocker22

Antiplatelet Drugs Dipyridamole, short- Ineffective for For stroke prevention: low-dose , clopidogrel acting (Persantine) prevention & (Plavix), aspirin/dipyridamole (Aggrenox)19 (B); for or dementia; orthostatic stroke (C) hypotension5,15

Ticlopidine (Ticlid) Not more effective Low dose aspirin, clopidogrel (Plavix), (B) than aspirin, but more aspirin/dipyridamole (Aggrenox)19 toxic5 CNS AE, , (Risperdal)*, (Haldol)26 (Serentil) (B), extrapyramidal effects5 *Atypicals associated with increased mortality when (Mellaril) (B) used to treat behavioral problems in elderly with dementia31 Fall risk15 Haloperidol, with monitoring15 (Thorazine) in patient with history of postural hypotension (C) (Clozaril) Lower seizure Risperidone (Risperdal)*, haloperidol (Haldol)26 in patient with threshold5 seizures (B) *Atypicals associated with increased mortality when used to treat behavioral problems in elderly with dementia31 (Zyprexa), Increased , Risperidone (Risperdal)*, haloperidol (Haldol)26 (B) *Atypicals associated with increased mortality when used to treat behavioral problems in elderly with dementia31 Thiothixene Lower seizure Risperidone (Risperdal)*, haloperidol (Haldol)26 (Navane), in patient threshold5 with seizure disorder *Atypicals associated with increased mortality when (B) used to treat behavioral problems in elderly with dementia31

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(Detail-Document #230907: Page 4 of 12) Drug Concern Alternative Treatment Long-acting Dependence, For : shorter acting benzodiazepines (B, depression, prolonged (appropriately dosed) ( C): sedation, confusion, [Xanax], [Ativan], [Serax]; falls, fractures, (Buspar)15,19 (Tranxene, etc), respiratory depression in COPD, For : nondrug (See our Detail- (Librium), incontinence5,15 Document #211015 [U.S.]/#210918 []); (Valium), (Restoril) 7.5 mg*, (Ambien) (Doral) 5 mg*, Ambien CR 6.25 mg, (Sonata) 5 mg*, (Rozerem) 8 mg, (Lunesta) 1 mg* for difficulty falling asleep, 2 mg for difficulty staying asleep15,19,32 *Initial dose

Short-acting Falls5 For anxiety: shorter acting benzodiazepines benzodiazepines, (appropriately dosed) (alprazolam daily doses greater [Xanax],lorazepam [Ativan], oxazepam [Serax]; than (B): buspirone (Buspar)15,19 alprazolam (Xanax) 2 mg, lorazepam For sleep: nondrug therapy (See our Detail- (Ativan) 3 mg, Document #211015 [U.S.]/#210918 [Canada]); oxazepam (Serax) temazepam (Restoril) 7.5 mg*, zolpidem (Ambien) 60 mg 5 mg*, Ambien CR 6.25 mg, zaleplon (Sonata) Dependence, sedation5 5 mg*, ramelteon (Rozerem) 8 mg, eszopiclone (Miltown) (B) (Lunesta) 1 mg* for difficulty falling asleep, 2 mg for difficulty staying asleep15,19,32 *Initial dose

Cardiac Drugs QT prolongation, Depends on type of ; (Cordarone, , (Tambocor), (Betapace), beta-blocker, Pacerone) (B) lack of in (Tikosyn)27 elderly5 Beta-blockers in Worsening disease15 Alternate antihypertensive; or calcium patient with , channel blocker15 COPD, or Raynaud’s (C)15 Calcium channel Worsening heart , ACE inhibitor, appropriately titrated beta- blocker in patient failure; blocker15 with systolic heart constipation5,15 failure (C) or chronic constipation (B, C) (Lanoxin) due to Dose reduction, with monitoring19 doses >0.125 mg/d reduced renal except for atrial clearance5 arrhythmias (B) Negative ; Depends on type of arrhythmia; for , (Norpace) (B, C) anticholinergic; digoxin, , , sotalol, sudden death5,15 flecainide15,27 More. . . Copyright © 2007 by Therapeutic Research Center Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 Phone: 209-472-2240 ~ Fax: 209-472-2249 www.pharmacistsletter.com ~ www.prescribersletter.com

