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Re: Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug-Disease Interactions in the Elderly Quality Measures
GERIATRICS
668
adults due to the increased risk of hyponatremia in this population and the availability of safer alternatives. All providers who care for geriatric patients should be familiar with the updated Beers Criteria and understand the implications for clinical practice. Tomas L. Griebling, MD, MPH
Suggested Reading AUA White Paper on the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Baltimore, Maryland: American Urological Association Education and Research, Inc. 2015. Available at https://www.auanet.org/common/pdf/education/clinical-guidance/beers-criteria.pdf. Accessed November 13, 2015.
Re: How to Use the American Geriatrics Society 2015 Beers CriteriadA Guide for Patients, Clinicians, Health Systems, and Payors M. A. Steinman, J. L. Beizer, C. E. DuBeau, R. D. Laird, N. E. Lundebjerg and P. Mulhausen Division of Geriatrics, University of California at San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California, College of Pharmacy and Health Sciences, St. John’s University, Queens and American Geriatrics Society, New York, New York, Departments of Medicine, Family Medicine and Community Health, and Obstetrics and Gynecology, University of Massachusetts Medical School, Worcester, Massachusetts, Florida Hospital, Winter Park, Florida, and Telligen, West Des Moines, Iowa J Am Geriatr Soc 2015; Epub ahead of print. doi: 10.1111/jgs.13701
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26446776 Editorial Comment: The Beers Criteria, an evidence-based list of medications to potentially avoid in geriatric patients to improve prescribing quality and outcomes, have recently been updated (see preceding comment). One of the major complaints about prior versions of the Beers Criteria was that they were often misinterpreted and misused, particularly by third party payers and pharmacy benefits groups, to alter decisions made by clinicians. This article serves as a companion piece to the 2015 Beers Criteria update, and provides recommendations and guidance on how the document is and is not intended to be used. The authors specifically highlight that the Beers Criteria should never supplant clinician judgment in relation to specific needs of individual patients, nor should they be used outside of their original intentions. Key principles include understanding that listed medications are potentially but not definitely inappropriate, depending on circumstance; reading and understanding the rationale for inclusion of specific medications on the lists and adjusting approach to use of those medications; offering safer nonpharmacological or pharmacological options when available; using the Beers Criteria as a starting point for improving medication use and safety; and understanding that recommendations are not equally applicable in all countries. Importantly the authors also identify that access to medications on the lists should not be excessively restricted due to prior authorization and/or health plan coverage policies simply because they are included in the document. Hopefully these recommendations will help facilitate appropriate use of the Beers Criteria in actual practice. Tomas L. Griebling, MD, MPH
Suggested Reading Averch TD, Stoffel J, Goldman HB et al: AUA white paper on catheter associated urinary tract infections: definitions and significance in the urological patient. Urol Pract 2015; 2: 321.
Re: Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug-Disease Interactions in the Elderly Quality Measures J. T. Hanlon, T. P. Semla and K. E. Schmader Division of Geriatrics, Department of Medicine and Department of Biomedical Informatics, School of Medicine, Department of Pharmacy and Therapeutics, School of Pharmacy, Department of Epidemiology, School of Public Health and Geriatric Pharmaceutical Outcomes, and Gero-Informatics Research and Training Program, Clinical and Translational Science Institute, University of Pittsburgh and Geriatric Research, Education and Clinical Center, and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, Department of Veterans Affairs, Pharmacy Benefits Management Services, Hines, and Departments of Medicine, and Psychiatry and Behavioral Science, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, and Division of Geriatrics, Department of Medicine, School of Medicine, Duke University Medical Center and Geriatric Research, Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
GERIATRICS
669
J Am Geriatr Soc 2015; Epub ahead of print. doi: 10.1111/jgs.13807
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26447889 Editorial Comment: One of the major criticisms of prior versions of the Beers Criteria is that although they identified medications to potentially avoid, they did not provide suggestions for safer options. This article, another companion piece to the 2015 Beers Criteria update, is designed to help outline possible alternatives to medications on the list, including alternative pharmacological agents and nonpharmacological options. This article will be useful to clinicians searching for high quality evidence of medication options for use in their geriatric patients. From a regulatory perspective this issue is particularly important because several groups, including the National Committee for Quality Assurance, Pharmacy Quality Alliance, and the Centers for Medicare and Medicaid Services, use these concepts in defining quality care measures of providers and health plans. Several alternative options are provided for medications that are commonly used in urological practice but should potentially be avoided in older adults. Included are recommendations for drugs that may be safer to use in patients with chronic renal failure (estimated glomerular filtration rate less than 30 ml per minute). Clinicians who treat geriatric patients should be familiar with the recommendations in the Beers Criteria and the recommended options outlined in this companion article. Tomas L. Griebling, MD, MPH
