What's the Best Brew for Grandma?
2012 Beers List Update
Hospitalist Best Practice
J Rush Pierce Jr, MD, MPH
June 20, 2012
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
Agenda
• Background of Beers list (rationale, history,
methodology of update)
• Focused review of update
• Usefulness and limitations
• Relevance to hospital medicine/resources
What the Beers list is not
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
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?
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?
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
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
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
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)
Anticholinergics
Source: JAGS 2012;60:616
Antibiotics
Source: JAGS 2012;60:616
Cardiovascular drugs
Source: JAGS 2012;60:616
Cardiovasc drugs (contd)
Source: JAGS 2012;60:616
Psych drugs
Source: JAGS 2012;60:616
Psych drugs (contd)
Source: JAGS 2012;60:616
Endocrine drugs
Source: JAGS 2012;60:616
Pain
Source: JAGS 2012;60:616
Drug – disease/synd interactions
Source: JAGS 2012;60:616
Source: JAGS 2012;60:616
Source: JAGS 2012;60:616
Source: JAGS 2012;60:616
Drugs to use with caution
Source: JAGS 2012;60:616
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
Beers criteria and hosp studies
• Onder et al (Eur J Clin Pharmacol 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 Clin Pharm 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
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
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
Source: Arch Intern Med 2011;171:1013
Source: Arch Intern Med 2011;171:1013
Source: Arch Intern Med 2011;171:1013
Source:http://www.bgs.org.uk/powerpoint/aut10/Mahony_inappropriate_prescribing.pdf
Source:http://www.bgs.org.uk/powerpoint/aut10/Mahony_inappropriate_prescribing.pdf
Source:http://www.bgs.org.uk/powerpoint/aut10/Mahony_inappropriate_prescribing.pdf
http://www.americangeriatrics.org/files/documents/annual_meeting/2012/handouts/friday/Joseph_Hanlon.pdf
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?
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?
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