II. Background: Sources of information

  1. Beers' Criteria
  2. Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP)

III. Pathophysiology: Factors in older adults that increase Drug Reaction risk

  1. Hepatic blood flow reduced 40% in older adults
    1. Reduced first pass clearance
  2. Renal blood flow reduced 50% by age 80 years
    1. Creatinine Clearance decreases by 10% per decade after age 20 years old
    2. Chronic Kidney Disease affects 50% of older adults
    3. Check Renal Function before starting agents and periodically (dose adjustment may be needed)
  3. Congestive Heart Failure affects 40% by age 80 years
  4. Drug distribution altered in older adults
    1. Serum Proteins reduced resulting in decreased drug protein binding
    2. Decreased ratio of Lean Body Weight to body fat

IV. Adverse Effects: Predictors of adverse drug effects in elderly

  1. Age 85 years or older
  2. Multiple chronic medical conditions (6 or more)
  3. Creatinine Clearance <50 ml/min
  4. Low Body Mass Index
  5. Polypharmacy
    1. Medications number nine or more
    2. More than 12 medication doses daily
  6. References
    1. Fouts (1997) Consultant Pharmacist 12:1103-11 [PubMed]

V. Management: Methods to improve Medication Compliance

  1. Reduce number of daily doses (once daily is best)
  2. Time doses to meal times
  3. Establish partnerships to ensure compliance
    1. Patient
    2. Family (educate on indications and adverse effects)
    3. Pharmacists
    4. Home health aids
  4. Use devices that aid taking of medication
    1. Pill boxes and pill calendars
    2. Label containers with large type
    3. Pill containers should open easily
    4. Keep accurate medication list
  5. Ensure easy access to medications
    1. Affordability
    2. Medication delivery
  6. Evaluate for patient factors affecting compliance
    1. Dementia
    2. Major Depression

VI. Medications: To use lower dosages (decreased clearance)

  1. Decreased renal clearance in the elderly
    1. Aminoglycosides
    2. Vancomycin
    3. Fluoroquinolones
    4. Penicillins
    5. Imipenem
    6. Digoxin (limit dose to 0.125 mg/day, consider qod)
    7. ACE Inhibitors
    8. Beta Blockers (Atenolol, Nadolol)
    9. Sotalol
    10. Glyburide (avoid in general)
    11. Ranitidine, Cimetidine, Famotidine
    12. Lithium
  2. Decreased hepatic clearance in the elderly
    1. Benzodiazepines (avoid in general - see below)
    2. Calcium Channel Blockers
    3. Lidocaine
    4. Phenytoin
    5. Celecoxib (Celebrex)
    6. Theophylline
    7. Imipramine or Desipramine, Trazodone
    8. Isoniazid
    9. Procainamide

VII. Medications: Avoid in age >65 - Short List

  1. Beer's List most common items
    1. Sedating Antihistamines (e.g. Diphenhydramine)
    2. Long acting Benzodiazepines (e.g. Diazepam)
    3. Tricyclic Antidepressants (e.g. Amitriptyline)
    4. Antispasmodics (e.g. Oxybutynin, dicyclomine)
    5. Fick (2003) Arch Intern Med 163:2716 [PubMed]
  2. STOPP List most common items (in addition to those on short Beer's List)
    1. Non-selective Beta Blockers
    2. Proton Pump Inhibitors
    3. Ryan (2009) Br J Clin Pharmacol 68(6): 936-47 [PubMed]

