Narrator - Dr. Abel 00:00 Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. Narrator - ? 00:11 This podcast is provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy. Narrator - Dr. Abel 00:17 This podcast contains general information for educational purposes only. This is not professional advice, and should not be used in lieu of obtaining advice from a qualified health care provider. Narrator - ? 00:27 And now on to the show. Dr. Sean Kane 00:31 Welcome to HelixTalk. Episode 182 I'm your co host, Dr. Kane, and I'm Dr. Khyati Patel 00:36 Dr. Patel, and the title of today's episode 182 is 2023 beers criteria, update, navigating medication safety in older patients. Dr. Sean Kane 00:48 Dr. Patel, I learned about the beers list or the beers criteria way back in pharmacy school. It comes up pretty commonly in clinical practice, especially when electronic health record systems alert you or flag you for beers, meds, kind of the name is a little interesting. So why don't we start with what exactly is a beers list, or beers criteria, medication, and then what is the status of this update? Dr. Khyati Patel 01:10 That's right, Dr. Kane, this sounds like beers. And you know, beers and medications don't really combine, but in this case, this very first version of beers. Criteria was developed by Dr. Mark beers and his colleagues at University of California in 1991 and the purpose was to identify medications where the risk of using them outweighs the benefits in patients that are residing in nursing homes. And later, they were expanded to all adults that are older, not only those who are residing in nursing home. And back in 2010 American Geriatric Society kind of took over that stewardship, and since then, this represents the seventh update, so the 2023 update that we're talking about today overall, from the inception of this beers criteria. This is the seventh update. Dr. Sean Kane 02:03 So this document really contains medications to be wary of in elderly patients. It doesn't mean you can't give it to them, but you should be cognizant that sometimes the risks may outweigh the benefits, and you should at least think about it for that elderly patient population. Dr. Khyati Patel 02:17 Yeah, and that's a big disclaimer that this interprofessional panel that puts together the criteria based on the recommendation, says that, yes, this, you know, this is a guidance for the clinicians and the patients, and the overall goal is to reduce adverse drug events, as well as serve as a tool for care, quality, cost and drug pattern use. But that doesn't mean that this is how the practice should be, that the clinicians really need to individualize medication decisions accordingly. And I do want to emphasize that this criteria is applicable to any adults, 65 and older that are in ambulatory care, acute care or even institutionalized care setting, except for those who are in hospice or end of life care, where they're receiving palliative management. Dr. Sean Kane 03:05 And then the full document, which is linked in our show notes at HelixTalk.com it's about 30 pages, and there's five different sub categories. So very briefly, table two shows meds that are potentially inappropriate. Again, doesn't mean that you can't use them, but you should be weary of the side effects or some concern with it. And the document outlines exactly what those concerns would be. Yeah. Dr. Khyati Patel 03:27 And table three basically takes these medication, but categorize them under certain health conditions. So if you are looking, you know, treating somebody's delirium, for example, you could just directly go to that section and know, like, what are the do's and don'ts of medications pertaining to that region? Dr. Sean Kane 03:44 And then table four, are meds that should be used with caution. Again, kind of similar to table two, in the concept of being wary of, typically, a side effect associated with a given medication. Dr. Khyati Patel 03:54 And then table five, kind of poses that big drug drug interaction list. I know there are plenty of drug interactions out there, but particularly the drug interactions that would increase safety issues in this patient population. Dr. Sean Kane 04:07 Then finally, because every year you get older, your renal function declines. Unfortunately, table six is a renal dose adjustment for medications, given that elderly patients are more prone to having renal impairment, and any med that goes through the kidney might need to be adjusted for that reason. Dr. Khyati Patel 04:23 And then these are kind of the tables for the guidance. There is one additional table called Table seven, basically list our anticholinergic medication. So any medications that have strong anticholinergic properties that we should be using carefully in this patient population are kind of summarized in that table. Dr. Sean Kane 04:41 Now, Dr. tell it's interesting that we have a document just for older individuals geriatric patients. What is it about medications and older individuals that justifies a 30 page document with multiple tables and things like that? Dr. Khyati Patel 04:56 Yeah, and you know this concept is multifold. And there is lot of issues and concerns that we deal with this patient population. First and foremost is polypharmacy, right? These patients are seeing multiple providers, and because of that, there is lot of different medications. Plus, as we age, you know, our organ functions and stuff start to decline, and