(Detail-Document #230907: Page 5 of 12) Drug Concern Alternative Treatment Drugs Prolonged (Amaryl), (Glucotrol)19 (Diabinese) (B) ; SIADH5 Avoid glyburide (Micronase, etc) and Glucotrol XL due to hypoglycemia risk.33 Gastrointestinal Drugs , long- Anticholinergic AE; Diet therapy (fiber, fluids)15,23 term use (B); for IBS worsened & Constipation: , in dementia patient behavioral problems (Miralax, etc), stool softener (e.g., ), (C): belladonna in dementia; urinary (Amitiza)19,23 (Donnatal), retention or : (Imodium, etc), aluminum Clindinium (in incontinence; hydroxide (e.g., AlternaGel), cholestyramine Librax), questionable (Questran, etc)15,19 Dicyclomine (Bentyl), efficacy5,15 (Levsin, etc), Propantheline (Pro- Banthine) (Tagamet) Confusion, other CNS Alternative H2 blocker ( [Zantac], (B); in patient taking AE, interaction with [Pepcid], [Axid])15 (C) warfarin5,15 Dependence, sedation, Change in diet; loperamide (Imodium, etc)15 (Lomotil, etc), long- cognitive term use (C) impairment15 Antidopaminergic : (Zofran), (Kytril), (Reglan) in patient effect5 (Anzemet)19 with Parkinson’s disease (B) (B) Aspiration5 Diet therapy (fiber, fluids)15,23 Constipation: Psyllium, polyethylene glycol (Miralax, etc), stool softener (e.g., docusate), lubiprostone (Amitiza)19,23 May worsen bowel Diet therapy (fiber, fluids)15,23 (e.g., function5 Constipation: Psyllium, polyethylene glycol [Dulcolax, etc]), long- (Miralax, etc), stool softener (e.g., docusate), term use, except with lubiprostone (Amitiza)19,23 (B) Poor efficacy; Ondansetron (Zofran), granisetron (Kytril), (Tigan) (B) extrapyramidal AE5 dolasetron (Anzemet)19

Prochlorperazine (Compazine, etc), metoclopramide (Reglan) (avoid long-term use, and avoid in Parkinson’s disease)26 (oral) , endometrial Hot flashes: nondrug therapy (cool environment, (Premarin, etc) (B) ; not layered clothing, cool compress), SSRIs, , cardioprotective5 venlafaxine24 density: calcium, D, , (Evista) More. . . Copyright © 2007 by Therapeutic Research Center Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 Phone: 209-472-2240 ~ Fax: 209-472-2249 www.pharmacistsletter.com ~ www.prescribersletter.com

