CHAMP Drugs and Aging Paula M. Podrazik, MD Paula M. Podrazik, MD University of Chicago University of Chicago

CHAMPCHAMPDrugs and AgingDrugs and Aging

Paula M. Podrazik, MDPaula M. Podrazik, MD

University of ChicagoUniversity of Chicago

CHAMP: Drugs and AgingCHAMP: Drugs and AgingSession ObjectivesSession Objectives

• Content-based objectivesContent-based objectivesReview key topics in Aging PharmacoRxReview key topics in Aging PharmacoRx

• Factors that add to Factors that add to risk of ADRs/ADEs risk of ADRs/ADEs– polypharmacypolypharmacy– aspects of aging pharmacologyaspects of aging pharmacology– high risk/low benefit drugshigh risk/low benefit drugs

• Medication reviewMedication review

• Teaching method-based objectivesTeaching method-based objectives• Trigger to teach Trigger to teach MARMAR• Use of the CHAMP acronym to teachUse of the CHAMP acronym to teach• Use of audit toolsUse of audit tools

CHAMP: Drugs and AgingCHAMP: Drugs and AgingOverview Overview

• Prevalence of drug use in the elderlyPrevalence of drug use in the elderly• Risk factors for ADRsRisk factors for ADRs• Drugs & the inpatient settingDrugs & the inpatient setting

– Etiology of admission complaintEtiology of admission complaint– ADRs/ ADEs while in-hospitalADRs/ ADEs while in-hospital– Discharge medsDischarge meds

• Link to geriatric syndromes, e.g.,delirium, Link to geriatric syndromes, e.g.,delirium, falls, UIfalls, UI

• Med Review--guidelines, no simple Med Review--guidelines, no simple algorhythmalgorhythm

CHAMP: Drugs and AgingCHAMP: Drugs and AgingADEs, Research and AgingADEs, Research and Aging

• Elderly excluded from investigational trials• small sample sizes Phase III trials• exclusion criteria=vulnerable elder•“in vivo” no look at drugs in combo

• Under-reporting of drug safety problems Schmucker DL, et al:J Clin Pharmacol 1999;39:1103-8 Avorn J: Br Med J 1997;315:1033-1034

CHAMP: Drugs and AgingCHAMP: Drugs and AgingADR/ADE--definedADR/ADE--defined

• Adverse Drug Reaction (ADR)Adverse Drug Reaction (ADR)any undesirable or noxious drug effect at any undesirable or noxious drug effect at

standard drug treatment dosesstandard drug treatment doses WHO;1996 Technical Report Series No. 425WHO;1996 Technical Report Series No. 425

• Adverse Drug Event (ADE)Adverse Drug Event (ADE)ADRs + errors in drug administrationADRs + errors in drug administration

CHAMP: Drugs and AgingCHAMP: Drugs and AgingADRs/ADEsADRs/ADEs

ADRs

Amplified drug effects

Drug-nutrient interaction

Drug-drug interaction

Drug-disease interaction

Side-effects

*not therapeutic failures*not ADWEs

CHAMP: Drugs and AgingCHAMP: Drugs and AgingADR Risk FactorsADR Risk Factors

Carbonin P, et al JAGS 1991;39:1093-1099

CHAMP: Drugs and AgingCHAMP: Drugs and AgingADR Risk FactorsADR Risk Factors

? prior ADRs

high risk drugs

# of drugs

# medical problems

? aging pharm

? fragmented care

AdverseDrug

Reaction

CHAMP: Drugs and AgingCHAMP: Drugs and AgingADEs and HospitalizationADEs and Hospitalization

Recent inhospital studies look at ADEsRecent inhospital studies look at ADEs How big a problem?How big a problem?

• 4th-6th leading cause of hospital death 4th-6th leading cause of hospital death (serious ADRs 6.2%, fatal ADRs 0.32%)(serious ADRs 6.2%, fatal ADRs 0.32%)

• Increased length of stayIncreased length of stay• Increased costIncreased cost

Lazarou J, et al JAMA 1998; 280(20):1741-44Lazarou J, et al JAMA 1998; 280(20):1741-44 Classen D, et al JAMA 1997; 277(4): 301-6Classen D, et al JAMA 1997; 277(4): 301-6

CHAMP: Drugs and AgingCHAMP: Drugs and AgingADEs and Hospital CostADEs and Hospital Cost

Preventable error?Preventable error?Preventable cost?Preventable cost?

