Post on 20-Jan-2016
BEERS CRITERIAPotentially Inappropriate Medication Use
in Older Adults
Medication-related problems are common, costly and often preventable in older adults and lead to poor outcomes.
Estimates in past studies in ambulatory and long-term care settings found that 27% of adverse drug events (ADE’s) in primary care and 42% of ADE’s in long-term care were preventable, with most problems occurring at the ordering and monitoring stages of care.
In a study of the 2000/2001 Medical Expenditure Panel Survey, the total estimated healthcare expenditures related to the use of PIM’s was $7.2 billion.
Explicit criteria can identify high-risk drugs using a list of PIM’s that have been identified through expert panel review as having an unfavorable balance of risks and benefits by themselves and considering the alternatives available.
A list of PIM’s was developed and published by Beers and colleagues for nursing home residents in 1991 and subsequently expanded and revised in 1997 and 2003 to include all settings of geriatric care.
The 2012 update continues to categorize the PIM’s in three categories: Medications to avoid regardless of diseases or conditions, medications considered potentially inappropriate when used in certain diseases or syndromes and medications that should be used with caution.
GROUP ONEANTICHOLINERGICS(excludes TCA’S)
Rationale
Brompheniramine Highly anticholinergic; clearance
Carbinoxamine reduced with advanced age and
Chlorpheniramine tolerance develops when used as
Clemastine hypnotic; greater risk of confusion,
Cyproheptadine dry mouth, constipation and other
Dexbrompheniramine anticholinergic effects and toxicity.
Dexchlorpheniramine Use of diphenhydramine in special
Diphenhydramine (oral) situations such as acute treatment
Doxylamine of severe allergic reaction may be
Hydroxyzine appropriate.
Promethazine
Triprolidine
ANTIPARKINSON AGENTS Rationale
Benztropine (oral) Not recommended for prevention
Trihexyphenidyl of extrapyramidal symptoms with
antipsychotics; more effective
agents available for treatment
of Parkinson disease.
ANTISPASMODICS Rationale
Belladonna alkaloids Highly anticholinergic, uncertain
Clidinium-chlordiazepoxide effectiveness.
Dicyclomine
Hyocyamine
Propantheline
Scopolamine
ANTITHROMBOTICS Rationale
Dipyridamole, oral short acting* May cause orthostatic
(does not apply to extended hypotension; more effective
Release combination with aspirin) alternatives available; intravenous
form acceptable for use in cardiac
stress testing.
Ticlopidine* Safer effective alternatives
available.
ANTI-INFECTIVES Rationale
Nitrofurantoin Potential for pulmonary toxicity;
safer alternatives available; lack
of efficacy in patients with
CrCl under 60ml/min due to
inadequate drug concentration
in the urine.
CARDIOVASCULAR Rationale
ALPHA-1 BLOCKERS: High risk of orthostatic
Doxazosin hypotension; not recommended as
Prazosin routine treatment for hypertension;
Terazosin alternative agents have superior
risk benefit profile.
ALPHA AGONISTS, CENTRAL High risk of adverse CNS effects;
Clonidine may cause bradycardia and
Guanabenz* orthostatic hypotension; not
Guanfacine* recommended as routine
Methyldopa* treatment for hypertension.
Reserpine (under 0.1 mg/d)*
CARDIOVASCULAR continued Rationale
Antiarrythmic drugs (Class Ia, IC, Data suggests that rate control
III) yields better balance of benefits
Amiodarone and harms than rhythm control for
Dofetilide most older adults.
Dronedarone Amiodarone is associated with
Flecainide multiple toxicities, including
Ibutilide thyroid disease, pulmonary
Procainamide disorders and QT interval
Propafenone prolongation.
Quinidine
Sotalol
CARDIOVASCULAR, continued Rationale
Disopyramide* Disopyramide is a potent negative
inotrope and therefore may induce
heart failure in older adults;
strongly anticholinergic; other
antiarrhythmic drugs preferred.