(Detail-Document #230907: Page 6 of 12) Drug Concern Alternative Treatment Hormones, cont. Prostatic hyperplasia, None (Android, etc) (B) cardiac AE5 , desiccated (B) Cardiac AE5 (Levoxyl, Synthroid, etc) , except Dependence; higher Nondrug therapy (See our Detail-Document #211015 for risk of AE (falls, [U.S.]/#210918 [Canada]); temazepam (Restoril) seizures (B); long- fractures, confusion, 7.5 mg*, zolpidem (Ambien) 5 mg*, Ambien CR term for insomnia (C) cognitive impairment) 6.25 mg, zaleplon (Sonata) 5 mg*, ramelteon than other (Rozerem) 8 mg, eszopiclone (Lunesta) 1 mg* for hypnotics5,15 difficulty falling asleep, 2 mg for difficulty staying asleep 15,19,32 *Initial dose Long-acting See entry under See entry under Anxiolytics. benzodiazepines (B, Anxiolytics. C) (See entry under Anxiolytics) Diphenhydramine Confusion, sedation, Nondrug therapy (See our Detail-Document #211015 (Benadryl, etc) (B) anticholinergic [U.S.]/#210918 [Canada]); temazepam (Restoril) effects5 7.5 mg*, zolpidem (Ambien) 5 mg*, Ambien CR 6.25 mg, zaleplon (Sonata) 5 mg,* ramelteon (Rozerem) 8 mg, eszopiclone (Lunesta) 1 mg* for difficulty falling asleep, 2 mg for difficulty staying asleep 15,19,32 *Initial dose Sedation, falls, Nondrug therapy (See our Detail-Document #211015 (Dalmane) (B) accumulation5 [U.S.]/#210918 [Canada]); temazepam (Restoril) 7.5 mg*, zolpidem (Ambien) 5 mg*, Ambien CR 6.25 mg, zaleplon (Sonata) 5 mg*, ramelteon (Rozerem) 8 mg, eszopiclone (Lunesta) 1 mg* for difficulty falling asleep, 2 mg for difficulty staying asleep 15,19,32 *Initial dose (Halcion) Cognitive/behavioral Nondrug therapy (See our Detail-Document #211015 (C) disturbances15 [U.S.]/#210918 [Canada]); temazepam (Restoril) 7.5 mg*, zolpidem (Ambien) 5 mg*, Ambien CR 6.25 mg, zaleplon (Sonata) 5 mg*, ramelteon (Rozerem) 8 mg, eszopiclone (Lunesta) 1 mg* for difficulty falling asleep, 2 mg for difficulty staying asleep15,19,32 *Initial dose Muscle Relaxants Muscle relaxants (B): Anticholinergic Physiotherapy; correct seating & footwear15,19 (Soma), effects, sedation, For , use antispasmodics (e.g, , , cognitive impairment, [Zanaflex]) or nerve blocks; treat problems , urine that may worsen condition19 (Flexeril) (C), retention; questionable efficacy (Skelaxin), at lower doses5 (Robaxin) (C), (Norflex) More. . . Copyright © 2007 by Therapeutic Research Center Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 Phone: 209-472-2240 ~ Fax: 209-472-2249 www.pharmacistsletter.com ~ www.prescribersletter.com

(Detail-Document #230907: Page 7 of 12) Drug Concern Alternative Treatment NSAIDs Aspirin for pain in Bleeding15 Acetaminophen15 patient on warfarin (C) NSAIDs, longer half- GI bleeding, renal Ibuprofen (Motrin, Advil, etc), acetaminophen, life, full dose, long failure, , topical agents (e.g., lidocaine patch [Lidoderm], duration (B): heart failure5 capsaicin [Zostrix, etc]), (Aleve, trisalicylate (Trilisate); start with lowest dose and Naprosyn, etc), increase slowly19 (Daypro), *See Detail-Document #221003, “Cardiovascular (Feldene) Risks of NSAIDs and COX-2 inhibitors” (C) Indomethacin CNS AE, GI effects, Ibuprofen (Motrin, Advil, etc), acetaminophen, (Indocin) (B); long- fluid retention5,15 topical agents (e.g., lidocaine patch [Lidoderm], term use (C) capsaicin [Zostrix, etc]), choline magnesium trisalicylate (Trilisate); start with lowest dose and increase slowly19

Gout, chronic treatment: allopurinol15 Gout, : alternative NSAID, short-term indomethacin15,19 NSAID, long-term for GI bleeding, renal Acetaminophen,15 capsaicin [Zostrix, etc] osteoarthritis (C) failure, hypertension, heart failure15 NSAID for Bleeding risk15 Acetaminophen; NSAID with gastroprotective agent osteoarthritis patient (e.g., proton pump inhibitor; receiving warfarin (C) [Cytotec]),15 capsaicin [Zostrix, etc] NSAID in patient New ulcers; bleeding Acetaminophen; NSAID with gastroprotective agent with history of peptic risk5,15 (e.g., proton pump inhibitor; misoprostol [Cytotec])15 ulcer (B, C) NSAID, long-term in Worsening Acetaminophen15 patient with hypertension15 hypertension (C) Respiratory Drugs , oral, Worsening Inhaled and bronchodilator15 long-term for COPD, control15 patient with diabetes (C) in Increased blood Saline nasal spray, nasal steroid25 patient with pressure; incontinence5 hypertension or bladder outflow obstruction(B) , patient May contribute to Inhaled corticosteroid and with insomnia (B) insomnia5