• 4031 adult admissions to 700-bed Harvard 4031 adult admissions to 700-bed Harvard teaching hospitalsteaching hospitals

• Look at ADEs & preventable ADEsLook at ADEs & preventable ADEs• ~$ 5.6 million/year for all ADE~$ 5.6 million/year for all ADE• ~$ 2.8 million/year in preventable ADEs~$ 2.8 million/year in preventable ADEs

Bates DW, et al JAMA 1997;277: 307-311Bates DW, et al JAMA 1997;277: 307-311

CHAMP: Drugs and AgingCHAMP: Drugs and AgingHospital ADEs--Preventable ErrorHospital ADEs--Preventable Error

247 ADEs, 70 deemed preventable247 ADEs, 70 deemed preventable PresentationPresentation

CNS complicationsCNS complications• 21% preventable ADEs--delirium most common21% preventable ADEs--delirium most common

• Cardiovascular complicationsCardiovascular complications• 19% of preventable ADEs--hypotension most common19% of preventable ADEs--hypotension most common

Culprit drugsCulprit drugs Combined analgesics, sedatives and Combined analgesics, sedatives and

antipsychotics antipsychotics 46% of preventable ADEs 46% of preventable ADEs

Bates DW, et al JAMA 1997;277:307-311Bates DW, et al JAMA 1997;277:307-311

CHAMP: Drugs and AgingCHAMP: Drugs and AgingTeaching & ToolsTeaching & Tools

What to teach? How to teach?What to teach? How to teach?−Teach on a topic--polypharmacy, aspects of Teach on a topic--polypharmacy, aspects of

aging pharmacology, high risk/low benefit aging pharmacology, high risk/low benefit drugsdrugs

−Teach about a drug--high risk/low benefit Teach about a drug--high risk/low benefit drug or class of drugsdrug or class of drugs

−Teach medication reviewTeach medication review−Use MAR as teaching triggerUse MAR as teaching trigger−Use of auditsUse of audits

CHAMP: Drugs and AgingCHAMP: Drugs and AgingMAR as the Teaching MAR as the Teaching TriggerTrigger

An acronym for teaching that An acronym for teaching that captures the factors that put the captures the factors that put the elderly at risk for ADRs and more...elderly at risk for ADRs and more...• C--Cost, complianceC--Cost, compliance• H--Hazardous interactionsH--Hazardous interactions• A--Aging pharmacologyA--Aging pharmacology• M--Medications to avoidM--Medications to avoid• P--PolypharmacyP--Polypharmacy

CHAMP: Drugs and AgingCHAMP: Drugs and AgingCase #1Case #1

• • 85 y/o with h/o DM, CHF, lumbar spinal stenosis admitted with increasing 85 y/o with h/o DM, CHF, lumbar spinal stenosis admitted with increasing confusion and falls. Lives alone, daughter involved. Daughter notes patient confusion and falls. Lives alone, daughter involved. Daughter notes patient h/o anxiety but c/o insomnia and phoning her continuously throughout the h/o anxiety but c/o insomnia and phoning her continuously throughout the night for the past 3 nights.night for the past 3 nights.

• • Brought to U of C ER by daughter after a witnessed fall. New patient to Brought to U of C ER by daughter after a witnessed fall. New patient to the U of C system. Admitted at 3AM to telemetry. the U of C system. Admitted at 3AM to telemetry.

• • On exam, alternately agitated and somnolent, oriented to person only.On exam, alternately agitated and somnolent, oriented to person only. VS: T99, P54, RR20, BP110/50 lying supine wt. 100lbs. 5’1”VS: T99, P54, RR20, BP110/50 lying supine wt. 100lbs. 5’1” Cor: RRR, +SCor: RRR, +S33 Lungs: dry crackles in basesLungs: dry crackles in bases Abd: soft, nontender, nondistended, firm stool felt throughout colonAbd: soft, nontender, nondistended, firm stool felt throughout colon

• • ER data:CT head neg., dirty urine, CXR with ER data:CT head neg., dirty urine, CXR with cor, KUB FOS, BUN 48/CR cor, KUB FOS, BUN 48/CR 2.7, glc= 74, K2.7, glc= 74, K++ hemolyzed at 6.3 F/U pending,INR=3.0, EKG SB-rate 58, no hemolyzed at 6.3 F/U pending,INR=3.0, EKG SB-rate 58, no peaked t waves. Given dose IV antibiotics in ER.peaked t waves. Given dose IV antibiotics in ER.