Dronedarone Worse outcomes have been
reported in patients taking
dronedarone with permanent
atrial fibrillation or heart failure. In
general, rate control is preferred
over rhythm control for atrial
fibrillation.
CARDIOVASCULAR, continued Rationale
Digoxin, above 0.125 mg/d In heart failure, higher doses
associated with no additional
benefit and may increase risk of
toxicity; slow renal clearance may
lead to risk of toxic effects.
Nifedipine, immediate release* Potential for hypotension; risk of
precipitating myocardial ischemia.
Spironolactone, above 25mg/d In heart failure, the risk of
hyperkalemia is higher in older
adults especially if taking
above 25mg/d or taking
concomitant NSAID, angiotensin
converting enzyme inhibitor,
angiotensin receptor blocker, or
potassium supplement.
CENTRAL NERVOUS SYSTEM Rationale
Tertiary TCA’s, alone or in Highly anticholinergic, sedating
combination: and cause orthostatic hypotension;
Amitriptyline safety profile of low dose doxepin
Chlordiazapoxide-amitriptyline (below 6mg/d) is comparable with
Clomipramine that of placebo.
Doxepin, above 6mg/d
Imipramine
Perhenazine-amitriptyline
Trimipramine
CENTRA NERVOUS SYSTEM , continued
Rationale
Antipsychotics, first generation (conventional):
Increased risk of cerebrovascular
Chlorpromazine accident (stroke) and mortality in
Fluphenazine persons with dementia.
Haloperidol
Loxapine
Molindone
Perphenazine
Pimozide
Promazine
Thioridazine
Thiothixene
Trifluoperazine
Triflupromazine
CENTRAL NERVOUS SYSTEM, continued
Rationale
Antipsychotics, second generation (atypical)
Same as first generation.
Aripiprazole
Asenapine
Clozapine
Iloperidone
Lurasidone
Olanzapine
Paliperidone
Quetiapine
Risperidone
Ziprasidone
CENTRAL NERVOUS SYSTEM, continued
Rationale
Thioridazine Highly anticholinergic and risk of
Mesoridazine QT interval prolongation.
Barbiturates: High rate of physical dependence;
Amobarbital* tolerance to sleep benefits; risk of
Butabarbital* overdose at low dosages.
Butalbital
Mephobarbital*
Pentobarbital*
Phenobarbital
Secobarbital*
CENTRAL NERVOUS SYSTEM, continued
Rationale
Benzodiazepines Older adults have increased
Short and intermediate acting: sensitivity to benzodiazepines and
Alprazolam slower metabolism of long acting
Estazolam agents. In general, all
Lorazepam benzodiazepines increase risk of
Oxazepam cognitive impairment, delirium,
Temazepam falls, fractures and motor vehicle
Triazolam accidents in older adults.
Long acting: May be appropriate for seizure
Clorazepate disorders, rapid eye movement
Chlordiazepoxide sleep disorders, benzodiazepine
Chlordiazepoxide-amitriptyline withdrawal, ethanol withdrawal,
Clidinium-chlordiazepoxide severe generalized anxiety
Clonazepam disorder, periprocedural
Diazepam anesthesia, end of life care.
Flurazepam
Quazepam
Chloral hydrate* Tolerance occurs within 10 days,
and risks outweigh benefits in
light of overdose with doses only
3 times the recommended dose.
Meprobamate High rate of physical dependence;
very sedating.
Nonbenzodiazepine hypnotics Benzodiazepine receptor agonists
Eszopiclone that have adverse effects similar to
Zolpidem those of benzodiazepines in older
Zaleplon adults (e.g., delirium, falls,
fractures); minimal improvement
in sleep latency and duration.
Ergot mesylates* - Isoxsuprine Lack of efficacy.