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(Detail-Document #230907: Page 8 of 12) Drug Concern Alternative Treatment Stimulant Drugs , Dependence, For weight control: Diet and lifestyle modification; anorexics (B) hypertension, myocardial , For depression: CNS stimulation Tricyclic without active metabolites (Nortriptyline (agitation, insomnia)5 [Pamelor], desipramine [Norpramin])15 Trazodone19 SSRI15 Bupropion (Wellbutrin) (for cardiac patient)19 Mirtazapine (Remeron) (for insomnia or anorexia)19

Any stimulant in Appetite suppression5 For depression: patient with Tricyclic without active metabolites (Nortriptyline anorexia/malnutrition [Pamelor], desipramine [Norpramin])15 (B) Trazodone (for insomnia)19 SSRI15 Mirtazapine (Remeron) (for insomnia or anorexia)19 for CNS stimulation, Tricyclic without active metabolites (Nortriptyline depression (C) agitation, seizures15 [Pamelor], desipramine [Norpramin])15 Trazodone19 SSRI15 Bupropion (Wellbutrin) (for cardiac patient)19 Mirtazapine (Remeron) (for insomnia or anorexia)19

Urinary Drugs Nitrofurantoin Nephrotoxicity5 Depends on (Macrodantin, etc) (B) Oxybutyninb Urine retention, For urge incontinence: Behavioral therapy (e.g., (Ditropan), in patient confusion, urge suppression, bladder retraining)28 with bladder outflow hallucinations, obstruction (B) sedation5,34 For BPH: 5-alpha-reductase inhibitor ( [Proscar], [Avodart]) Tolterodineb (Detrol) Urinary retention, For urge incontinence: Behavioral therapy (e.g., in patient with confusion, urge suppression, bladder retraining)28 bladder outflow hallucinations, obstruction (B) sedation5,34 For BPH: 5-alpha-reductase inhibitor (finasteride [Proscar], dutasteride [Avodart]) Miscellaneous Anticholinergic (e.g., Agitation, , Decrease dose or discontinue;15 ) to cognitive impairment15 manage antipsychotic extrapyramidal effects (C) mesylates Unproven efficacy5 (Aricept), rivastigmine (Exelon), etc. (Hydergine) (B)

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(Detail-Document #230907: Page 9 of 12) Drug Concern Alternative Treatment Miscellaneous, cont. Ferrous sulfate Constipation, without None >325 mg per day (B) increased absorption5 Lack of efficacy5 (for peripheral arterial disease) (Vasodilan) (B) containing Worsening heart Various, depending on drug & indication drugs in failure5 (B)

ACE – converting , AE – adverse effects, APAP – acetaminophen, B – Beers list drug, BPH – benign prostatic hyperplasia, C – Canadian list drug, CNS – central , COX – , GI – gastrointestinal, IBS – , MAOI – inhibitor, NSAID – antiinflammatory drug, SIADH – syndrome of inappropriate diuretic secretion, SSRI – selective inhibitor a. Meperidine: while not mentioned specifically in Beers/Canadian listings, meperidine should be used cautiously in all elderly patients due to increased risk of seizures with renal impairment.26 b. Since the Beers list was last published, newer agents for (OAB) have been developed. All OAB drugs should be avoided in patients with bladder outlet obstruction. For a listing of these agents see Detail-Documents #210209 (U.S.) and #220616 (Canada).

Users of this document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national organizations. Information and Internet links in this article were current as of the date of publication.