so naturally, medications kind of come in the picture to help sustain or maintain them. So these patients are going to be on multiple different chronic medications they might be on over the counter, supplements and stuff which can interact with it. This patient population, particularly, also might be at risk of not having enough social support, right? So who's managing their medications? Who's, you know, filling their pill boxes, ordering medications, organizing reminding them they need to take it. Certain medications may even require dexterity, like administration of injection medication, right? Like, do they have enough support with that or not? Dr. Sean Kane 05:52 And it sounds kind of silly, but this is actually an understudied patient population in randomized, controlled trials, and it does depend on the disease state and the medication, but generally speaking, most clinical trials don't focus on elderly patients, especially comorbid elderly patients. So because of that, we just don't have a lot of data for those elderly individuals, especially with multiple chronic health conditions and medications, may behave differently in those patients than someone who's otherwise healthier or younger, which is why, you know, there's an increased emphasis on especially safety in this population, right? Dr. Khyati Patel 06:26 And then I think the biggest reason why there is a need for safe medication use in this patient population is the changes that age can bring upon the pharmacokinetic and pharmacodynamic properties of a drug we know as we age, organ function changes. So we talked about, you know, renal function declines, and so our EGFR, or EGFR, in itself, is low. We also know that the blood supply to the liver is decreased. So here we talk about drugs, right, that metabolize through liver, that go through the first pass metabolism and stuff. And if that function is not working properly, there's going to be changes in the bioavailability of the drug, or the metabolism of the drug, Dr. Sean Kane 07:09 also things like less stomach acid. So depending on the medication, some meds require more stomach acid. Elderly individuals are more likely to be on a GERD type medication, like a ppi, or just intrinsically, they have less stomach acid secretion as you get older, that can change how the drug is either broken down or absorbed in the body, right? Dr. Khyati Patel 07:28 And then there is this imbalance, you know, not, not really an organ function change, but imbalance between the total body water as well as the lean muscle mass. And so overall, there is an increase in the body fat, right? And so we talk about water soluble drugs versus lipid soluble drugs. And then the volume of distribution of these drugs can change because the total body water, as well as the fat content, is changing as we are aging. Dr. Sean Kane 07:54 So really, because of all of these reasons, kinetically, a drug may behave differently in an elderly individual versus someone who is younger. So for example, drug absorption into the body period, but then absorption into different tissues depending on lipophilicity, the volume of distribution, even something like albumin. So as you get older, your albumin levels, especially as you get more comorbidities, they go down. And if the drug relies on a certain amount of albumin as a binding site, then the distribution of that drug and the protein binding is going to change. Dr. Khyati Patel 08:25 So these are the good, you know, pkpd changes. We summarize them really quickly. We can go more into the detail Dr. Kane here. But the one last thing that kind of poses the risk here is gait and balance issues in this patient population, due to musculoskeletal deconditioning and stuff. And then, addition to medications that can bring about dizziness, orthostatic hypotension, the delirium, the sedation and stuff increases their risk of fall and fracture even more. Dr. Sean Kane 08:50 And kind of segueing off of that, Dr. Patel, probably the first drug class that I learned as a student, and also the first drug class that really comes up when you talk about the beers criteria are anticholinergic or antihistamine type medications. So the classic is going to be diphenhydramine or Benadryl, because it's really commonly available over the counter, but there's a number of other antihistamines, like diamond hydro Nate, doxillamine, meclizine, hydroxyzine, all of these are anticholinergic in nature, and they cause some trouble in elderly patients, right? Dr. Khyati Patel 09:20 Such as confusion, increased risk of falls, delirium and even dementia. So obviously there isn't a severe allergic reaction. Go ahead and use or Benadryl that you need to but otherwise, use these drugs with caution. Dr. Sean Kane 09:32 And then, from a cardiovascular standpoint, kind of interesting, aspirin comes up in the beers list or criteria as a area of concern for primary prevention. So secondary prevention, if you've had a heart attack or stroke, you should take aspirin if it's indicated. But what about primary prevention? Dr. Khyati Patel 09:49 So yeah, primary prevention here is a little bit dicey. We know that an older adult patient population, the risk of GI bleed or bleeding is higher, so we. Put more emphasis on the harm from coming from aspirin versus the benefit that will drive reduction in future occurrences of MI or stroke. We're talking primary prevention here, Dr. Sean Kane 10:12 and this has been a hot