ENDOCRINE: Androgens Potential for cardiac problems and
Methyltestosterone* contraindicated in men with
Testosterone prostate cancer.
Desiccated thyroid Concerns about cardiac effects;
safer alternatives available.
ENDOCRINE RATIONALE
Estrogens with or without Evidence of carcinogenic potential
progestins (breast and endometrium); lack of
cardioprotective effect and
cognitive protection in older
women.
Evidence that vaginal estrogens
for treatment of vaginal dryness is
safe and effective in women with
breast cancer, especially at
doses of estradiol below 25 ug
twice weekly.
Growth hormone Effect on body composition is
small and associated with edema,
arthralgia, carpal tunnel syndrome,
gynecomastia, impaired fasting
glucose.
ENDOCRINE Rationale
Insulin, sliding scale Higher risk of hypoglycemia
without improvement in
hyperglycemia management
regardless of care setting.
Megestrol Minimal effect on weight;
increases risk of thrombotic
events and possibly death in older
adults.
Sulfonylureas, long duration Chlorpropamide: prolonged
Chlorpropamide half-life in older adults; can cause
Glyburide prolonged hypoglycemia; causes
syndrome of inappropriate
antidiuretic hormone secretion.
Glyburide: greater risk of severe
prolonged hypoglycemia in older
adults.
GASTROINTESTINAL RATIONALE
Metoclopramide Can cause extrapyramidal effects
including tardive dyskinesia; risk
may be even greater in frail older
adults.
Mineral oil, oral Potential for aspiration and
adverse effects; safer alternatives
available.
Trimethobenzamide One of the least effective
antiemetic drugs; can cause
extrapyramidal adverse effects.
PAIN
Meperidine Not an effective oral analgesic in
doses commonly used; may
cause neurotoxicity; safer
alternatives available.
PAIN RATIONALE
Non-COX selective NSAID’s, oral Increase risk of GI bleeding and
Aspirin (above 325 mg/d) peptic ulcer disease in high risk
Diclofenac groups, including those
Diflunisal aged above 75 or taking oral or
Etodolac parental corticosteroids,
Fenoprofen anticoagulants or antiplatelet
Ibuprofen agents. Use of proton pump
Ketoprofen inhibitor or misoprostol reduces
Meclofenamate but does not eliminate risk. Upper
Mefenamic acid GI ulcers, gross bleeding or
Meloxicam perforation caused by NSAID’s
Nabumetone occur in approximately 1% of
Naproxen patients treated for 3-6 months
Oxaprozin and in approximately 2-4% of
Piroxicam patients treated for 1 year. These
Sulindac trends continue with longer
Tolmetin duration of use.
GASTROINTESTINAL Rationale
Indomethacin Increases risk of GI bleeding and
Ketrolac, includes parental peptic ulcer disease in high risk
groups. (See above Non-COX
selective NSAID’s).
Of all the NSAID’s, indomethacin
has most adverse effects.
Pentazocine* Opiod analgesic that causes CNS
adverse effects, including
confusion and hallucinations, more
commonly than other narcotic
drugs; is also a mixed agonist and
antagonist; safer alternatives
available.
PAIN Rationale
Skeletal muscle relaxants: Most muscle relaxants are poorly
Carisoprodol tolerated by older adults because
Chlorzoxazone of anticholinergic adverse effects
Cyclobenzaprine sedation, risk of fracture,
Metaxalone effectiveness at dosages tolerated
Methocarbamol by older adults is questionable.
Orphenadrine
GROUP TWODISEASE OR SYNDROME
DRUG RATIONALE
CARDIOVASCULAR:
Heart Failure NSAID’s and COX-2 inhibitors
Potential to promote fluid retention and
Nondihydropyridine CCB’s (avoid -
exacerbate heart failure.
only for for systolic heart failure):
Diltiazem
Verapamil
Pioglitazone, rosiglitazone
Cilostazol
Dronedarone
DISEASE OR SYNDROME
DRUG RATIONALE
Syncope AChEls Increase risk of
Peripheral alpha blockers: orthostatic
Doxazosin hypotension
Prazosin or bradycardia.