VIII. Medications: Neuropsychiatric Agents to avoid in age >65

  1. Anticholinergic Agents (see Antihistamines, Antidepressants, Benzodiazepines below)
  2. Selective Serotonin Reuptake Inhibitors (SSRI)
    1. Associated with increased fall risk more than TCA agents
      1. Boyle (2010) Clin Geriatr Med 26(4): 583-605 [PubMed]
    2. Prozac is no longer contraindicated in the elderly despite long half-life (as safe as other SSRIs)
    3. Avoid SSRIs if non-iatrogenic Hyponatremia with Serum Sodium <130 mmol/L in last 2 months (STOPP)
  3. Tricyclic Antidepressants (TCA)
    1. Indications to avoid TCA agents (STOPP)
      1. Dementia due to cognitive Impairment
      2. Glaucoma due to exacerbation risk
      3. Cardiac conduction abnormalities due to pro-arrhythmic effect
      4. Constipation or in combination with Opioids or Calcium Channel Blockers due to exacerbation risk
      5. Benign Prostatic Hyperplasia due to urinary obstruction risk
    2. Avoid TCA Agents in general due to Anticholinergic and sedating effects
      1. Most Anticholinergic and sedating agents: Amitriptyline, Doxepin, Imipramine
      2. Nortriptyline may be slightly less Anticholinergic
      3. Consider less sedating alternatives for pain management: Neurontin, Lyrica
  4. First-Generation Sedating Antihistamines (Benadryl, Periactin, Atarax, Tylenol PM)
    1. Avoid use longer than one week (STOPP)
    2. Use Second Generation Antihistamines instead
    3. Avoid Antihistamines for Insomnia management
    4. Avoid if at least one fall in the last 3 months (STOPP)
  5. Barbiturates (e.g. Fiorinal, Nembutal, Seconal)
  6. Benzodiazepines (Librium, Valium, Dalmane, Halcion)
    1. Increased risk of physical performance decline, confusion, Sedation, falls
    2. Use Benzodiazepines only with caution
      1. Avoid longer acting agents (e.g. Clonazepam) or those with long acting metabolites (e.g. Diazepam)
        1. Use shorter acting agents (e.g. Ativan, Restoril)
      2. Use lower doses (<1 mg Ativan, <15 mg Restoril)
      3. Avoid use longer than 1 month (STOPP)
      4. Avoid if at least one fall in the last 3 months (STOPP)
    3. Avoid Benzodiazepine analogs used in Insomnia (e.g. Ambien, Sonata, Lunesta)
      1. Avoid these agents for any duration (previously limited to 3 months)
      2. See Insomnia for alternative agents
    4. References
      1. Gray (2003) J Am Geriatr Soc 51:1563-70 [PubMed]
  7. Neuroleptics (Antipsychotics)
    1. Avoid Haloperidol (Haldol) due to two fold increase in mortality in older Nursing Home residents
      1. Consider Quetiapine (Seroquel) as alternative
      2. Huybrechts (2012) BMJ 344:e977 [PubMed]
    2. Avoid longterm use >1 month, especially in Parkinsonism (STOPP)
    3. Avoid Anticholinergic Medications to treat Extrapyramidal Side Effects of Antipsychotic agents (STOPP)
    4. Avoid if at least one fall in the last 3 months (STOPP)
  8. Meprobamate (addictive and sedating)
  9. Stimulants: Amphetamines and Methylphenidate (Ritalin)
  10. Skeletal Muscle Relaxants (e.g. Flexeril, Soma, Robaxin, Norflex)
  11. Thioridazine (Mellaril)
  12. Cholinesterase inhibitors (e.g. Aricept) in patients with Syncope

IX. Medications: Cardiovascular Agents to avoid in age >65

  1. Amiodarone
    1. Risk of QT Prolongation and Torsade de Pointes
  2. Disopyramide (Norpace)
    1. Anticholinergic, risk of Congestive Heart Failure
  3. Methyldopa
  4. Reserpine
  5. Ticlopidine
  6. Digoxin >125 mcg daily
    1. Avoid longterm use at >125 mcg if GFR <50 ml/min (STOPP)
    2. Limit use to Congestive Heart Failure and Atrial Fibrillation
  7. Loop Diuretic
    1. Avoid use for lower extremity edema only (e.g. no history of Heart Failure, STOPP)
    2. Avoid use as first-line monotherapy for Hypertension (STOPP)
  8. Thiazide Diuretic
    1. Avoid use in Gouty Arthritis (STOPP)
  9. Beta Blockers
    1. Avoid Non-selective Beta Blockers such as Propranolol in COPD (STOPP)
    2. Avoid Beta Blocker in combination with Verapamil due to AV Nodal block risk (STOPP)
    3. Avoid in Diabetes Mellitus with more than 1 hypoglycemic episode monthly due to risk of masking symptoms (STOPP)
  10. Calcium Channel Blockers
    1. Avoid Diltiazem or Verapamil in NYHA Class III or Class IV Heart Failure due to exacerbation risk (STOPP)
  11. Vasodilators
    1. Avoid in persistent Postural Hypotension with SBP drop on standing >20 mmHg if at least one fall in the last 3 months (STOPP)