topic, not just in elderly patients, but just generally, from a variety of different guidelines that are out there in terms of the role of aspirin for primary prevention, we've had some studies that have been done that were very large tended to kind of not show a huge benefit, but if any benefit that was there was offset by that bleeding risk. So it's not surprising that the guidelines are also kind of covering Dr. Khyati Patel 10:32 that as well, right? And some of the recommendation Dr. Kane, as you alluded earlier, too, are not particularly limited to how we use medications in other patient population. But this list wants to make it comprehensive, because a lot of institution governed guidelines for medication safety and stuff kind of look at beers criteria. So if they omitted something that is, you know, kind of part of the bigger picture as well from the this patient population in general, then that would be a myth. So this is more of a comprehensive stuff, but some of the stuff we talk about today, we know that's true for a general patient population as Dr. Sean Kane 11:09 well, regarding, you know, anti thrombotic therapy. Anticoagulants is a huge area, and this actually was pretty a big deal when it came out, because the guidelines actually have some specific recommendations regarding Warfarin and doacs as well. Dr. Khyati Patel 11:22 Yeah, and you know, this anti COAG discussion is kind of dispersed among different tables and stuff, but then this recommendation is so different, they call out an attention by having its own box. It's not a table, but having its own box about how to use anti COAG. And so obviously we know that doacs have better safety profile than the warfarin and so they come out and say, if you don't have to use warfarin, avoid Warfarin use due to the risk of major bleeding. Obviously, this is for patients who are newly starting the warfarin therapy. If an older patient is has been on Warfarin for a long period of time where they are safe, their INR has been stable and sub, you don't have to go out and change it. However, don't start them new on warfarin. Really. Dr. Sean Kane 12:08 The big thing that caused a stir was these guidelines recommend the use of apixaban over dabigatran and rivaroxaban. And that was kind of a big deal because CHEST guidelines as an example or the ACC/AHA, those guidelines typically have not had a strong preference with respect to a DOAC selection. They generally will say, any DOAC is preferred over warfarin. But in this case, the preference of apixaban is kind of a big deal. Dr. Khyati Patel 12:35 Yeah, it is. And so they come out and say, avoid rivaroxaban again, due to higher risk of major bleeding and GI bleeding compared to apixaban. Again, they say if somebody can't take the twice‑daily apixaban, and adherence is an issue, sure, go ahead and use rivaroxaban because it's once daily. But in general, yeah, they are coming out labeling avoid of rivaroxaban in this patient population. Dr. Sean Kane 12:59 And the same is true with Dabigatran, and that the preference is to not use Dabigatran over other doex as well, correct. And then when it comes to other cardiovascular medications, you know, Hypertension is really common in elderly patients, so something like alpha one blockers, so prazosin, doxazocin, terrazasin, things like that, they recommend against their use because of a higher incidence of orthostasis, which, again, as you mentioned, Dr. Patel, even for run of the mill hypertension, we tend to not use these anyway, but especially in elderly patients, because the fall can result in head trauma, a fracture, things like that, more commonly than a 40 year old patient as an example, right? Dr. Khyati Patel 13:38 And then, for the same reason, the central Alpha agonist like clonidine, is also kind of in the avoid category, you know, obviously due to orthostatic hypotension, but also from bradycardia or other CNS adverse effects. Dr. Sean Kane 13:52 Then they recommend against the use of amiodarone for atrial fibrillation, with the caveat that sometimes it's kind of the most appropriate therapy. So someone with heart failure as an example. But the problem with amiodarone, in addition to the drug interactions that come along with it, it has a ton of adverse effects that could become problematic in anyone, but especially in elderly Dr. Khyati Patel 14:13 patients, right? And then same thing with digoxin, you know, I know for heart failure, digoxin doesn't have mortality data, and so we tend not to use it. We have better medications out there. However, particularly in this patient population, because there is this decreased clearance of the drug, they are technically at a higher risk of having toxicities, and so they are asking to avoid shocks and use for AFib or heart failure, Dr. Sean Kane 14:39 then switching gears a little bit to centrally acting medications for psychiatric type indications. So antidepressants that have lots of anticholinergic activity should be avoided. So this is our tricyclic antidepressants, like amitriptyline, desipramine, but also some of our SSRIs, like paroxetine, which tends to be a little bit more sedate. And more of that anticholinergic effect. And you know, it's not just sedation. We're also worried about orthostasis, where the patient gets up too quickly, and then that can lead to a fall, right? Dr. Khyati Patel 15:10 And then there is the big section and conversation about use of that first and second