Terazosin
Tertiary TCA’s
Chlorpromazine,olanzapine,
thioridazine
Chronic seizures Bupropion Lowers seizure
or epilepsy Chlorpromazine threshold; may
Clozapine be acceptable
Maprotiline in patients with
Olanzapine well controlled
Thioridazine seizures in whom
Thiothixene alternatives are
Tramadol not effective.
DISEASE OR SYNDROME
DRUG RATIONALE
Delirium All TCA’s Avoid in older adults
Anticholinergics with or at high risk of
delirium because of
Benzodiazepines inducing or worsening
Chlorpromazine delirium in older adults;
Corticosteroids if discontinuing drugs
H2-receptor antagonist
used chronically, taper to avoid withdrawal
symptoms.
Meperidine
Sedative Hypnotics
Thioridazine
DISEASE OR SYNDROME
DRUG RATIONALE
Dementia and Anticholinergics Avoid because of
cognitive Benzodiazepines adverse CNS effects.
impairment H2-receptor antagonists
Avoid antipsychotics for behavioral
Zolpidem problems of
Antipsychotics, chronic
dementia unless
and as-needed use nonpharmacological
options have failed
and patient is a threat
to themselves or others
Antipsychotics are
associated with an
increased risk of
cerebrovascular
accident (stroke) and
mortality in persons
with dementia.
DISEASE OR SYNDROME
DRUG RATIONALE
History of Anticonvulsants Ability to produce
falls or Antipsychotics ataxia, impaired
Fractures Benzodiazepines psychomotor function,
Nonbenzodiazepine hypnotics
syncope, and additional
Eszopiclone falls; shorter-acting
Zaleplon benzodiazepines are
Zolpidem not safer than long-
TCA’s and selective acting ones.
serotonin reuptake inhibitors
DISEASE OR SYNDROME
DRUG RATIONALE
Insomnia Oral decongestants: CNS stimulant effects
Pseudoephedrine
Phenylephrine
Stimulants:
Amphetamine
Methylphenidate
Pemoline
Theobromines:
Theophylline
Caffiene
DISEASE OR SYNDROME
DRUG RATIONALE
Parkinson’s All antipsychotics Dopamine receptor
disease Antiemetics: antagonists with
Metochlopramide potential to worsen
Prochlorperzaine parkinsonion symptoms.
Promethazine Quetiapine and
clozapine appear to
be less likely to
precipitate worsening
of Parkinson’s disease.
DISEASE OR SYNDROME
DRUG RATIONALE
Chronic Antimuscarinics for Can worsen
Constipation urinary incontinence constipation; agents
Darfenacin urinary incontinence:
Fesoterodine antimuscarinics overall
Oxybutynin (oral) differ in incidence of
Solifenacin constipation; response
Tolterodine variable; consider
Trospium alternative agent if
Nondihydropyridine CCB:
constipation develops.
Diltiazem
Verapamil
DISEASE OR SYNDROME
DRUG RATIONALE
Chronic constipation, First-generation antihistamines as
continued single agent or part of
combination products:
Brompheniramine
Carbinoxamine
Chlorpheniramine
Clemastine
Cyproheptadine
Dexbropheniramine
Dexchlorpheniramine
Diphenhydramine
Doxylamine
Hydroxyzine
Promethazine
Triprolidine
DISEASE OR SYNDROME
DRUG RATIONALE
Chronic constipation, Anticholinergics and
continued Antispasmotics:
Antipsychotics
Belladonna alkaloids
Clidinium- chlordiazepoxide
Dicyclomine
Hyoscyamine
Propantheline
Scopolamine
Tertiary TCA’s:
Amitriptyline
Clomipramine
Doxepin
Imipramine
Trimipramine
DISEASE OR SYNDROME
DRUG RATIONALE
Chronic constipation, Anticholinergics and
continued Antispasmotics:
Antipsychotics
Belladonna alkaloids
Clidinium- chlordiazepoxide
Dicylcomine
Hyoscyamine
Propantheline
Scopolamine
Tertiary TCA’s:
Amitriptyline, Clomipramine,
Doxepin, Imipramine,
Trimipramine
DISEASE OR SYNDROME
DRUG RATIONALE
History of gastric Aspirin (above 325 mg)
May exacerbate
or duodenal ulcers Non-COX2 selective NSAID’s
existing ulcers or cause
new or additional
ulcers.