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(Detail-Document #230907: Page 10 of 12) Preventing Adverse Drug Events in the Elderly: the Role of the Beers List

Another Round of Beers healthcare outcomes. Most have been In 1991, Dr. Mark Beers published a methods retrospective cohort studies. A paper describing the development of a consensus of these studies revealed an association between list of considered to be inappropriate use of Beers list and hospitalization for long-term care facility residents.4 The Beers in community-dwelling elderly. However, there criteria or “Beers list” is now in its third was no association with mortality or other permutation.5,6 Some medications are of concern healthcare use. Evidence for an impact on quality in all elderly patients, but others are of concern of life or cost was inconclusive. In nursing only in certain situations (e.g., bupropion in homes, there was no evidence of association with patient with seizure disorder).5 mortality. Association with hospitalization was The Beers list was originally constructed inconclusive. For hospitalized elderly, evidence specifically for long-term care, but it has been was insufficient to make any associations.14 revised for use in hospital, outpatient, managed Clearly, prospective studies are needed to see if care, and other settings. The Beers list has been these criteria make a difference in patient used to evaluate clinical drug use, to study the outcomes. effect of intervention on reducing adverse drug effects in older patients, and to analyze The Bottom Line computerized administrative data sets.7-13 Adverse drug effects may go unrecognized in The Beers list is increasingly being used as a the elderly because they are nonspecific (e.g., quality measure. The Centers for Medicare & confusion, lethargy, falls). Many of the drugs on Medicaid Services (CMS) has adopted the Beers the Beers and Canadian lists are included because list to regulate long-term care facilities. In 2006, of and anticholinergic adverse effects. the Health Plan Employer Data and Information CNS can cause sedation and cognitive Set (HEDIS) used Beers list to create a list of impairment in the elderly, resulting in difficulty medications used to assess quality of managed with self-care and falls. (e.g., care plans. They plan to expand this in 2007.14 diphenhydramine, amitriptyline) cause cognitive There is also a “Canadian criteria” list. These problems by adding to the age-related decrease in criteria for inappropriate prescribing practices in transmission.2 Anticholinergics can 2,18 elderly people were developed by a national also cause constipation and urinary retention. consensus panel in Canada.15 The Canadian The chart above lists medicines that should be criteria give more consideration to indication, avoided in elderly patients based on the Beers list , and duration of therapy than the and Canadian criteria. Drugs on this list are not Beers list. On the Beers list many drugs are contraindicated, but should be used cautiously, considered potentially inappropriate regardless of with consideration of alternatives. For example, diagnosis or indication. For example, low-dose amitriptyline (Elavil) may be helpful for indomethacin is inappropriate per Beers, but per .13 And although using the Canadian criteria is okay short-term for acute propoxyphene (Darvon) is not “wrong,” better gout.5,15 analgesics are available. Make decisions based on Valid concerns about using a “hit list” the whole patient, taking into account their approach to inappropriate prescribing have been medical, social, and psychological conditions, raised. Concerns include paucity of evidence, lack prognosis, and quality of life [Evidence level C; of allowance for exceptions (e.g., ), consensus].16 and misuse resulting in patient harm.16 Also, The Beers list is only one tool for reducing research that provides a complete picture of adverse drug events in the elderly. Drugs not on diagnoses, drug dose and duration, as well as the Beers list can also cause trouble in the potential drug interactions and adverse drug geriatric population (e.g., glyburide [Micronase]- effects, is lacking.17,18 induced hypoglycemia).20 Consider Several studies have examined the association recommendations from and between use of drugs on the Beers list and computerized alerts, periodic review, More. . . Copyright © 2007 by Therapeutic Research Center Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 www.pharmacistsletter.com ~ www.prescribersletter.com (Detail-Document #230907: Page 11 of 12) and patient education [Evidence level B; 2. Kim J, Cooper A. Geriatric drug use. In: systematic review].21 These methods have been Koda-Kimble MA, Young LY, Kradjan WA, Guglielma BJ, eds. Applied therapeutics: the shown to improve prescribing in the elderly; clinical use of drugs. 