X. Medications: Endocrine Agents to avoid in age >65

  1. Chlorpropamide (Diabinese)
    1. Risk of prolonged Hypoglycemia (STOPP)
  2. Glyburide
    1. Risk of Hypoglycemia
    2. Use Glipizide or Glimepiride instead
  3. Pioglitazone (Actos)
    1. Avoid in Heart Failure
  4. Sliding Scale Insulin
    1. Risk of Hypoglycemia
  5. Desiccated Thyroid (Armour Thyroid)
  6. Methyltestosterone (Provokes BPH)
  7. Megestrol
    1. Low efficacy for stimulation of appetite
    2. Risk of thrombosis
  8. Estrogens
    1. Avoid Estrogen if history of VTE or Breast Cancer (STOPP)
    2. Avoid Unopposed Estrogen without Progesterone with intact Uterus (STOPP)

XI. Medications: Analgesic Agents to avoid in age >65

  1. Opioids
    1. Avoid longterm Opioids if at least one fall in the last 3 months (STOPP)
    2. Avoid longterm high potency Opioids such as Morphine or Fentanyl as first-line management of mild to moderate pain (STOPP)
    3. Avoid regular Opioids for more than 2 weeks if Chronic Constipation and no without prophylactic Laxative (STOPP)
      1. See Constipation Prophylaxis in Chronic Opioid Use
    4. Avoid longterm Opioids in Dementia patients outside of Palliative Care or moderate-severe Chronic Pain (STOPP)
    5. Avoid Meperidine (Demerol) completely
    6. Avoid Propoxyphene (Darvon) completely
  2. Pentazocine (Talwin)
  3. Corticosteroids
    1. Avoid use longer than 3 months as monotherapy for Rheumatoid Arthritis, gout or Osteoarthritis (STOPP)
  4. NSAIDs
    1. Limit to low dose, short duration, short half-life
      1. Avoid use longer than 3 months for mild osteoarthritic pain (STOPP)
      2. Avoid prolonged use for gout prevention in place of Allopurinol when not contraindicated (STOPP)
      3. Use alternative management (e.g. Acetaminophen, Contrast Bath)
    2. NSAIDs to avoid completely
      1. Indomethacin (CNS and gastrointestinal effects)
      2. Ketorlac (Toradol)
      3. Long-acting NSAIDs (Feldene, Naprosyn, Daypro)
    3. Avoid use completely in high risk patients
      1. Over age 75 years
      2. GFR <50 ml/min (STOPP)
      3. Concurrent Corticosteroid use
      4. Concurrent Anticoagulant use such as Warfarin or Pradaxa (STOPP)
      5. History of PUD or GI Bleeding and no GI prophylaxis with H2 Blocker, PPI, or Misoprostol (STOPP)
      6. Moderate to Severe Hypertension with BP >160/100 mmHg due to exacerbation risk (STOPP)
      7. Congestive Heart Failure history due to exacerbation risk (STOPP)

XII. Medications: Gastrointestinal and Genitourinary Agents to avoid in age >65

  1. Antiemetics
    1. Avoid Phenergan, Tigan
    2. Avoid Metoclopramide (Reglan) or Prochlorperazine (Compazine) in Parkinsonism due to exacerbation risk (STOPP)
    3. Avoid Pheothiazines (e.g. Compazine) in Epilepsy due to exacerbation risk (STOPP)
  2. Gastrointestinal antispasmodics (e.g. Donnatal, Bentyl, Levsin, Clidinium)
    1. Avoid Anticholinergic antispasmodic drugs in Chronic Constipation (STOPP)
  3. Antidiarrheal agents (Lomotil, Imodium, Codeine)
    1. Avoid antidiarrheals in Diarrhea of unknown cause due to risk of toxic Megacolon, exacerbation of overflow Diarrhea (STOPP)
    2. Avoid antidiarrheals in dysentary (bloody Diarrhea, fever, toxicity) due to risk of exacerbation (STOPP)
  4. Proton Pump Inhibitors (e.g. Omeprazole)
    1. Avoid >8 weeks at high dose Peptic Ulcer Disease management doses (STOPP)
    2. Stop or if continuation indicated (e.g. severe GERD, Barrett's Esophagus), decrease to standard dosing
    3. PPIs increase the risk of Clostridium difficile, Fractures and Pneumonia
  5. Nitrofurantoin (Macrobid)
    1. May worsen Renal Insufficiency and risk interstitial fibrosis
    2. Avoid if Creatinine Clearance <30 ml/min (previously not recommended if <60 ml/min)
  6. Stimulant Laxatives (worsen bowel function in elderly)
  7. Urinary antispasmodics (e.g. Ditropan)
    1. Typically marginal benefit does not outweigh significant Anticholinergic effects
    2. Look for other causes of Urinary Incontinence (e.g. cholinesterase inhibitors such as Aricept)
    3. Avoid use if contraindicating conditions (STOPP)
      1. Dementia
      2. Chronic Glaucoma
      3. Chronic Constipation
      4. Benign Prostatic Hyperplasia (BPH) with obstruction
  8. Alpha-Blockers
    1. Avoid alpha-blockers with one or more episodes of daily Incontinence due to exacerbation risk (STOPP)
    2. Indwelling Urinary Catheter present >2 months due to lack of indication (STOPP)

