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What's the Best Brew for Grandma? 2012 Beers List Update

What's the Best Brew for Grandma? 2012 Beers List Update. Hospitalist Best Practice J Rush Pierce Jr , MD, MPH June 20, 2012. Disclosures.

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What's the Best Brew for Grandma? 2012 Beers List Update

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  1. What's the Best Brew for Grandma? 2012 Beers List Update Hospitalist Best Practice J Rush Pierce Jr, MD, MPH June 20, 2012

  2. Disclosures • I am member and serve on Emergency Preparedness Special Interest Group for the American Geriatrics Society, who played a major role in the 2012 Beers update • 5% of my salary supported by Donald W Reynolds Foundation for education of hospital care of the elderly

  3. Agenda • Background of Beers list (rationale, history, methodology of update) • Focused review of update • Usefulness and limitations • Relevance to hospital medicine/resources

  4. What the Beers list is not

  5. Beers list - background • 1991 – for use in NH’s • 1997 – update for elderly in all settings • 1999 – adopted by CMS for NH regulation • 2003 – update; adopted by Medicare D, HEDIS, NCQA • 2012 – evidence-based update

  6. Case Q1 82 y/o white man admitted with CAP, now ready to go home after completion of CAP rx. PMHx: diabetes, HTN, painful diabetic neuropathy Home meds : glyburide, lovastatin, clonidine, ASA, amitriptyline, pantoprazole Q1 How many of these meds are on the Beers list? Q2 What will you send the patient home on?

  7. Case Q2 77 y/o woman with dementia has recurrent UTI’s and nausea. Urology suggests long-term suppressive therapy. Recent organisms have been sensitive to nitrofurantoin and Bactrim. Q1 What is best choice for urinary suppression? Q2 What drug is best choice for nausea?

  8. Criticisms of previous Beers list iterations • Not evidence-based • Many drugs on list were infrequently used • Unstructured • Uncertain relevance to clinical practice • Many studies settings show that 20 – 30% of patients on Beers list meds • Inconsistent assoc with ADE in epidemiologic studies

  9. NEISS-CADES • Setting: 53 US hospitals • Patients: 5077 pts > 64 years adm to hospital for ADE • Findings: • Half of hospitalizations were for pts >79 yrs old • Two-thirds due to warfarin (33.3%), insulins (13.9%), oral antiplatelet agents (13.3%), and oral hypoglycemic agents (10.7%). • Beers medications were implicated in 6.6% of hospitalizations for ADE, half of these digoxin Source: NEJM 2011;365:2002

  10. 2012 Beers Update • Evidence-based approach by American Geriatric Society • Incorporate exceptions • Divide into three categories (Drugs to avoid, Drug-disease/syndrome interactions, Drugs to use with caution) • Publish grade of evidence and strength of recommendation

  11. Evidence grade and strength of recommendations • Grade of evidence • High (>1 RCT or multiple consistent high quality observational studies) • Moderate (1 RCT, or multiple consistent lower quality observational studies) • Low (important study design flaws, inconsistent findings among studies) • Strength of recommendations • Strong (risk/burden clearly > benefit) • Weak (benefits finely balanced with risk/burden) • Insufficient (insufficient evidence to determine)

  12. Anticholinergics Source: JAGS 2012;60:616

  13. Antibiotics Source: JAGS 2012;60:616

  14. Cardiovascular drugs Source: JAGS 2012;60:616

  15. Cardiovasc drugs (contd) Source: JAGS 2012;60:616

  16. Psych drugs Source: JAGS 2012;60:616

  17. Psych drugs (contd) Source: JAGS 2012;60:616

  18. Endocrine drugs Source: JAGS 2012;60:616

  19. Pain Source: JAGS 2012;60:616

  20. Drug – disease/synd interactions Source: JAGS 2012;60:616

  21. Source: JAGS 2012;60:616

  22. Source: JAGS 2012;60:616

  23. Source: JAGS 2012;60:616

  24. Drugs to use with caution Source: JAGS 2012;60:616

  25. Beers criteria and outpt studies • Chang et al (Pharmacotherpy 2005;25:831) • Setting: Taiwan • Patients: 550 older pts seen in outpt clinic • Findings: ADE OR = 15 • Budnitz et al (Ann Intern Med 2007;147:755) • Setting: Brazil • Patients: 186 older outpts • Findings: ADE OR = 2.3