8th ed. Lippincott however, keep in mind they have not been shown Williams & Wilkins; 2005. to decrease adverse events.21 See our Detail- 3. Goulding MR. Inappropriate medication Document #221211, “ prescribing for elderly ambulatory care Visits Due to Adverse Drug Events,” and Detail- patients. Arch Intern Med 2004;164:305-12. 4. Beers MH, Ouslander JG, Rollingher I, et al. Document #190822, “Drugs to Avoid in Patients Explicit criteria for determining inappropriate with Dementia” for more tips. medication use in nursing home residents. UCLA Division of Geriatric . Arch Intern Med 1991;151:1825-32. 5. Fick DM, Cooper JW, Wade WE, et al. Users of this document are cautioned to use their own Updating the for potentially professional judgment and consult any other necessary inappropriate medication use in older adults: or appropriate sources prior to making clinical results of a US consensus panel of experts. judgments based on the content of this document. Our Arch Intern Med 2003;163:2716-24. editors have researched the information with input 6. Beers MH. Explicit criteria for determining from experts, government agencies, and national potentially inappropriate medication use by the elderly. An update. Arch Intern Med organizations. Information and Internet links in this 1997;157:1531-6. article were current as of the date of publication. 7. Fick DM, Waller JL, Maclean JR, et al. Potentially inappropriate medication use in a Medicare managed care population: Levels of Evidence association with Yeser costs and utilization. J In accordance with the trend towards Evidence-Based Managed Care Pharm 2001;7:407-413. Medicine, we are citing the LEVEL OF EVIDENCE 8. Onder G, Landi F, Cesari M, et al. Inappropriate medication use among for the statements we publish. hospitalized older adults in Italy: results from Level Definition the Italian Group of Pharmacoepidemiology in A High-quality randomized controlled trial (RCT) the Elderly. Eur J Clin Pharmacol High-quality meta-analysis (quantitative 2003;59:157-62. systematic review) 9. Hanlon JT, Fillenbaum GG, Kuchibhatla M, et B Nonrandomized al. Impact of inappropriate drug use on Nonquantitative systematic review mortality and functional status in Lower quality RCT representative community dwelling elders. Clinical cohort study Med Care 2002;40:166-76. Case-control study 10. Mort JR, Aparasu RR. Prescribing potentially Historical control inappropriate psychotropic medications to the Epidemiologic study ambulatory elderly. Arch Intern Med C Consensus 2000;160:2825-31. Expert opinion 11. Doucet J, Chassagne P, Trivalle C, et al. D Anecdotal evidence Drug-drug interactions related to hospital or animal study admissions in older adults: a prospective study Adapted from Siwek J, et al. How to write an evidence-based of 1000 patients. J Am Geriatr Soc 1996; 44: clinical review article. Am Fam 2002;65:251-8. 944-8. 12. Golden AG, Preston RA, Barnett SD, et al. Inappropriate medication prescribing in homebound older adults. J Am Geriatr Soc Project Leader in preparation of this Detail- 1999;47:948-53. Document: Gayle Nicholas Scott, Pharm.D., 13. Zhan C, Sangl J, Bierman AS, et al. BCPS. ELS, Assistant Editor, Melanie Cupp, Potentially inappropriate medication use in the Pharm.D., BCPS community -dwelling elderly: findings from the 1996 Medical Expenditure Panel Survey. JAMA 2001;286:2823-9. 14. Jano E, Aparasu RR. Healthcare outcomes associated with Beers’ criteria: a systematic References review. Ann Pharmacother 2007;41:438-47. 1. Beyth RJ, Shorr RI. Principles of drug therapy 15. McLeod PJ, Huang AR, Tamblyn RM, Gayton in older patients: rational drug prescribing. Clin DC. Defining inappropriate practices in Geriatr Med 2002;18:577-92. prescribing for elderly people: a national consensus panel. CMAJ 1997;156: 385-91. More. . . Copyright © 2007 by Therapeutic Research Center Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 www.pharmacistsletter.com ~ www.prescribersletter.com (Detail-Document #230907: Page 12 of 12)

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