The Updated 2019 AGS Beers Criteria for Potentially Inappropriate Medication Use Lisa C Hutchison, PharmD, MPH, BCPS, BCGP, FCCP Professor, UAMS College of Pharmacy Dept of Pharmacy Practice Professor, UAMS College of Medicine Dept of Geriatrics

Objectives Describe the methods used to develop the AGS Beers Criteria Compare the changes in the 2019 AGS Beers Criteria Apply the Beers Criteria in patient care and quality improvement

Reference American Geriatrics Society Beers Criteria Update Expert Panel.  American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019; 00:1-21. doi.org/10.1111/jgs.15767.  ePub ahead of print. https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.15767 (accessed 2019 Mar 19).

Outline Development of the Beers Criteria 2019 AGS Beers Criteria Example Application to Clinical Practice Questions?

How were the Beers Criteria developed?

Mark H. Beers, MD 1954-2009 “A ballet-dancing opera critic who hiked the Alps and took up rowing after diabetes cost him his legs” MD degree, Univ of Vermont Faculty, UCLA/RAND First medical student to do a geriatrics elective at Harvard’s new Division on Aging Co-editor, Merck Manual of Geriatrics Editor in Chief, Merck Manuals

Beers Criteria History Developed 1991: Nursing home residents 1997 revision: All elderly patients 2003 update Adoption by NCQA, HEDIS 2012 AGS update Adoptions by Medicare Part D insurers 2015 AGS update Added Drug-Drug Ix and Renal Dosing Tables 2019 AGS update

Goals of Beers Criteria Annoy prescribers who prescribe these drugs for their patients and harass pharmacists who fill the scripts Improve care by decreasing exposure to potentially inappropriate medications Educational tool Quality measure Research tool

Purpose of Beers Criteria Identify drugs to avoid in older adults Independent of diagnosis Considering diagnosis Reduce adverse drug events and drug-related problems by improving medication selection and use Be useful in any clinical setting

Framework: 2019 Expert Panel Co-chairs: Donna Fick, PhD, RN & Todd Semla, PharmD Voting Panelists: 6 MDs, 4 PharmDs, 1 APN Non-voting Members: CMS, NCQA, PQA AGS Staff, Non-voting: 2 members Literature Researcher and Editor, Non-voting

Literature Search 25,549 citations 2001-2011 Terms used: Drugs & Drug classes, conditions, and combinations along with: ADE, inappropriate drug use, medication errors, polypharmacy X age/human/English 25,549 citations 2001-2011 258 included in 2012 Beers Criteria 20,748 citations 2011-2014 17,627 citations 2015-17 17,627 preliminary review 12,224 excluded 1,422 reviewed by panel 377 included in evidence tables

Framework: Methods GRADE criteria for clinical trials and observational studies AMSTAR for systematic reviews Each article rated for Risk of Bias Quality of Evidence for articles supporting recommendation High---Moderate----Low Strength of Recommendation based on potential for harm and available alternatives Strong---Weak---Insufficient Cochrane Risk of Bias, Jadad Scoring System, American College of Physicians' Guideline Grading System, 2010; AMSTAR, BMC Med Res Methodol, 2007

Info included in Recommendations Therapeutic Category and/or Drug (s) Recommendation Avoid Avoid in Avoid except in Rationale Quality of Evidence Strength of Recommendation

PIMs to Avoid in all Older Adults Anticholinergics Antithrombotics* Anti-infective Cardiovascular Central Nervous System Endocrine* Gastrointestinal* Pain Medications* Genitourinary PIM = potentially inappropriate medication; * = changes made

PIM Table: Antithrombotics Deleted Ticlopidine No longer on US market

PIM Table Endocrine Agents: Changes Growth hormone Avoid except for patients rigorously diagnosed…with GH deficiency… Insulin, Sliding Scale Insulin regimens containing only short/rapid-acting insulin without concurrent use of basal or long-acting insulin Sulfonylureas, long acting Added Glimepiride as a drug to avoid

PIM Table: GI Agents Metoclopramide Avoid, unless for gastroparesis…duration… not to exceed 12 weeks…

PIM Table: Pain Medications Meperidine Deleted phrase “especially…with chronic kidney disease” Pentazocine Deleted: oral removed from US market

Dz/Cn PIMs Interactions Table Cardiovascular Central Nervous System* Delirium Dementia Falls/Fracture Gastrointestinal Kidney/Urinary Tract Dz/Cn PIMs = Potentially inappropriate medications due to drug-disease or condition interactions; * = changes made

Dz/Cn Table: CNS Deletions Chronic Seizures or Epilepsy Removed list of drugs that lower threshold Insomnia Removed list of CNS stimulants Not specific to older adults: Deleting does not mean endorsement of use!

