Geropharmacology Lecture Notes PDF

Geropharmacology Clinical Sciences IV Geriatrics Paul B. Volker, MD, FAAFP Assistant Professor Department of Family and Internal Medicine 1 April 2024 Objectives Describe the purpose of the Beers criteria Understand the five categories in the Beers criteria and be able to apply their concepts in the...

Geropharmacology Clinical Sciences IV Geriatrics Paul B. Volker, MD, FAAFP Assistant Professor Department of Family and Internal Medicine 1 April 2024 Objectives Describe the purpose of the Beers criteria Understand the five categories in the Beers criteria and be able to apply their concepts in the evaluation of medical regimens Recommend optimal prescribing and deprescribing patterns based on the Beers criteria and other common adherence issues 1 April 2024 Volker Geropharmacology 2 So how should we know what to do? What are the guidelines? BEERS CRITERIA 1 April 2024 Volker Geropharmacology 3 Beers Criteria Mark H. Beers, MD 1991 evaluate inappropriate Rx in nursing home residents in “common” situations Suggested research on Potentially Inappropriate Medicines (PIMs) 2015 revision published in JAGS – J Am Geriatr Soc 63:2227-2246, 2015. – http://www.americangeriatrics.org 1 April 2024 Volker Geropharmacology 4 2023 Updated Beers Criteria J Am Geriatr Soc. 2023; 71:2052–2081. doi: 10.1111/jgs.18372 1 April 2024 Volker Geropharmacology 5 Intent of the Beers Criteria Improve care by decreasing exposure to PIMs Educational tool Quality measure Research tool These are guidelines to help, not rules to follow 1 April 2024 Volker Geropharmacology 6 Beers Criteria Intend to improve drug selection and reduce exposure to potentially inappropriate medications in older adults Recommendations are evidence-based and in five categories 1) 2) 3) 4) 5) 1 April 2024 Drugs to avoid (except if…) Drugs to avoid in specific diseases Drugs to use with caution Drug-drug interactions Drugs to avoid in renal failure Volker Geropharmacology 7 Abridged Beers What follows are abridged tables of the drugs listed in the Beers Criteria Common themes are highlighted (focus your study on these) 1 April 2024 Volker Geropharmacology 8 1) Drugs to Avoid (except if…) Antipsychotics Benzodiazepines Non-benzo hypnotics (“z” drugs) Muscle relaxants 1 April 2024 Increased CV death, cognitive effects Cognitive effects, falls Cognitive effects, falls Falls, anticholinergic Volker Geropharmacology 9 1) Drugs to Avoid (except if…) Insulin (especially complex regimens), sulfonylureas Proton pump inhibitors (acid blockers) NSAIDS Estrogens 1 April 2024 Hypoglycemia Increased C. difficile, mineral malabsorption Peptic ulcer, renal injury Thromboembolism, carcinogenesis Volker Geropharmacology 10 2) Drugs/Disease Interactions Syncope Insomnia 1 April 2024 Anticholinergics (Antihistamines, TCAs, alpha-blockers, anticholinesterase inhibitors) Theophylline, oral decongestants Volker Geropharmacology 11 3) Use with Caution Dabigatran, new anticoagulants Bleeding Drugs linked with SIADH SSRIs, TCAs, thiazides, cyclobenzaprine, antipsychotics 1 April 2024 Volker Geropharmacology 12 4) Drug-Drug Interactions ACE + amiloride/triamterene Anticholinergic + Anticholinergic Antidepressant + other CNS drugs Antipsychotics + other CNS drugs 1 April 2024 Hyperkalemia Falls Falls Falls Volker Geropharmacology 13 4) Drug-Drug Interactions Steroids + NSAIDs Alpha-blockers + loop diuretics Warfarin (CYP1A2, CYP3A4, CYP2C9) + many Erythromycin + CCBs, cisapride 1 April 2024 PUD, GI bleeding Urinary incontinence Potentiation of anticoagulation Hypotension, Torsades de pointes (cardiac dysrhythmia) Volker Geropharmacology 14 5) Caution in Renal Failure (FYI) Cardiovascular Drugs Amiloride Apixaban Dabigatran Edoxaban Enoxaparin Fondaparinux Rivaroxaban Spironolactone Triamterene 1 April 2024 CNS Drugs Duloxetine Gabapentin Levetiracetam Pregabalin Tramadol Volker Geropharmacology 15 5) Caution in Renal Failure Gastrointestinal Drugs Cimetidine – This is a bad drug in the first place Gout Drugs Colchicine Probenecid Famotidine Nizatidine Ranitidine 1 April 2024 Volker Geropharmacology 16 NSAIDS