CHAMP: Drugs and AgingCHAMP: Drugs and AgingMed List on AdmissionMed List on Admission

Medication list Medication list • Lisinopril 40 mg qAMLisinopril 40 mg qAM• Digoxin 0.25 mg qAMDigoxin 0.25 mg qAM• Lasix 40 mg po qAMLasix 40 mg po qAM• Aldactone 25 mg po qAMAldactone 25 mg po qAM• Glucotrol XL 10 mg BIDGlucotrol XL 10 mg BID• Amitryptiline 25mg qHSAmitryptiline 25mg qHS• Amiodarone 200 mg BIDAmiodarone 200 mg BID• Coumadin 5 mg qHSCoumadin 5 mg qHS• Paxil 10 mg qHSPaxil 10 mg qHS• Ativan 1 mg BID prn Ativan 1 mg BID prn

anxietyanxiety

PrnsPrns• Lomotil prn diarrheaLomotil prn diarrhea• Unisom prn sleepUnisom prn sleep• Tylenol #3 prn LBPTylenol #3 prn LBP


• C--Cost, ComplianceC--Cost, Compliance• H--Hazardous InteractionsH--Hazardous Interactions• A--Aging PharmacologyA--Aging Pharmacology• M--Medications to AvoidM--Medications to Avoid

• P--PolypharmacyP--Polypharmacy

CHAMP: Drugs and AgingCHAMP: Drugs and AgingPolypharmacyPolypharmacy

Hazzard, Principles of Geriatric Medicine and Gerontology

CHAMP: Drugs and AgingCHAMP: Drugs and AgingPolypharmacy SummaryPolypharmacy Summary

PolypharmacyPolypharmacy• Administration of more drugs than Administration of more drugs than

clinically indicated clinically indicated • Risk of ADR greatly Risk of ADR greatly on >5 meds on >5 meds• ~50 % of elderly take one or more ~50 % of elderly take one or more

unnecessary medsunnecessary meds• at hospital D/C, elderly take greatest # at hospital D/C, elderly take greatest #

medsmeds

Schmader K, et al JAGS 1994;42:1241-47Schmader K, et al JAGS 1994;42:1241-47 Lipton HL, et al Med Care 1992;30:646-58Lipton HL, et al Med Care 1992;30:646-58

risk geri syndromes

CHAMP: Drugs and AgingCHAMP: Drugs and AgingCost of Polypharmacy?Cost of Polypharmacy?

Polypharmacy

health care costs

risk inappropriate Rx

risk drug interactions

functional status


• C--Cost, ComplianceC--Cost, Compliance• H--Hazardous InteractionsH--Hazardous Interactions• A--Aging PharmacologyA--Aging Pharmacology

• M--Medications to AvoidM--Medications to Avoid• P--PolypharmacyP--Polypharmacy

CHAMP: Drugs and AgingCHAMP: Drugs and AgingDrugs to AvoidDrugs to Avoid

• High risk/low benefit drugsHigh risk/low benefit drugs– meds/classes of meds that meds/classes of meds that should should

generally be avoidedgenerally be avoided in > 65 in > 65• ineffectiveineffective• high risk w/safer alternative availablehigh risk w/safer alternative available

– meds to avoid due to meds to avoid due to specific medical conditionspecific medical condition

• Consensus expert panelConsensus expert panel Fick DM Arch Intern Med 2003;163:2716-2724Fick DM Arch Intern Med 2003;163:2716-2724 Beers MH Arch Intern Med 1997;157:1531-1536Beers MH Arch Intern Med 1997;157:1531-1536



anxietyanxiety


CHAMP: Drugs and AgingCHAMP: Drugs and AgingAmiodarone use MAR #1Amiodarone use MAR #1

• On Beers avoid listOn Beers avoid list• IndicationsIndications• DosingDosing• Side-effectsSide-effects• Other treatment optionsOther treatment options


• C--Cost, ComplianceC--Cost, Compliance• H--Hazardous InteractionsH--Hazardous Interactions• A--Aging PharmacologyA--Aging Pharmacology• M--Medications to AvoidM--Medications to Avoid• P--PolypharmacyP--Polypharmacy