Re: Factors Influencing Deprescribing Habits among Geriatricians inı´n, C. Nı´ Chro inı´n and A. Beveridge D. Nı´ Chro Department of Geriatric Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia, and Mater Misericordiae University Hospital, Dublin, Ireland Age Ageing 2015; 44: 704e708. doi: 10.1093/ageing/afv028
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25758409 Editorial Comment: Polypharmacy is among the most common geriatric syndromes. Although older adults comprise about 13% of the total population in the United States, more than 37% of all prescription medications are used by this group. This finding reflects increased rates of underlying comorbidities in older adults, which require pharmacological therapy. However, to some degree it also reflects overprescribing and medication overuse in this group. A key element of high quality geriatric care is careful medication monitoring and elimination of unnecessary medications. Efforts to emphasize medication reconciliation have been promoted for inpatient and outpatient care. This study examines rates of medication deprescribing within the framework of evidence-based guidelines among a group of geriatricians. The authors identify estimated remaining life expectancy, cognitive impairment and overall pill burden as major criteria used when making decisions about stopping medications for older adult patients. Some clinician characteristics, including gender and length of time in practice, also influence deprescribing patterns. Clinicians need to be careful to avoid the “prescribing cascade,” where a new medication is administered to treat what is essentially an adverse effect of another medication. In those cases deprescribing or adjusting current drugs may be more appropriate than prescribing additional medications. This study did not specifically examine urological medications, but many drugs used in urology practice can have important implications for older adults. Urological providers should be aware of the goal to optimize medication use for their older patients and consider discontinuing or deprescribing drugs when clinically appropriate. Tomas L. Griebling, MD, MPH
668
adults due to the increased risk of hyponatremia in this population and the availability of safer alternatives. All providers who care for geriatric patients should be familiar with the updated Beers Criteria and understand the implications for clinical practice. Tomas L. Griebling, MD, MPH
Suggested Reading AUA White Paper on the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Baltimore, Maryland: American Urological Association Education and Research, Inc. 2015. Available at https://www.auanet.org/common/pdf/education/clinical-guidance/beers-criteria.pdf. Accessed November 13, 2015.
Re: How to Use the American Geriatrics Society 2015 Beers CriteriadA Guide for Patients, Clinicians, Health Systems, and Payors M. A. Steinman, J. L. Beizer, C. E. DuBeau, R. D. Laird, N. E. Lundebjerg and P. Mulhausen Division of Geriatrics, University of California at San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California, College of Pharmacy and Health Sciences, St. John’s University, Queens and American Geriatrics Society, New York, New York, Departments of Medicine, Family Medicine and Community Health, and Obstetrics and Gynecology, University of Massachusetts Medical School, Worcester, Massachusetts, Florida Hospital, Winter Park, Florida, and Telligen, West Des Moines, Iowa J Am Geriatr Soc 2015; Epub ahead of print. doi: 10.1111/jgs.13701
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26446776 Editorial Comment: The Beers Criteria, an evidence-based list of medications to potentially avoid in geriatric patients to improve prescribing quality and outcomes, have recently been updated (see preceding comment). One of the major complaints about prior versions of the Beers Criteria was that they were often misinterpreted and misused, particularly by third party payers and pharmacy benefits groups, to alter decisions made by clinicians. This article serves as a companion piece to the 2015 Beers Criteria update, and provides recommendations and guidance on how the document is and is not intended to be used. The authors specifically highlight that the Beers Criteria should never supplant clinician judgment in relation to specific needs of individual patients, nor should they be used outside of their original intentions. Key principles include understanding that listed medications are potentially but not definitely inappropriate, depending on circumstance; reading and understanding the rationale for inclusion of specific medications on the lists and adjusting approach to use of those medications; offering safer nonpharmacological or pharmacological options when available; using the Beers Criteria as a starting point for improving medication use and safety; and understanding that recommendations are not equally applicable in all countries. Importantly the authors also identify that access to medications on the lists should not be excessively restricted due to prior authorization and/or health plan coverage policies simply because they are included in the document. Hopefully these recommendations will help facilitate appropriate use of the Beers Criteria in actual practice. Tomas L. Griebling, MD, MPH
Suggested Reading Averch TD, Stoffel J, Goldman HB et al: AUA white paper on catheter associated urinary tract infections: definitions and significance in the urological patient. Urol Pract 2015; 2: 321.
