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Navigating the Beers Criteria: Balancing Medication Safety and Efficacy in the Geriatric Patient Kimberly Grant, Pharm.D

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Navigating the Beers Criteria: Balancing Medication Safety and Efficacy in the Geriatric Patient Kimberly Grant, Pharm.D NAVIGATING THE BEERS CRITERIA: BALANCING MEDICATION SAFETY AND EFFICACY IN THE GERIATRIC PATIENT KIMBERLY GRANT, PHARM.D. DISCLOSURE STATEMENT I, the speaker, have no relative financial relationships to disclose. LEARNING OBJECTIVES At the conclusion of this presentation, the audience will be able to: 1. Identify updates made to the American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication Use in Older Adults 2. Recommend alternatives to medications not recommended for use in the older adult 3. Identify supporting research and rationale for Beers recommendations 4. Discuss the role of the pharmacist to improve patient safety and wellness in the geriatric population BACKGROUND: PIM Potentially Inappropriate Medication (PIM) Risk > Benefit The Beers Criteria is the most cited resource in regards to PIMs Beers List/Criteria. American Society of Consultant Pharmacists. Online. Available at: https://www.ascp.com/articles/beers-list-criteria Hanlon JT, et al. Geriatric Pharmacotherapy and Polypharmacy. Brocklehurst’s Textbook of Geriatric Medicine. 2010:880-885. BACKGROUND . Two-thirds of those over age 65 use 3 or more prescription drugs a month 42% of older adults have at least one medication filled that meets the requirement of a Potentially Inappropriate Medication (PIM) NSAIDs Sulfonylureas Estrogens Use of PIMs is associated with poor outcomes Falls Increased confusion Increased mortality The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60:616-631. http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf National Center for Health Statistics. Health, United States, 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD. 2012 http://www.cdc.gov/nchs/data/hus/hus11.pdf BACKGROUND Medication-related problems in community-dwelling seniors cost over $177 billion per year Hospital admission: $121.5 billion Long-term care admissions: $32.8 billion Physician costs: $13.8 billion Emergency department visit costs: $5.8 billion Estimated Annual Cost of Medication Related Problems. American Society of Consultant Pharmacists. 2014. Available at: https://www.ascp.com/articles/about-ascp/ascp-fact-sheet Ernst F. R., A. J. Grizzle. Drug-related morbidity and mortality: updating the cost-of-illness model. J Am Pharm Assoc 2001;41:192–9. BACKGROUND Up to 25% of hospital admissions in the elderly may be drug-related ~16 % due to adverse drug reactions (ADRs) 5-11% due to therapeutic failures 1-9% due to adverse drug withdrawal effect (ADWEs) Hanlon JT, et al. Geriatric Pharmacotherapy and Polypharmacy. Brocklehurst’s Textbook of Geriatric Medicine. 2010:880-885. Cahir C, Fahey T, Teeling M, Teljeur C, Feely J, Bennett K. Potentially inappropriate prescribing and cost outcomes for older people: a national population study. Br J Clin Pharmacol. 2010;69:543-552. Abstract BACKGROUND: AGE RELATED CHANGE Pharmacokinetics Pharmacodynamics Absorption Homeostatic Regulation Distribution Disease States Metabolism Body Weight Excretion Adherence BACKGROUND: AGE RELATED CHANGES Liver Decrease in size Decrease in blood flow Kidneys Decrease in mass Decrease in secretory function Decrease in blood flow Decrease in filtration rate Image available at: http://www.news-medical.net/image.axd?picture=2009%2f12%2fch3_liver.jpg BACKGROUND: AGS BEERS CRITERIA The American Geriatrics Society (AGS) first released The Beers List in 1991 under the direction of Dr. Mark Beers . Consensus list of potentially inappropriate medications for long-term care facility residents . Incorporated into CMS (Centers for Medicare & Medicaid Services’) Interpretive Guidelines in 1999 Beers List/Criteria. American Society of Consultant Pharmacists. Online. Available at: https://www.ascp.com/articles/beers-list-criteria BACKGROUND: AGS BEERS CRITERIA Who is included? Age ≥ 65 Excludes palliative care Excluded hospice care BACKGROUND: AGS BEERS CRITERIA TIMELINE The Beers List is first released AGS assumes responsibility for Beers CMS adopts Beers Criteria Update 1991 1997 1999 2003 2012 2015 • Added new PIMS • Added strength and • 6 panelists quality ratings • Added PIMS • Medications to avoid • Maximum dose • 12 panelists • Drug-disease interactions • Drugs with safer alternatives Beers List/Criteria. American Society of Consultant Pharmacists. Online. Available at: https://www.ascp.com/articles/beers-list-criteria BACKGROUND: AGS BEERS CRITERIA Literature search August 1, 2011- July 1, 2014 Reviewed by 13 member interdisciplinary panel of geriatric experts 1,188 citations were chosen for full panel review Focusing on adverse drug events or adverse drug reactions AGS 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. JAGS. 2015. BACKGROUND: AGS BEERS CRITERIA 2015 Update: Literature search August 1,2011- July 1, 2014 Systematic reviews Meta-analyses Randomized controlled trials Observational studies . 