Chronic kidney NSAID’s May increase risk of
disease, Stages IV or V
Triamterene (alone or kidney injury.
in combination)
Urinary Estrogen oral and Aggravation of
Incontinence transdermal (excludes incontinence.
(all types) intravaginal estrogen)
in women
GROUP THREE
DRUG RATIONALE RECOMMENDATION
Aspirin Lack of evidence of Use with caution in
for primary prevention
benefit versus risk in adults over 80.
of cardiac events individuals over 80
Dabigatran Greater risk of Use with caution in
bleeding than with adults aged above 75
warfarin in adults aged
or if CrCl below
above 75; lack of 30mL/min.
evidence for efficacy
and safety in
individuals with CrCl
Below 30 mL/min
Pasugrel Greater risk of Use with caution in
bleeding in older adults above 75.
adults; risk may be
offset by benefit in
highest risk older adults
(e.g., with prior
myocardial infarction
or diabetes mellitus
DIEASE OR SYNDROME
DRUG RATIONALE
Lower urinary tract symptoms,
Inhaled anicholinergic agents
May decrease urinary flow and cause
benign prostatic hyperplasia
Strongly anitcholinergic drugs
urinary retention.
except antimusscarinics for
urinary incontinence
Stress or mixed Alpha blockers: Aggravation of
urinary incontinence Doxazosin incontinence.
Prazosin
Terazosin
GROUP THREEDRUG RATIONALE RECOMMENDATION
Aspirin, for primary prevention
Lack of evidence of benefit versus risk in
Use with caution in adults over age 80.
of cardiac events individuals over age 80
Dabigatran Greater risk of Use with caution in
bleeding than with adults over age 75 or
warfarin in adults aged
If CrCl less than 30mL
above 75; lack of /min.
evidence for efficacy
and safety in
individuals with CrCl less than 30mL/min
Prasugrel Greater risk of Use with caution in
bleeding (may benefit adults above age 75.
higher risk adults with
prior myocardial injury or diabetes mellitus
DRUG RATIONALE RECOMMENDATION
Antipsychotics May exacerbate or Use with caution.
Carbamazepine cause syndrome of
Carboplatin inappropriate
Cisplatin antidiuretic hormone
Mirtazapine secretion or
Serotonin-norepinephrine
hyponatremia;need to
reuptake inhibitor monitor sodium level
Selective serotonin closely when starting
reuptake inhibitor or changing dosages
Tricyclic antidepressants
in older adults due to increased risk
Vincristine
Vasodilators May exacerbate Use with caution.
episodes of syncope
in individuals
with history of syncope
Previously, as many as 40% of older adults received one or more of the medications on this list, depending on the care setting.
These criteria have some limitations: Older adults are often underrepresented in drug trials, The criteria does not address other types of PIM’s that are not unique to aging and Hospice and palliative care patients needs (symptom control being paramount) are not completely addressed.
Finally, these criteria are not meant to supersede clinical judgment or an individual’s values and needs. Prescribing and managing disease conditions should be individualized and involve shared decision making.
REFERENCE
The American Geriatric Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. JAGS 2012:1-16.
Victor J. Sobolewski, III, D.O.Visiting Physicians
West Allis, WI262-949-1893