Dz/CN PIMs Table CNS Section Delirium Evidence level for H2-receptor antagonists changed to LOW (from moderate) Dementia Removed H2-receptor antagonists History of Falls/Fractures: Added SNRIs Parkinson disease/Antipsychotics Replaced aripiprazole with pimavanserin as an exception

Use with Caution Table: Increased Bleeding Risk Aspirin in primary prevention—changed to caution age 70 or older due to major bleeding risk Added Rivaroxaban to Dabigatran due to GI bleeding risk Prasugrel remains on list

Use with Caution Table: Increased SIADH or hyponatremia Deleted chemotherapy drugs from this list Antidepressants: SSRIs, SNRIs, TCA, Mirtazapine Antipsychotics; Carbamazepine/Oxcarbazepine Diuretics Added Tramadol Dextromethorphan/Quinidine limited efficacy in behavioral symptoms of dementia Trim-Sulfa in patients on ACE or ARB with decreased CrCl due to hyperkalemia risk

Drug-Drug Interactions Biggest Changes for 2019 Opioids/Benzos Increased risk for overdose Opioids/Gabanoids Increased risk for respiratory depression/death Added Anti-infectives Ciprofloxacin, Macrolides, Trimethoprim-sulfamethoxazole

PIMs based on Kidney Function Table Biggest Changes Added Anti-infectives: Ciprofloxacin, Trimethoprim-sulfamethoxazole Modified criteria for level of renal function to take action

Outline Development of the Beers Criteria 2019 AGS Beers Criteria Application to Clinical Practice Questions?

Purpose of Beers Criteria Identify drugs to avoid in older adults Independent of diagnosis Considering diagnosis Reduce adverse drug events and drug-related problems by improving medication selection and use Be useful in any clinical setting

Even healthy elderly at risk JAMA Internal Medicine, July 27,2015

Part 2

Part 3 JAMA Internal Medicine, July 27,2015

Clinical Application Mrs. P, a 74 YO woman, complains of itching that keeps her awake at night now that the winter season is here What treatment would you provide: First-generation antihistamines? Second-generation antihistamines? Alternative products? Basic lotions/creams/ointments Topical steroids Non-pharmacologic options

Clinical Application 88 YO socially active, clear-thinking woman with osteoarthritis that is interfering with her tai chi and yoga classes What do you do? Cyclobenzaprine 10mg TID prn pain Recommend acetaminophen or naproxen short-term (with a PPI) instead Non-pharmacologic options

Beers Criteria for Quality Improvement Quality Performance Measurement Looking at populations Benchmark goals Requires system-level approaches

UAMS EPIC Best Practice Advisory Implemented in April 2016 An alert fires when providers order selected Beers Criteria medications for patients ≥ 65 years of age Suggests alternative therapy options

QA Study Objective and Design Pharmacy Resident 2017-18 Project Did the BPA have desired effect? Retrospective review of selected Beers Criteria medications prescribed during selected time period Inclusion criteria: Age ≥ 65 years; Inpatient admission; Exclusion criteria: Outpatient visit; Palliative care/hospice orders; Unusual frequencies (every 30 days, weekly, code/trauma) Jul – Dec 2015 Jul-Dec 2016 Jul-Dec 2017 Prior 3-9 mo Post 1+ years post Personal Communication, Meredith Stefanik

Prescribing by Year Personal Communication, Meredith Stefanik

Clinic example Providers in clinic agree to avoid use of meperidine, chlorpropamide, glimepiride, and glyburide (from Beers’ Criteria) in clinic patients >65 YO. Benchmark of 5 patients EHRs are searched to find: Chlorpropamide – 1 patient Meperidine – 8 patients Glyburide – 99 patients Glimepiride – 123 patients

QI Cycle Focus on meperidine, glyburide, & glimepiride Provide education, EHR reminders Review EHRs for change Repeat EHR reports to see if usage dropping Repeat cycle— Same drug Different techniques Choose other drugs

AGS Resources Sign up with an account to access (free) Criteria Pocket Card Smartphone App Available at: GeriatricsCareOnline.org Sign up with an account to access (free)

Outline Questions? Development of the Beers Criteria 2019 AGS Beers Criteria  Application to Clinical Practice Questions?