XIII. Medications: Respiratory Agents to avoid in age >65

  1. Inhaled Anticholinergics (Atrovent, Spiriva)
    1. Avoid in men with severe BPH
    2. Avoid nebulized Ipratropium in Glaucoma due to exacerbation risk (STOPP)
  2. Theophylline
    1. Avoid as monotherapy for COPD due to safer alternatives with better efficacy (STOPP)
  3. Systemic Corticosteroids
    1. Avoid in place of Inhaled Corticosteroids as maintenance therapy in moderate to severe COPD (STOPP)

XIV. Medications: Hematologic Agents to avoid in age >65

  1. Avoid antiplatelet agents such as Aspirin, Dipyridamole or Clopidogrel in concurrent Bleeding Disorder (STOPP)
  2. Aspirin
    1. Avoid for primary prevention in over age 80 years old
    2. Avoid without cardiovascular indication such as CAD, PAD, CVA (STOPP)
    3. Avoid as treatment for undifferentiated Dizziness
    4. Avoid dose >150 mg daily due to increased bleeding risk without added efficacy (STOPP)
    5. Avoid without the use of GI Protection (e.g. H2 Blocker or Proton Pump Inhibitor, STOPP)
      1. Concurrent Warfain use
      2. History of Peptic Ulcer Disease in the last year
  3. Warfarin
    1. Avoid >6 months for first uncomplicated DVT or >12 months for first uncomplicated PE (STOPP)
    2. Multiple significant drug interactions (e.g. Amiodarone, Anticholinergics)
  4. Pradaxa
    1. Avoid in severe Chronic Kidney Disease
  5. Dipyridamole
    1. Avoid as monotherapy for cardiovascular secondary prevention due to lack of efficacy (STOPP)

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Ontology: Inappropriate Prescribing (C2936303)

Definition (MSH) The practice of administering medications in a manner that poses more risk than benefit, particularly where safer alternatives exist.
Concepts Health Care Activity (T058)
MSH D057970
English Prescribings, Inappropriate, Prescribing, Inappropriate, Inappropriate Prescribing, Inappropriate Prescribings
French Prescription inappropriée, Prescription inadéquate, Prescription inadaptée, Prescription à mauvais escient
German Unangemessene Verordnung, Unangemessene Verschreibung
Czech nevhodné předepisování
Italian Prescrizione inappropriata
Spanish Prescripción Inadecuada, Prescripción Inapropiada, Prescripciones Inapropiadas
Russian НЕРАЦИОНАЛЬНОЕ НАЗНАЧЕНИЕ ЛЕКАРСТВЕННЫХ СРЕДСТВ, НЕСООТВЕТСТВУЮЩЕЕ ПРЕДПИСАНИЕ, NESOOTVETSTVUIUSHCHEE PREDPISANIE, NERATSIONAL'NOE NAZNACHENIE LEKARSTVENNYKH SREDSTV
Portuguese Prescrição Inadequada, Prescrições Inapropriadas, Prescrição Inapropriada
Polish Nadmierne zapisywanie leków, Niepoprawne zapisywanie leków, Niepoprawność leczenia farmakologicznego, Niepoprawność farmakoterapii, Potencjalna niepoprawność leczenia, Ordynowanie leków niewłaściwe, Potencjalne błędy farmakoterapii
Norwegian Upassende forskrivning, Upassende reseptutskriving