CHAMP: Drugs and AgingCHAMP: Drugs and AgingDrug PharmacologyDrug Pharmacology

PharmacokineticsPharmacokinetics– drug absorption, distribution, transformation, drug absorption, distribution, transformation,

eliminationelimination

PharmacodynamicsPharmacodynamics– intensity of the drug response at its receptor intensity of the drug response at its receptor

sitesite

CHAMP: Drugs and AgingCHAMP: Drugs and AgingDrug Distribution with Drug Distribution with AgingAging

body fat to age 60-70body fat to age 60-70 antipsychotics, antipsychotics, TCAsTCAs

in lean body mass and fat after 70in lean body mass and fat after 70 digoxin conc.digoxin conc. protein-binding can effect Vd protein-binding can effect Vd no sign. no sign. in total protein binding in total protein binding

CHAMP: Drugs and AgingCHAMP: Drugs and AgingHepatic BiotransformationHepatic Biotransformation

• Age- related declineAge- related decline– Reduction in liver blood flowReduction in liver blood flow– Reduction in hepatic oxidation: CYP450Reduction in hepatic oxidation: CYP450

• No age-related changesNo age-related changes– Hepatic acetylationHepatic acetylation– Hepatic conjugationHepatic conjugation

CHAMP: Drugs and AgingCHAMP: Drugs and AgingCytochrome P450 SystemsCytochrome P450 Systems

• CYP3ACYP3A– Metabolizes >60% of prescribed drugs Metabolizes >60% of prescribed drugs

including: Calcium channel blockers, certain including: Calcium channel blockers, certain beta-blockers, most “statins”, warfarin, beta-blockers, most “statins”, warfarin, amiodaroneamiodarone

• CYP2D6CYP2D6– Metabolizes: metoprolol, propranolol, tramadol, Metabolizes: metoprolol, propranolol, tramadol,

codeine,oxycodone,TCAs, SSRIscodeine,oxycodone,TCAs, SSRIs

CHAMP: Drugs and AgingCHAMP: Drugs and AgingCytochrome P450 InhibitorsCytochrome P450 Inhibitors

• CYP3A InhibitorsCYP3A Inhibitors– Amiodarone, cimetadine, cyclosporin, Amiodarone, cimetadine, cyclosporin,

erythromycin, erythromycin, itra-/ketoconazole,grapefruit juiceitra-/ketoconazole,grapefruit juice

• CYP2D6 InhibitorsCYP2D6 Inhibitors– Cimetidine, SSRIs, quinidineCimetidine, SSRIs, quinidine

CHAMP: Drugs and AgingCHAMP: Drugs and AgingRenal Clearance and AgingRenal Clearance and Aging

• ~ age 40~ age 40, renal func. declines 1% per year, renal func. declines 1% per year• Normal serum Cr Normal serum Cr normal GFR normal GFR• Estimate using Cockcroft-Gault equationEstimate using Cockcroft-Gault equation

Creatinine clearance =Creatinine clearance =

((140-age) * Wt (kg) 140-age) * Wt (kg) ( ( 0.85 in women) 0.85 in women)

72 * serum Cr72 * serum Cr

• Modified MDRDModified MDRDGFR estimate=GFR estimate= 186x(Cr)186x(Cr)-1.154-1.154x (Age)x (Age)-0.203-0.203x (0.742, if female) x (1.21, if x (0.742, if female) x (1.21, if

African American)African American)

CHAMP: Drugs and AgingCHAMP: Drugs and AgingAging PharmacodynamicsAging Pharmacodynamics

With aging:With aging:• Beta-adrenergic responsiveness Beta-adrenergic responsiveness • Anticholinergic drugs Anticholinergic drugs CNS effects CNS effects• Baroreceptor reflex bluntedBaroreceptor reflex blunted


Vestal RE,et al. Clin Pharmacol Ther 1979; 79:181-186


Vestal RE,et al. Clin Pharmacol Ther 1979; 79:181-186


With aging:With aging:• Beta-adrenergic responsiveness Beta-adrenergic responsiveness • Anticholinergic drugs Anticholinergic drugs CNS CNS

effectseffects• Baroreceptor reflex bluntedBaroreceptor reflex blunted


With aging:With aging:• Beta-adrenergic responsiveness Beta-adrenergic responsiveness • Anticholinergic drugs Anticholinergic drugs CNS effects CNS effects• Baroreceptor reflex bluntedBaroreceptor reflex blunted