and the glomerulus Acute renal insufficiency from decreased GFR 1 April 2024 Volker Geropharmacology 17 Beers Criteria Here are the rules I use: 1 April 2024 Volker Geropharmacology 18 Don’t use drugs that… Cause delirium or mental status changes Make you fall or pass out Make some other medical problem worse Try to correct side effects from some other drug Fight with other drugs Hurt your kidneys 1 April 2024 Volker Geropharmacology 19 Quality prescribing includes Correct drug for correct diagnosis Appropriate dose (label; dose adjustments for comorbidity, drug-drug interactions) Avoiding underuse of potentially important medications (e.g., bisphosphonates for osteoporosis) Avoiding overuse (e.g., antibiotics) Avoiding potentially inappropriate drugs Avoiding withdrawal effects with discontinuation Consideration of cost 1 April 2024 Volker Geropharmacology 20 Perceived Barriers to Appropriate Prescribing Polypharmacy, can’t review such a long list “Best” drugs may cost too much Worrying about drug interactions if making drug changes Time involved Difficulty communicating with pt’s other prescribing clinicians Lack of knowledge re: Beers Lack of therapeutic alternatives Patient unwillingness to change Discomfort changing a med another clinician prescribed 1 April 2024 Volker Geropharmacology 21 Beers Take Homes Don’t let the perfect be the enemy of the good Beers PIMs are only part of appropriate prescribing Target initiatives to high prevalence/high severity meds (based on local data, where possible) Stopping meds should be done with same consideration as starting Beers Criteria = Patient-centered care 1 April 2024 Volker Geropharmacology 22 AGS Beers Criteria Resources 23 Criteria AGS Updated Beers Criteria How-to-Use Article Alternative Medications List Coming Soon! Updated Beers Criteria Pocket Card Updated Beers Criteria App Public Education Resources for Patients & Caregivers AGS Beers Criteria Summary 10 Medications Older Adults Should Avoid Avoiding Overmedication and Harmful Drug Reactions What to Do and What to Ask Your Healthcare Provider if a Medication You Take is Listed in the Beers Criteria My Medication Diary - Printable Download Eldercare at Home: Using Medicines Safely - Illustrated PowerPoint Presentation © Nicolò Paternoster PRESCRIBING AND DEPRESCRIBING 1 April 2024 Volker Geropharmacology 24 Optimizing Prescribing Achieve balance between over- and underprescribing of beneficial therapies >20% of ambulatory older adults receive at least one potentially inappropriate medication Nearly 4% of office visits and 10% of hospital admissions result in prescription of medications classified as never or rarely appropriate Underprescribing (age bias) can result from thinking that older adults will not benefit from: – Medications intended as primary or secondary prevention – Aggressive treatment of chronic conditions Use your art and your heart: preserve function and QOL What Matters to the patient? 1 April 2024 Volker Geropharmacology 25 Commonly Overprescribed Drugs Androgens/testosterone Anti-infective agents Anticholinergic agents Aspirin Urinary & GI antispasmodics Antipsychotics Benzodiazepines Nonbenzodiazepine hypnotics Tricyclic antidepressants 1 April 2024 Digoxin as first-line for AFib or heart failure H2 receptor antagonists Proton-pump inhibitors Insulin, basal/bolus NSAIDs Sedating antihistamines Skeletal muscle relaxants Vitamins Volker Geropharmacology 26 Commonly Underprescribed Drugs ACE inhibitors for patients with diabetes and proteinuria Angiotensin-receptor blockers Anticoagulants (they prevent stroke and clots in pts at risk of all ages) Antihypertensives and diuretics for uncontrolled hypertension β-blockers for patients after MI or with heart failure Bronchodilators for pulmonary pts Proton-pump inhibitors or misoprostol for GI protection from NSAIDs Statins Vitamin D and calcium for patients with or at risk of osteoporosis 1 April 2024 Volker Geropharmacology 27 Principles of prescribing for older patients Start low and go slow Start low and go slow Start low and go slow 1 April 2024 Volker Geropharmacology 28 Principles