Re: Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug-Disease Interactions in the Elderly Quality Measures J. T. Hanlon, T. P. Semla and K. E. Schmader Division of Geriatrics, Department of Medicine and Department of Biomedical Informatics, School of Medicine, Department of Pharmacy and Therapeutics, School of Pharmacy, Department of Epidemiology, School of Public Health and Geriatric Pharmaceutical Outcomes, and Gero-Informatics Research and Training Program, Clinical and Translational Science Institute, University of Pittsburgh and Geriatric Research, Education and Clinical Center, and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, Department of Veterans Affairs, Pharmacy Benefits Management Services, Hines, and Departments of Medicine, and Psychiatry and Behavioral Science, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, and Division of Geriatrics, Department of Medicine, School of Medicine, Duke University Medical Center and Geriatric Research, Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
GERIATRICS
669
J Am Geriatr Soc 2015; Epub ahead of print. doi: 10.1111/jgs.13807
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26447889 Editorial Comment: One of the major criticisms of prior versions of the Beers Criteria is that although they identified medications to potentially avoid, they did not provide suggestions for safer options. This article, another companion piece to the 2015 Beers Criteria update, is designed to help outline possible alternatives to medications on the list, including alternative pharmacological agents and nonpharmacological options. This article will be useful to clinicians searching for high quality evidence of medication options for use in their geriatric patients. From a regulatory perspective this issue is particularly important because several groups, including the National Committee for Quality Assurance, Pharmacy Quality Alliance, and the Centers for Medicare and Medicaid Services, use these concepts in defining quality care measures of providers and health plans. Several alternative options are provided for medications that are commonly used in urological practice but should potentially be avoided in older adults. Included are recommendations for drugs that may be safer to use in patients with chronic renal failure (estimated glomerular filtration rate less than 30 ml per minute). Clinicians who treat geriatric patients should be familiar with the recommendations in the Beers Criteria and the recommended options outlined in this companion article. Tomas L. Griebling, MD, MPH
Re: Factors Influencing Deprescribing Habits among Geriatricians inı´n, C. Nı´ Chro inı´n and A. Beveridge D. Nı´ Chro Department of Geriatric Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia, and Mater Misericordiae University Hospital, Dublin, Ireland Age Ageing 2015; 44: 704e708. doi: 10.1093/ageing/afv028
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25758409 Editorial Comment: Polypharmacy is among the most common geriatric syndromes. Although older adults comprise about 13% of the total population in the United States, more than 37% of all prescription medications are used by this group. This finding reflects increased rates of underlying comorbidities in older adults, which require pharmacological therapy. However, to some degree it also reflects overprescribing and medication overuse in this group. A key element of high quality geriatric care is careful medication monitoring and elimination of unnecessary medications. Efforts to emphasize medication reconciliation have been promoted for inpatient and outpatient care. This study examines rates of medication deprescribing within the framework of evidence-based guidelines among a group of geriatricians. The authors identify estimated remaining life expectancy, cognitive impairment and overall pill burden as major criteria used when making decisions about stopping medications for older adult patients. Some clinician characteristics, including gender and length of time in practice, also influence deprescribing patterns. Clinicians need to be careful to avoid the “prescribing cascade,” where a new medication is administered to treat what is essentially an adverse effect of another medication. In those cases deprescribing or adjusting current drugs may be more appropriate than prescribing additional medications. This study did not specifically examine urological medications, but many drugs used in urology practice can have important implications for older adults. Urological providers should be aware of the goal to optimize medication use for their older patients and consider discontinuing or deprescribing drugs when clinically appropriate. Tomas L. Griebling, MD, MPH