CHAMP: Drugs and AgingCHAMP: Drugs and AgingMAR as the Teaching TriggerMAR as the Teaching Trigger


CHAMP: Drugs and AgingCHAMP: Drugs and AgingInteractions to BewareInteractions to Beware

Doucet J, et al JAGS 1996;44:944-948

CHAMP: Drugs and AgingCHAMP: Drugs and AgingInteractions to BewareInteractions to Beware

Drug-Disease Interactions to AvoidDrug-Disease Interactions to Avoid

dementia+ benzodiazepines or anticholinergicsdementia+ benzodiazepines or anticholinergics

bladder outlet obstruction+ anticholinergics, TCAs, bladder outlet obstruction+ anticholinergics, TCAs, antispasmodics, antihistaminesantispasmodics, antihistamines

CRF, CHF, PUD + NSAIDSCRF, CHF, PUD + NSAIDS

constipation + anticholinergics, TCAs, calcium channel blockersconstipation + anticholinergics, TCAs, calcium channel blockers

falls +TCAs, benzodiazepinesfalls +TCAs, benzodiazepines

Fick DM Arch Intern Med 2003;163:2716-2724Fick DM Arch Intern Med 2003;163:2716-2724 Beers MH Arch Intern Med 1997;157:1531-1536Beers MH Arch Intern Med 1997;157:1531-1536



anxietyanxiety


CHAMP: Drugs and AgingCHAMP: Drugs and AgingMAR#1—Hospital Day #3MAR#1—Hospital Day #3

Labs returned with Digoxin level 2.4, K+5.6, repeat EKG with SB and PR 0.24, no acute Labs returned with Digoxin level 2.4, K+5.6, repeat EKG with SB and PR 0.24, no acute changes.First hospital day, po meds held. Given one dose IV lasix. Monitored BP, Exam, changes.First hospital day, po meds held. Given one dose IV lasix. Monitored BP, Exam, BS. Disimpacted.Urine C/S positive, rest cultures negative. By third hospital morning, BS. Disimpacted.Urine C/S positive, rest cultures negative. By third hospital morning, awake, conversant, oriented to person, place. Eating breakfast with daughter’s helpawake, conversant, oriented to person, place. Eating breakfast with daughter’s help ..

Acetaminophen 1-2 tabs po q 8 hours prn poAcetaminophen 500 mg tab

Sliding Insulin—see belowCS qid, Call for glucose <60, >350

Ativan 0.5 mg q 8 hours prn agitationLorazepam 0.5 mg tab

Furosemide 40 mg q AM poFurosemide 40 mg tab

Lisinopril 20mg qAM poLisinopril 20 mg tab

Ciprofloxacin 500mg BID poCiprofloxacin 500mg tab

CHAMP: Drugs and AgingCHAMP: Drugs and AgingMAR#1—Hospital Day#4MAR#1—Hospital Day#4

Outside cards contacted,MMSE 17/30, GDS 1. Digoxin 1.4, K+ 4.5, Outside cards contacted,MMSE 17/30, GDS 1. Digoxin 1.4, K+ 4.5, BUN/CR 40/2.1, INR 2.5, glc 168BUN/CR 40/2.1, INR 2.5, glc 168

Acetaminophen 2 tabs po q 8 hoursAcetaminophen

Digoxin 0.125 mg po q M,W,Fri AM poDigoxin 0.125 mg po

Amiodarone 200 mg qAM poAmiodarone 200 mg tab

Coumadin 3 mg qhs poCoumadin 1mg tab

Glipizide ER 10 mg q AM poGlucotrol XL 10 mg tab

Ciprofloxacin 500mg BID poCiprofloxacin 500mg tab

Furosemide 40mg qAM poFurosemide 40 mg tab

Lisinopril 20mg qAM poLisinopril 20mg tab



CHAMP: Drugs and AgingCHAMP: Drugs and AgingCostCost

• Important to ask: “How do you pay for Important to ask: “How do you pay for your medications?”your medications?”