1,188 citations were chosen for full panel review . AGS members also contributed evidence: 342 studies, 49 RCT, 233 other publications 2015 UPDATES AGS BEERS CRITERIA AGS BEERS CRITERIA 2015 Update Added guidance on renally-dose adjusted medications Added section regarding drug-drug interactions Enhanced section regarding drug-disease interactions Incorporated new evidence for listed Potentially Inappropriate Medications (PIMS) Companion guide article AGS 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. JAGS. 2015. AGS BEERS CRITERIA: RENAL DOSING RECOMMENDATIONS 2015 update provides drugs to be avoided or dose-adjusted according to renal function Not to be utilized as a comprehensive list Anti-infectives are not included Adapted from published consensus guidelines organized by two Beers panelists +/- some medications AGS 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. JAGS. 2015. Hanlon JT, Aspinall SL, Semla TP et al. Consensus guidelines for oral dosing of primarily renally cleared medications in older adults. J Am Geriatr Soc 2009;57:335–340. AGS BEERS CRITERIA: RENAL DOSING RECOMMENDATIONS Estimated Cockcroft-Gault Estimated MDRD Hanlon JT, et al. Geriatric Pharmacotherapy and Polypharmacy. Brocklehurst’s Textbook of Geriatric Medicine. 2010:880-885 AGS BEERS CRITERIA: RENAL DOSING RECOMMENDATIONS Drugs to avoid in reduced renal function Drugs Estimated CrCl (mL/min) NOACS Amiloride < 30 Drugs Est CrCl Colchicine 10-29 (mL/min) Duloxetine <30 Apixaban <15 Fondaparinux <30 Dabigatran <30 Probenecid <30 Spirinolactone <30 Edoxoban <30 Tramadol (ER) <30 Rivaroxaban <30 Triamterene <30 Drugs Est CrCl (mL/min): ADJUST Est CrCl (mL/min): AVOID Amiloride 30-50: Administer ½ normal dose < 30 (or SCr > 1.5 mg/dL, or BUN >30mg/dL) Apixaban 15-25 (SCr ≥ 1.5 mg/dL + ≥ 80 yo or BW ≤ 60 kg <15 AGSCimetidine BEERS CRITERIA: RENAL<50: Administer DOSING ½ of normal doseRECOMMENDATIONS Colchicine <30: Monitor for adverse effects <10 Dabigatran 30-50 + P-gp inhibitor: 75 mg BID <30: *75 mg BID based upon PK data Edoxaban 30-50: 30 mg once daily (Mft labeling): DVT, PE, Afib. <30 or >95 Enoxaparin <30 * Not FDA approved in dialysis Famotidine <50: Administer 50% of normal dose or increase interval (q36h or q48h) Fondaparinux 30-50: Administer 50% of normal dose or heparin <30 Gabapentin <60: Increase dosing interval Levetiracetam <80: Reduce dose Pregabalin <60: Dosing chart based on indication Ranitidine <50: Administer 150 mg q24h Rivaroxaban 30-50: 15 mg once daily (A.fib) <30 Spirinolactone 30-50: Maximum dose 25 mg daily <30 Tramadol <30: Increase dosing interval to q12h (IR) <30 Avoid (ER) Triamterene <30 QUESTION 1 For a patient with a creatinine clearance = 36mL/min using a total daily dose of 900 mg of gabapentin, which choice would represent a safe and effective dose of gabapentin? A. 300 MG TID B. 300 MG BID C. 400 MG BID D. 400 MG QAM + 500 MG QPM E. 500 MG QAM + 400 MG QPM CASE EXAMPLE: GABAPENTIN Gabapentin Dosing recommendations Seizures >60 mL/minute 300 to 1,200 mg 3 times daily Diabetic neuropathy 30-59 mL/minute 200 to 700 mg twice daily Neuropathic pain Restless legs syndrome 15-29 mL/minute 200 to 700 mg once daily Anxiety <15 mL/minute Reduce daily dose in proportion to creatinine clearance Dialysis Dose based on CrCl plus a single supplemental dose of 125 to 350 mg (given after each 4 hours of hemodialysis) LexiComp Online. 2016. CASE EXAMPLE: GABAPENTIN Resident receiving Gabapentin 300 mg BID for anxiety. (Estimated CrCl ~ 36 mL/min) Increased behaviors noted Increase gabapentin 300 mg TID Resident experiences 3 falls within 2 weeks CASE EXAMPLE: GABAPENTIN Increase the dose, not the interval Total daily dose = 300mg + 300 mg + 300 mg= 900 mg Recommend gabapentin 400 mg in the morning and 500 mg at bedtime. AGS BEERS CRITERIA: RENAL DOSING RECOMMENDATIONS Dosing of primarily renally cleared anti-infectives Drug Est CrCl (mL/min) Maximum Dosage Acyclovir 10-29 800 mg q8h <10 800 mg q12h Amantadine 30-59 100 mg qd 15-29 100 mg q48h <15 100 mg q7d Ciprofloxacin <30 500 mg q24h Nitrofurantoin <30 Avoid Valacyclovir 30-49 1000 mg q12h 10-29 1000 mg q24h <10 500 mg q24h Hanlon JT et al., JAGS 2009;57:335–340 AGS 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. JAGS. 2015. AGS BEERS CRITERIA: RENAL DOSING RECOMMENDATIONS
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