generation antipsychotics, such as, you know, halperidol or the cotijapine or Risperidone. The big thing here is because these medications tend to have lot of different indication and there is lot of off label use as well. The recommendation is to not use it for any of the off label uses. And the off label uses have been mainly of behavioral problem related to dementia or delirium. And the reason they say don't use it for this particular off label uses is because there is an increased risk of stroke and greater risk of cognitive decline and mortality in patients who have dementia, and then also increased risk of mortality in patients who don't have dementia. And so again, if your patient has conditions for which these drugs are FDA approved, such as Parkinson's disease, bipolar disorder or schizophrenia, okay to use, but don't use it for that behavioral issues of delirium or dementia, Dr. Sean Kane 16:14 and then similarly, things like benzodiazepines and barbiturates, again, Really any patient, but especially in elderly patients, we're worried about the risk of dependence, abuse and misuse, which is why they're DEA scheduled substances. And also older people are going to be more sensitive to these so those adverse effects that are associated with these two drug classes are going to be more common in elderly patients. Dr. Khyati Patel 16:40 And then with the bzds, my other Z drugs come to mind. So these are our sleep agents, and they should also be avoided for similar reasons as we talked about with benzodiazepines and Dr. Sean Kane 16:51 then moving on to endocrine drugs to avoid, or at least be cautious of, sliding scale insulin. So I would say this is more or less fallen out of favor in my neck of the woods in terms of patients that are coming into the hospital, we still use it on the inpatient setting a little bit in critically ill patients, just because it's really hard to predict what their sugar is going to do. But especially in the outpatient setting, this is kind of a no, no, right, Dr. Khyati Patel 17:14 right, no, no. Need to especially because we haven't seen improvement in glycemic control using sliding scale, plus it comes with, you know, glucose monitoring and extra pokes and stuff, which these patients are probably going to have a hard time doing. Anyways, I think the biggest thing over here, along with the insulin, is also another drug that causes hypoglycemia, and which is so funny, urea. And you know, they say, If you must use it for cost reason and stuff, try to use drugs that have shorter half life, such as glipizide, rather than the longer acting one like the Glyburide or the glimpse right? Dr. Sean Kane 17:48 And then they also have a nod to systemic estrogens, with or without progestin. So this would be, you know, used for something menopausal type symptoms. And the reason for that is that exposing patients to extra estrogen increases risk of certain kinds of cancer, especially heart disease, strokes, blood clots, maybe even dementia. So they say if you really need to use it, there are topical vaginal creams or low dose tablet that you could consider back in the Dr. Khyati Patel 18:16 day, when I practiced in my geriatric rotation at the VA, most patients were failing to thrive, and like the go to medication was that majestral For weight gain. And this guidelines have come out and said, don't do majestral. There is increased risk of VTE, and then the, you know, the thriving, and then the weight gain is very minimal. So there is more risk than the benefit here Dr. Sean Kane 18:41 and then from a gastrointestinal standpoint, they do make a nod to the long term complications of chronic use of proton pump inhibitors or PPIs. And yeah, a lot of these side effects are observational side effects in nature versus a randomized controlled trial. But still, it's a thought of these may be associated with certain complications, like risk of C Diff or pneumonia or GI malignancies or osteoporosis and fractures. So for that reason, for any patient, you should minimize it, but these are of higher concern in elderly patients, right? Dr. Khyati Patel 19:14 Obviously, patients who have reasons for to be on it for a long period of time, such as they're on maybe dual anti platelet therapy. So the risk of GI bleed is there or they have hyper secretory conditions, and then okay to use it, but otherwise, try to limit the use. And then meta copromide is another prokinetic gi drug that we tend to use to change the gastric emptying. And again, recommendation is we know metacobramide In general, can increase risk of EPs, extrapyramidal symptoms, which are Parkinson like symptoms, but in older patients, especially, this can impose risk on falls and fractures. Dr. Sean Kane 19:51 Then when it comes to pain medications, NSAIDS, for any patient, should be used at the minimum possible dose for the minimum duration of time and. Reason for that is a side effect profile. So if someone is going to be on NSAIDs, especially non selective NSAIDs, like more than 325 of aspirin or diclofenac, ibuprofen, Meloxicam, naproxen, things like that, we're definitely worried about GI bleeding. We're worried about peptic ulcer disease and even renal impairment because of higher doses of these medications, so shortest duration, smallest dose possible for every patient, including elderly patients, Dr. Khyati Patel 20:28 right and for any reason, these patients need to take these pain medications for a long period of