• Federal poverty level: $9310 for Federal poverty level: $9310 for individual, $12,490 for coupleindividual, $12,490 for couple

• Potential sources of aid: Medicare, Potential sources of aid: Medicare, Medicaid, Circuit Breaker, SeniorCare, Rx Medicaid, Circuit Breaker, SeniorCare, Rx buying club, manufacturer-sponsored buying club, manufacturer-sponsored programsprograms

CHAMP: Drugs and AgingCHAMP: Drugs and AgingCost/Month of Top DrugsCost/Month of Top Drugs

Forbes.com, September 2004

Walgreens.com, September 2004

Lipitor 20 mgLipitor 20 mg $107.99$107.99

Zocor 40 mg Zocor 40 mg $124.99$124.99

Zyprexa 5 mg Zyprexa 5 mg $203.99$203.99

Norvasc 10 mgNorvasc 10 mg $63.99$63.99

Prevacid 30 mg Prevacid 30 mg $125.99$125.99

Nexium 20 mg Nexium 20 mg $138.99$138.99

Plavix 75 mgPlavix 75 mg $121.49$121.49

Advair 250/50Advair 250/50 $155.99$155.99

Zoloft 50 mgZoloft 50 mg $80.99$80.99

CHAMP: Drugs and AgingCHAMP: Drugs and AgingCost/Month of Top DrugsCost/Month of Top Drugs

Lipitor 20 mgLipitor 20 mg $107.99$107.99 Lovastatin 20 Lovastatin 20 mg mg

$36.99$36.99

Zocor 40 mg Zocor 40 mg $124.99$124.99 CrestorCrestor $85.99$85.99

Zyprexa 5 Zyprexa 5 mg mg

$203.99$203.99 RisperdalRisperdal $89.99$89.99

Norvasc 10 Norvasc 10 mgmg

$63.99$63.99 Sular 20 mgSular 20 mg $55.99$55.99

Prevacid 30 Prevacid 30 mg mg

$125.99$125.99 Omeprazole 10 Omeprazole 10 mgmg

$96.99$96.99

Nexium 20 Nexium 20 mg mg

$138.99$138.99

Plavix 75 mgPlavix 75 mg $121.49$121.49 Aspirin 325 mgAspirin 325 mg $10.00$10.00

Advair Advair 250/50250/50

$155.99$155.99 SereventSerevent

FloventFlovent$88.99$88.99

$133.9$133.999

Zoloft 50 mgZoloft 50 mg $80.99$80.99 FluoxetineFluoxetine $33.99$33.99

CHAMP: Drugs and AgingCHAMP: Drugs and AgingComplianceCompliance

• Compliance Adherence ConcordanceCompliance Adherence Concordance• Rates of 25 to 59% in the elderlyRates of 25 to 59% in the elderly• Factors associated with non-adherenceFactors associated with non-adherence

– Physical impairmentPhysical impairment– Psychosocial risksPsychosocial risks– Medication related factorsMedication related factors

• Higher risk of re-hospitalization Higher risk of re-hospitalization • Risk of noncompliance after dischargeRisk of noncompliance after discharge

Ryan AA. Int’l J Nursing Studies 1999; 36: 153-62.

Van Eijken M, et al. Drugs & Aging 2003; 20: 229-40.

CHAMP: Drugs and AgingCHAMP: Drugs and Aging Medication Review Medication Review

• Evaluating appropriateness of Evaluating appropriateness of prescribingprescribing

• Criteria for appropriatenessCriteria for appropriateness– ExplicitExplicit– ImplicitImplicit

• Use of the criteria in different Use of the criteria in different settingssettings

CHAMP: Drugs and AgingCHAMP: Drugs and AgingRX Appropriateness --RX Appropriateness --defineddefined

• Weighing drug risk /benefitWeighing drug risk /benefit• Achieving desired treatment Achieving desired treatment

outcomesoutcomes• Cost effectivenessCost effectiveness• Drug prescribing based on standards Drug prescribing based on standards

of careof care

Buetow SA, et al. Soc Sci Med 1997; 45(2): 261-271.

CHAMP: Drugs and AgingCHAMP: Drugs and AgingMed Review: Explicit/ImplicitMed Review: Explicit/Implicit

• Explicit criteriaExplicit criteria– Judgment about drug appropriateness already Judgment about drug appropriateness already

performed by consensus panelperformed by consensus panel– Results in list of drugs to avoidResults in list of drugs to avoid

• Implicit criteriaImplicit criteria– Though criteria stated and arrived at by expert Though criteria stated and arrived at by expert

panel, judgment of appropriateness is panel, judgment of appropriateness is individualindividual

– Results in list of tests drug must pass to be Results in list of tests drug must pass to be appropriateappropriate

CHAMP: Drugs and AgingCHAMP: Drugs and AgingExplicit Criteria --BeersExplicit Criteria --Beers

• List of medications to avoid in elderly List of medications to avoid in elderly nursing home patients nursing home patients

• Developed by consensus panel in Developed by consensus panel in 19911991

• Updated in 1997 and 2002Updated in 1997 and 2002

Beers, et al. Arch Intern Med 1991; 151: 1825-1832.

