Laird Harrison

October 22, 2015

SAN FRANCISCO — The first-ever list of alternatives to the drugs deemed by the Beers Criteria to be risky for elderly patients is now available.

This was promised by the American Geriatrics Society (AGS), said Todd Semla, PharmD, from Northwestern University in Chicago, who cochaired an AGS panel that updated the Beers Criteria.

"A lot of people have been asking about alternatives," he told Medscape Medical News.

Dr Semla gave an overview of the updated criteria and the list of alternatives here at the American College of Clinical Pharmacy 2015 Global Conference.

The update was published online October 8 in the Journal of the American Geriatrics Society, along with a guide for the use of the updated criteria and the list of alternative medications.

The Beers Criteria were developed in 1991 by Mark Beers, MD, from the University of California, Los Angeles, as a guideline for nursing homes, but they quickly caught on wherever geriatric patients could be found, said Dr Semla, who is a section editor for the Journal of the American Geriatrics Society.

"I'm still waiting for a paper that comes in and studies the use of the criteria by garden gnomes, because that's the only population that hasn't been studied yet," he quipped.

Despite all the attention, inappropriate drug prescriptions are increasing among the oldest and most vulnerable adults, increasing healthcare costs, mortality, and morbidity, he said.

Too Many Prescriptions

"I'm a big advocate of de-prescribing, where we remove drugs that are unnecessary and people just plain don't know why they're taking them," he added.

The Beers Criteria, which were updated in 1997, 2003, and 2012, have also been used by insurers and other payers. The National Committee for Quality Assurance (NCQA) and the Pharmacy Quality Alliance (PQA) relied on the 2012 Beers Criteria to create quality measures that the Centers for Medicare and Medicaid Services (CMS) uses to evaluate the quality of care provided to Medicare beneficiaries.

"Those are some of the other things we wrestle with as we develop new criteria or make use of the old ones," said Dr Semla. "How do we fit it into all those boxes?"

For the 2015 update, the AGS panel conducted a systematic literature review, and graded the quality of evidence for each recommendation. It offered a preview of the update in May, as reported by Medscape Medical News, and revised its list after extensive public comment.

To create a list of alternatives, Dr Semla and two of his colleagues focused on the medications incorporated by the NCQA and PQA in their quality measures.

After a literature review, they prepared a list of alternatives to these drugs, and then ran it by the NCQA, PQA, the AGS Beers Criteria panel, and the AGS executive committee.

Alternatives to High-Risk Medications

The table of alternatives to high-risk medications, for example, lists intranasal normal saline, second-generation antihistamines (such as cetirizine, fexofenadine, and loratadine), and intranasal steroids (such as beclomethasone and fluticasone) as alternatives to first-generation antihistamines (such as chlorpheniramine and oral diphenhydramine).

And selective serotonin reuptake inhibitors (except paroxetine), serotonin and norepinephrine reuptake inhibitors, bupropion, and psychotherapy are suggested instead of tertiary tricyclic antidepressants (such as amitriptyline, clomipramine, and imipramine).

The table also addresses antiplatelets, cardiovascular medications, immediate-release nifedipine, barbiturates and other drugs that act on the central nervous system, meprobamate, chloral hydrate, estrogens, sulfonylureas, desiccated thyroid, megestrol, skeletal muscle relaxants, nonsteroidal anti-inflammatory drugs, and opioids.

There is also a table of alternatives to medications that can cause potentially harmful drug–disease interactions. There, for example, levodopa with carbidopa is listed as an alternative to benztropine and trihexyphenidyl for patients with Parkinson's disease.

Nonpharmacologic Options

Although these two tables only offer pharmacologic alternatives, except for psychotherapy, Dr Semla's team provides an appendix of resources for nonpharmacologic alternatives.

The updated Beers Criteria and the documents on use and alternatives will be useful to pharmacists trying to help health plans gain good ratings from CMS, said Zachary Marcum, PharmD, PhD, from the University of Washington in Seattle.

But pharmacists have to go beyond the Beers Criteria and make sure that the correct drug is prescribed for the diagnosis in the appropriate dose. "We need to avoid underuse, which is not addressed by the Beers Criteria," he said.

Pharmacists also have to be mindful of withdrawal effects and consider costs, he said. They must respond to requests from the patient, the patient's family, and nurses. And they have to cope with a lack of tested nonpharmacologic alternatives, prescriptions from multiple providers at multiple pharmacies, palliative care, and other special conditions.

The Beers Criteria are not going to solve everything.

"This is a huge task, and the Beers Criteria are not going to solve everything," Dr Marcum said.

To deal with these conflicting demands, pharmacists should start with the goals of a patient's care; coordinate with patients, caregivers, and the rest of the medical team to develop a treatment plan; and continue communication with these stakeholders to make sure the treatment plan is followed, he advised.

An audience member asked the panelists about nonpharmacologic alternatives. "You said that you didn't evaluate the evidence for nonpharmacologic approaches, but you did recommend them as first-lines," she said.

Dr Semla explained that he is aware of good evidence for some forms of psychotherapy, such as cognitive behavioral therapy, but the panel did not have the expertise to recommend others. "Will we bring together a panel to do that?" he said. "I don't know."

Dr Semla reports relationships with LexiComp, the Omnicare pharmacy and therapeutics committee, the American Geriatrics Society, the AARP Caregivers Advisory Panel, and AbbVie. Dr Marcum reports relationships with the National Institutes of Health and Purdue Pharma.

American College of Clinical Pharmacy (ACCP) 2015 Global Conference. Presented October 20, 2015.


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