time, making sure that appropriate gi protection is in place, as we talked about, they might be on PPI or use misoprostol. We should make sure that, at least we do that to prevent gi bleeds. And then, last, but not the least, you know, in the category of pain management, muscle relaxants such as carisoprodol and cyclobenzaprine are on the list due to the increased risk of sedation, anticholinergic effect, as well as increased fracture risk. Interestingly enough, the baclofen and tizanidine, which are also muscle relaxants, don't fall into this warning category, but they say that there are their own side effects, so the list says, please use them with caution. We don't combine these two with the other muscle relaxant in this warning category. However, please use them judiciously, Dr. Sean Kane 21:20 which is wild to me, Dr. Patel, because I've had several patients that had hypotension induced by tizanidine as a muscle relaxant, especially at higher doses, because it's a clonidine‑like drug, so little interesting that they weren't more against that medication. Dr. Khyati Patel 21:36 But and then table three basically takes some of these medications, rather than under medication or pharmacologic class, but puts them under wherever we use them for a disease, stays or syndrome per se. So if you're looking for, you know, treating a patient with delirium, or treating a patient who had history of falls and fractures, you can go to these subsections and look at medications that should be avoided. Dr. Sean Kane 22:04 So as an example, if patients are having syncopal events, and you've ruled out other causes that are, you know, conditions that the patient might have, like sick sinus syndrome or some other condition, and you think it's medication induced, you should be thinking about, are they on an anti psychotic like olanzapine, are they on a tricyclic antidepressant? Because these medications definitely increase that risk. We're also thinking about drugs that cause bradycardia. So that would be your typical ones like calcium channel certain calcium channel blockers, meta blockers, but also maybe ones that you don't think immediately of, like cholinesterase inhibitors, like Donepezil or rivastigmine, can also cause bradycardia. Dr. Khyati Patel 22:42 And then, as we talked about earlier, nobody should be using those peripherally acting alphabet blockers for blood pressure, but especially in those patient populations, the prazosins should be avoided because of that increased risk of hypotension. Dr. Sean Kane 22:58 And then, in terms of delirium, if patients are having delirium. We're worried about Anticholinergics. And there's a whole table, table seven, that focuses on those anticholinergic type medications, but also antipsychotics, benzodiazepines, maybe h2, blockers, Z, drugs, certain opioids. And opioids are new in this category. In the 2023 update, these can also either worsen or cause delirium, especially in elderly patients. And again, we mentioned it earlier. Antipsychotics are commonly used, unfortunately off label, to treat patients with dementia or delirium, but they can cause harm in that patient population as well, right? Dr. Khyati Patel 23:39 And then talking about dementia or patients with cognitive impairment, anticholinergic drugs, again, you know, listed in those table seven, as well as any chronic use of antipsychotics that are off labelly used, or the Z drugs. Right our sleep agents should be avoided because of that increased risk of CNS effects. Dr. Sean Kane 23:57 And then for someone who has a history of falls or fractures. Again, we're worried about any drug that's going to drop blood pressure and cause them to fall. So we already mentioned Anticholinergics, also antidepressants, especially some of those more sedating antidepressants, certain anti epileptics, which can have a variety of neurocognitive side effects associated with them, antipsychotics, and then all of our sedating meds, like benzodiazepines, Z drugs, opioids, all of these we're worried about imbalance in coordination and risk of fall, in addition to orthostasis. And then finally, in patients who have BPH, so prostatic hypertrophy, these patients are going to have more difficulty urinating if they're given an anticholinergic type medication. So just being aware of that the same vein certain patients, especially if they have urinary incontinence problems, they may be on some of these anticholinergic medications for overactive bladder and things like that. So you have to pick an agent that is going to have less of that cholinergic property and just focus on that muscarinic activity. Dr. Khyati Patel 24:58 So. Now table four, Dr. Kane, you know, all of the previous tables and medications we talked about have a pretty strong recommendation avoid. Table four includes medications that should be used with caution. So they're not saying go out and avoid them, but maybe use with caution. We talked about Dabigatran earlier this that falls into this category. Again, it's not an avoid, but using caution, because we do have other doacs that have better safety profile, Dr. Sean Kane 25:27 and then some of our p2 i 12 inhibitors like prasogrel and ticagrelor, when these were studied versus clopidogrel, they were a little bit more effective, but they also increased the risk of bleeding. So especially because bleeding is of big concern in elderly patients, you may choose clopidogrel even though it was slightly less effective, because