of prescribing for older patients Start with a low dose Titrate upward slowly as tolerated by the patient Avoid starting two drugs, or making two dosage changes, at the same time 1 April 2024 Volker Geropharmacology 29 Consider… Is this medication necessary? What are the therapeutic end points? Do the benefits outweigh the risks? Is it used to treat side effects of another drug? Could one drug be used to treat two conditions? Could it interact with diseases or other drugs? Does patient know what it’s for, how to take it, and what ADEs to look for? Is it compatible with the 4Ms? 1 April 2024 Volker Geropharmacology 30 At least annually… Ask patient to bring in all medications (prescribed, OTC, supplements) for review (the “brown bag review”) Ask about side effects and screen for drug and disease interactions Look for duplicate therapies or pharmacologic effect Eliminate unnecessary medications and simplify dosing regimens 1 April 2024 Volker Geropharmacology 31 Nonadherence May be as high as 50% among older patients Predictors of nonadherence: – – – – – – – Asymptomatic disease Inadequate follow-up Patient’s lack of insight of value of treatment Missed appointments/transportation difficulties Multiple health-care providers Bad hand-offs (hospital → home) Poor provider-patient relationship 1 April 2024 Volker Geropharmacology 32 Drug Instructions This from the discharge instructions my 62 y/o pt received after hospitalization last week for nonketotic hyperglycemic hyperosmolar state (uncontrolled T2DM) 1 April 2024 Volker Geropharmacology 33 How much of which insulin does our patient take? Where lie the potential pitfalls? 1 April 2024 Volker Geropharmacology 34 Last night he was out of the needles for his glargine (long-acting) insulin pen. The sliding scale made no sense to him and he said no one explained it So he gave himself 70 units of aspart (short-acting) instead 1 April 2024 Volker Geropharmacology 35 Interventions to improve adherence Involve a caregiver Utilize a medication tray Robots Keep the pharmacist in your team 1 April 2024 Volker Geropharmacology 36 Interventions to improve adherence Medication reviews and counseling to identify barriers, simplify regimens, and provide education Telephone call reminders Reminder charts and calendars have been shown to be less effective Interactive technology to supervise, remind, and monitor drug adherence (limited availability, has not undergone extensive scientific analysis Pre-packaged pill packets from pharmacy 1 April 2024 Volker Geropharmacology 37 Summary Appropriate prescribing means choosing the correct dosage of the correct drug for the individual patient and the patient’s conditions Age alters pharmacokinetics (drug absorption, distribution, metabolism, and elimination) ADEs are common but can be minimized with strict attention to risk factors, drug-drug interactions, and drug-disease interactions 1 April 2024 Volker Geropharmacology 38 Take Home In the multimorbid polypharmacy patient, add medications with care Start low and go slow Periodically review and reduce Think globally, use your art and your heart Preserve function, use the 4Ms 1 April 2024 Volker Geropharmacology 39 1 April 2024 Volker Geropharmacology 40 References American Geriatrics Society 2015 Beers Criteria Update Expert Panel (2015). AGS Updated 2015 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc, 63, 2227–2246. American Geriatrics Society 2015 Beers Criteria Update Expert Panel (2016). AGS Updated 2015 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. [PowerPoint Slides]. Retrieved from http://geriatricscareonline.org/toc/grs-teaching-slides/S001/ Liu, L.M.,Campbell, I.G. (2016). Tips for Deprescribing in the Nursing Home. Annals of Long-Term Care: Clinical Care and Aging, 24(9):26-32. Medina-Walpole, A., Pacela, J.T., Potter, J.F. (Eds.). (2016). Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine (9th ed.). New York: American Geriatrics Society Semla, T.P. (2016) Pharmacology. [PowerPoint Slides]. Retrieved from http://geriatricscareonline.org/toc/grs-teaching-slides/S001/ 1 April 2024 Volker Geropharmacology 41