  26. Beers criteria and hosp studies • Onder et al (Eur J ClinPharmacol 2005;61:453) • Setting: Italy • Patients: 5,152 older pts adm to hosp • Findings: No assoc Beers list and ADE, LOS or mortality • LaRoche et al (Brit J ClinPharm 2007;63:177) • Setting: France • Patients: 2,018 pts > 70 adm to hosp • Findings: more ADR in pts on Beers list meds, but no diff in ADR attributable to Beers meds

  27. Beers and hospital studies • Franceschi M, et al (Drug Safety 2008;31:545) • Setting: Italy • Patients: 1,756 older pts adm to hospital • Findings: • 4.4% of hospitalizations related to ADE that was definitely or possibly avoidable • 1/5 of these (<1% or adms) had received an inappropriate med • Budnitz et al (Ann Intern Med 2007;147:755) • Setting: US • Patients: 177,504 older pts seen in ED • Findings: • No association between Beers meds and ADE

  28. BEERS vs STOPP (Hamilton. Arch Intern Med 2011; 171:1013) • STOPP = Screening Tool of Older Persons’ potentially inappropriate Prescriptions • Setting: Ireland • Patients: 600 pts > 64 years adm to hosp • Findings: • ADE 26% • 2/3 ADE causal or contributory to adm • OR ADE 1.84 (95% CI = 1.51 – 2.26) with STOPP, 1.27 (95% CI = 0.94 – 1.72) with Beers

  29. Source: Arch Intern Med 2011;171:1013

  30. Source: Arch Intern Med 2011;171:1013

  31. Source: Arch Intern Med 2011;171:1013

  32. Source:http://www.bgs.org.uk/powerpoint/aut10/Mahony_inappropriate_prescribing.pdfSource:http://www.bgs.org.uk/powerpoint/aut10/Mahony_inappropriate_prescribing.pdf

  33. Source:http://www.bgs.org.uk/powerpoint/aut10/Mahony_inappropriate_prescribing.pdfSource:http://www.bgs.org.uk/powerpoint/aut10/Mahony_inappropriate_prescribing.pdf

  34. Source:http://www.bgs.org.uk/powerpoint/aut10/Mahony_inappropriate_prescribing.pdfSource:http://www.bgs.org.uk/powerpoint/aut10/Mahony_inappropriate_prescribing.pdf

  35. http://www.americangeriatrics.org/files/documents/annual_meeting/2012/handouts/friday/Joseph_Hanlon.pdfhttp://www.americangeriatrics.org/files/documents/annual_meeting/2012/handouts/friday/Joseph_Hanlon.pdf

  36. Case Q1 82 y/o white man admitted with CAP, now ready to go home after completion of CAP rx. PMHx: diabetes, HTN, painful diabetic neuropathy Home meds : glyburide, lovastatin, clonidine, ASA, amitriptyline, pantoprazole Q1 How many of these meds are on the Beers list? Q2 What will you send the patient home on?

  37. Case Q2 77 y/o woman with dementia has recurrent UTI’s and nausea. Urology suggests long-term suppressive therapy. Recent organisms have been sensitive to nitrofurantoin and Bactrim. Q1 What is best choice for urinary suppression? Q2 What drug is best choice for nausea?

  38. Beers and Relevance to Hospital Medicine • Education/resources (google AGS) • Avoid starting Beers/STOPP meds in hospital • Phenergan, benzos • If Beers/STOPP meds started in hospital, consider stopping before go home • Antipsychotics, opiates, zolpidem, ?loop diuretics for edema not due to CHF or cirrhosis • For patients on Beers/STOPP meds on admission, consider communicating with PCP • Redo admission order set; clinical decision support

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