you're prioritizing the safety, the less bleeding risk with clopidogrel Dr. Khyati Patel 25:49 and now some of the meds here in the antidepressant and anti epileptic categories may have mentioned earlier. However, this particular use with caution comes because of the exacerbation of cyad or cause of hyponatremia, and that includes certain antidepressants such as mirtazapine or SNRIs, SSRIs, as well as tricyclic antidepressant, particular anti epileptic such as carbamazepine or oxcarbazepine, as well as diuretics, Tramadol and certain antipsychotics, again, that would be because the risk of causing zyad or hyponatremia, Dr. Sean Kane 26:30 then Bactrim comes up in this section, trimethoprim, cephalomethoxazole, because of the risk of hyperkalemia, especially because elderly patients are more likely to be on Drugs like ACE inhibitors or ARBs or arnies, and also have renal impairment. All of those are risk factors for Bactrim induced hyperkalemia. So it doesn't mean you can't do it, but you do Dr. Khyati Patel 26:50 need to be careful, right? And then in this 2023 update, they added sglt Two eyes in this like Use with caution category, because of the increased risk of urogenital infection as well as euglycemic decay. And again, this is, you know, applicable to non geriatric patient population as well. But they wanted to highlight that risk for this patient population too. Dr. Sean Kane 27:13 Then the next section was table five. These are drug drug interactions. And I mean, this could be its own 30 page publication on its own right. So they do highlight some drug drug interactions that should generally be avoided. So as an example, Ras inhibitors. So this is like an ACE inhibitor, ARB or Arni probably should not be used in combination with potassium sparing diuretics like amiloride. And the reason for that is that we're worried about having too much potassium increase caused by multiple Dr. Khyati Patel 27:42 drugs, opioids, right in this patient population. First of all, we're not supposed to use opioid for long term pain control, but combining them with benzodiazepine is going to increase the risk of not only CNS side effects, but risk of opioid overdose. Same with combining opioids with Gabapentin or pregabalin is also going to increase the risk of that sedation, respiratory depression and falls. So that should be used. That combination should be used with caution. Dr. Sean Kane 28:13 We've already covered anticholinergic but there's a concept of kind of anticholinergic burden that the more anticholinergic drugs you have at the higher doses, those are additive in nature, and you should really try to minimize that as much as possible, right? Dr. Khyati Patel 28:26 And then those CNS acting medications too, right? We mentioned many different categories, like anti epileptics, antidepressants, benzodiazepines, the sleep drug, the Z drugs, the muscle relaxant. And the recommendation is try not to add more than three or more of these drugs in the patient's medications. And then we spoke about Warfarin in terms of safety and efficacy in those patients who are stable, may still be left behind on warfarin, but Warfarin in general, has a lot of drug interaction. Dr. Kane, we know it in this patient population, particularly certain drugs that have larger interactions, such as the amiodarone, the Bactrian, the drugs that combinations that I can think I need to go out and change my war friend dose, they are highlighted in here. And then SSRIs were kind of added into this combination in 2023 update. Dr. Sean Kane 29:18 And then table six, this is a list of meds that are basically renally adjusted or eliminated and should either be avoided or adjusted in some way, and those who have renal impairment. And again, this could be a whole publication in itself, but focusing on drugs that are renally eliminated and commonly used in elderly patients, an example would be anti infectives. And this is and this is going to be something like our quinolones, like Ciprofloxacin or nitrofurantoin or Bactrim. These would be used for skin and soft tissue infections or urinary tract infections, and in people with renal impairment, they may need a dose adjustment, or maybe aren't appropriate for certain medications, right? Dr. Khyati Patel 29:56 And I think one thing that this table does is kind of gives you those thresholds. For renal dosing or renal dose adjustment. So definitely look at that not not all medications fall under that less than 30 creatinine clearance category. Some even are actually recommended for dose adjustment as as early as less than 60 or 80, right in the case of levetiracetam, for example, for our cardiovascular drugs, amiloride, dabigatran, edoxaban, you know, obviously our enoxaparin or rivaroxaban, these all are going to need renal dose Dr. Sean Kane 30:30 adjustment, and then our CNS acting medications like baclofen, that's actually a creatinine clearance less than 60, which was recently added to the guidelines, duloxetine, gabapentin, pregabalin, levetiracetam, NSAIDS, tramadol, a lot of these have fairly high thresholds that aren't just less than 30, right? Dr. Khyati Patel 30:48 And then agents such as the h2 blockers, as well as gout, agents like Colchicine are also added in this table for renal dosing. And as we mentioned, Dr. Sean Kane 30:58 kind of at the start of the episode Dr. Patel, one of the first drug classes I learned about in pharmacy. School were our antihistamine and anticholinergic type drugs, and this gets its own dedicated section in the guidelines. Why is that? Dr. Khyati Patel 31:11 Because they want to make sure that they provide a comprehensive list of medications that have anticholinergic properties. You know, Anticholinergics are kind of mentioned as a big umbrella term, but sometimes we miss that drugs like imipramine, for example, that falls under antidepressant category, does have anticholinergic property, right? We talked about first generation antihistamine that can have this risk as well. But even antiemetics, like the promethazine, which is something that commonly dispense that community pharmacy, right, they also tend to have anticholinergic properties. Another category is our anti Parkinson drugs, right? So benzotropin, for example, might be used in your patient with Parkinson's disease, but yeah, hey, that also has anticholinergic property, additional categories, such as we talked about, antipsychotics, but anti spasmodics, as well as muscle relaxants, are also added in here. And the reason again, to add here is, let's say you have a consult right at a clinic, and that says we want to make sure that patient had two falls already, and we want to review the medication and make sure that they're not an additional risk of fall. As a pharmacist, you know, anticholinergic medications increase the risk of sedation and all that stuff. So we're going to look after them. You can come to this table and screen the medication list of patients against this list to see, hey, what medications can we alter? What are our opportunities here to make the medication list more safer? Dr. Sean Kane 32:45 Dr. Patel, at the very beginning, we mentioned that the beers list, or beers criteria, was originally made by one person and then adopted by the American Geriatric Society. It's not surprising that there may be other lists out there that are kind of separate from the American Geriatric Society. What other things do we have out there, more internationally that focus on kind of the same concept as the beers list? Dr. Khyati Patel 33:08 Yeah, it's called Start and Stop criteria. And while beers list focuses on, you know, avoiding medication or stopping the medication or using with caution, the start and stop. Criteria focuses also on as the name start suggests starting a medication in a patient that will be beneficial as long as there is no concern and patient is not in the palliative care, right? So most recent publication was again also updated in 2003 there is version three out there, and this is published in the European Geriatric Medicine Journal. So this is, like you said, Dr. Kane, it's a little bit more international. You can compare and contrast what's in the beers list, and you know how they have provided their recommendation and the strength of recommendation against the stop criteria of this particular publication. But something that is different. Here is the drugs, an example of drugs that they recommend to start in this patient population, right? So please don't ignore these medication, because there is still potential benefit for these patient and there is a there's a long list a this particular start and stop criteria is published as an appendix to their main publication. So it is a little bit harder to find, but it's a nice list of things that clinicians should consider in starting as well as kind of avoiding with the stop criteria too. Dr. Sean Kane 34:33 And we have this also linked in our show notes. So if you'd like to go through the stop and start criteria from 2023 you're welcome to take a look at that as well. Dr. Khyati Patel 34:42 And some of the examples here of things that we should be starting is, let's say, let's pick a cardiovascular category, right? So they come out and say, Yeah, go ahead and use the sglt, two eye inhibitors in patients who have symptomatic heart failure with or without reduced ejection fraction. Regardless of diabetes. And this is kind of coming from the evidence we have of sglt two eyes thus far. Dr. Sean Kane 35:06 Another example would be the use of anticoagulation, that if someone has afib, for example, if they have an elevated risk of stroke or embolism, you should give them an anticoagulant. Even though anticoagulants do have a downside associated with them. For most patients, the upside outweighs the downside, right? Dr. Khyati Patel 35:22 And then, if we think in renal category, right, we talked about ACEs and ARBs. You know, renal dosing is important. We are kind of worried about it. But in terms of that benefit and chronic kidney disease, and especially if patient has presence of proteinuria, we do want to make sure that we we don't shy away from using ace and R, because we do know that there is benefit here Dr. Sean Kane 35:47 and then, kind of the slam dunk, obvious one, but it's really important. Are vaccination. So for example, pneumococcal vaccine, vaccination or Varicella Zoster vaccination, these are really important in elderly patients, like they're literally indicated as you get older. So it's not surprising that this would be a start recommendation in the guidelines, right? Dr. Khyati Patel 36:06 And so again, some of these recommendations we discussed Dr. Kane are not different than what we do for most patient population. However, both of these lists the beers criteria versus the start and stop criteria. It's kind of like that, one stop shop. If you have an older patient, you are practicing in geriatrics area, or you do have concerns related to falls and whatnot, you can screen through patient medication safety using these two criteria. Dr. Sean Kane 36:33 Dr. Patel, why don't we wrap up today's episode with a patient case to kind of bring everything together? Dr. Khyati Patel 36:38 That sounds great. So we have Mary, who's an 81 year old female patient. Past medical history is significant for hypertension, dyslipidemia, reduced ejection fraction, heart failure, the most recent ejection fraction was 35% she does have bilateral osteoarthritis of the knee, osteoporosis as well as urinary incontinence. Twist to the complications here is that she is going home after a four day hospital stay because she had a recent fall. It was a mechanical fall. Thankfully, even though she has osteoporosis, she did not have any fractures, and that's the goal of the treatment, but she does have some pain, no allergies to medications, but then you get to look at her prior to hospital medication list, and you see that she's on Losartan, 100 milligrams daily, Furosemide, 40 milligrams daily, Carvedilol, 6.25 milligrams twice daily. Atorvastatin, 20 milligrams daily, Tramadol, 50 milligrams, you know, three times a day as needed, I suppose that was put on for, you know, osteoarthritis prior to this incident, for osteoporosis, patient is on a Lange donate 70 milligrams once weekly, as well as calcium and vitamin D supplementation. And then for the urinary incontinence, she is on solifenacin 10 milligrams once daily, Dr. Sean Kane 37:59 in terms of thinking about why she fell. Her blood pressure when she came in was a little bit low, 98 over 72 and she confirms that she's been having low blood pressure and she's been feeling dizzy, and this isn't new. She's had it for a couple weeks now, even prior to her fall. So really, the question that is being posed to the pharmacy team is, are there any meds that are going to make her more likely to fall, or meds that would decrease her blood pressure and give her this, this dizziness, that would again increase the risk of fall, right? Dr. Khyati Patel 38:28 And Dr. Kane, she was really lucky to have this, sustain this fall and not have a fracture, because there is this, you know, osteoporosis diagnosis. Thankfully, she's treated okay. But then we think about, why is she having dizziness? Perhaps it's because of the low blood pressure, right? So look at her anti hypertensive. She's on Losartan, Carvedilol. Furosemide is not really an antihypertensive, but it could give that effect, especially when combined with other medication. Is this furosemide lead electrolyte imbalance issue that we are working with, right? Do we need to reduce any of these medications to make sure that she doesn't have hypotension? Dr. Sean Kane 39:09 And keep in mind, even though she has heart failure with reduced ejection fraction, for any heart failure patient, if they're having dizziness and hypotension, you would go down on their their pillars, right, the four pillars of their heart failure regimen, especially if they're having falls and things like that, because at some point, the risks of hypotension easily outweigh the benefits that you're getting from that mortality reduction Dr. Khyati Patel 39:31 100% right? And this is where that clinical decision making on benefit versus risk will come to play, right? We know she has urinary incontinence, and she is using solifenacin, solifenacin, technically it is an antimuscarinic. Again, it's okay to use for this particular indication, but it does come with that anticholinergic side effect, especially when you combine it with tramadol. Here is that drug interaction that we talked about right? Perhaps in a. Younger patient, this might not be an issue, but a patient like Mary, who is older, who has been having dizziness, who has had a fall, now this combination increases the risk of that dizziness, that drowsiness and the confusion on top of it, right? So some of these things need to be evaluated further, Dr. Sean Kane 40:19 depending on the nature of her pain and the chronicity of her pain, she might be able to get away with something like scheduled Tylenol that isn't going to have those cognitive impairments or hypotension, maybe an NSAID, maybe not, depending on if it's more acute and she gets good benefit from that, but if it's more chronic, probably a Tylenol would be a better option. Yeah, 100% Dr. Khyati Patel 40:38 so we kind of need to evaluate the patient from multi different facets, but these are kind of the recommendation that, as a pharmacist on the team, we can provide. Dr. Sean Kane 40:48 Well, Dr. tell, as we mentioned several times, we have both the updated beers list and also the stop and start criteria listed as a reference in our show notes at HelixTalk.com Again, this is episode 182 we have a mailing list, so while you're there looking at the show notes, you might as well sign up for our mailing list, and you'll get an email every time a new episode comes out. And we love the five star reviews on iTunes or Apple podcasts or wherever you're listening to us. So if you wouldn't mind taking five seconds to give us a five star review. Would really appreciate that. So with that, I'm Dr. Kane and Dr. Khyati Patel 41:19 I'm Dr. Patel, and as always, study hard. Narrator - Dr. Abel 41:22 If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there to Narrator - ? 41:33 suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.