Beers MH. Arch Intern Med 1997; 157(14): 1531-1536.

Fick DM, et al. Arch Int Med 2003; 163: 2716-24.

CHAMP: Drugs and AgingCHAMP: Drugs and AgingBeers Criteria--Application Beers Criteria--Application

• Inappropriate prescribing is prevalent Inappropriate prescribing is prevalent in many settingsin many settings

• Number of medications is a risk Number of medications is a risk factor for inappropriatenessfactor for inappropriateness

• Links between inappropriate meds Links between inappropriate meds and clinical outcomesand clinical outcomes

CHAMP: Drugs and AgingCHAMP: Drugs and AgingLimitations of Explicit Limitations of Explicit CriteriaCriteria

• Clinical relevanceClinical relevance– Many medications outdated or not used Many medications outdated or not used – Requires update by consensus panel Requires update by consensus panel

• Validity of dataValidity of data– Criteria developed from nursing home Criteria developed from nursing home

datadata– Applied in many unvalidated settingsApplied in many unvalidated settings

• Room for clinical judgement?Room for clinical judgement?

Buetow SA, et al. Soc Sci Med 1997; 45(2): 261-271.

CHAMP: Drugs and AgingCHAMP: Drugs and AgingImplicit Criteria -- MAIImplicit Criteria -- MAI

• Medication Appropriateness Index Medication Appropriateness Index (MAI)(MAI)– Developed by an expert panel in 1994Developed by an expert panel in 1994– IDs individual elements of prescribing IDs individual elements of prescribing

that may be inappropriatethat may be inappropriate– Summated score based on the severity Summated score based on the severity

of individual elementsof individual elements

Hanlon JT et al. J Clin Epidemiol 1992; 45(10): 1045-1051.

Samsa GP et al. J Clin Epidemiol 1994; 47(8): 891-896.

CHAMP: Drugs and AgingCHAMP: Drugs and AgingMAIMAI

• Is there an indication for the drug?Is there an indication for the drug?• Is the medication effective for the conditionIs the medication effective for the condition• Is the dosage correct?Is the dosage correct?• Are the directions correct?Are the directions correct?• Are the directions practical?Are the directions practical?• Are there clinically significant drug-drug interactions?Are there clinically significant drug-drug interactions?• Are the clinically significant drug-disease/condition Are the clinically significant drug-disease/condition

interactions?interactions?• Is there unnecessary duplication with other drugs?Is there unnecessary duplication with other drugs?• Is the duration of therapy acceptable?Is the duration of therapy acceptable?• Is this drug the least expensive alternative compared Is this drug the least expensive alternative compared

to others of equal utility?to others of equal utility?

Hanlon JT, et al J Clin Epidemiology 1992;45:1045-51Hanlon JT, et al J Clin Epidemiology 1992;45:1045-51

CHAMP: Drugs and AgingCHAMP: Drugs and AgingMAI - ApplicationMAI - Application

• Prevalence of inappropriate Prevalence of inappropriate prescribingprescribing

• Lack of studies linking MAI to clinical Lack of studies linking MAI to clinical outcomes outcomes – Outpatient VA studyOutpatient VA study– Inpatient frail studyInpatient frail study

Schmader K et al. Ann Pharmacother 1997; 31(5): 529-33.

Schmader K et al. JAGS 1994 Dec; 42(12): 1241-1247.

CHAMP: Drugs and AgingCHAMP: Drugs and AgingLimitations of Implicit Limitations of Implicit CriteriaCriteria

• Time consumingTime consuming• MAI validated for use by pharmacistsMAI validated for use by pharmacists• Lack of studies linking MAI scores to Lack of studies linking MAI scores to

clinical outcomesclinical outcomes• ReliabilityReliability


Teaching medication review:Teaching medication review:• MAI--cumbersome as a MAI--cumbersome as a teaching toolteaching tool for for

medication review medication review • Beers--high risk/low benefit drugs only Beers--high risk/low benefit drugs only

one factor for good Rxone factor for good Rx• Use of the CHAMP acronym to teach Use of the CHAMP acronym to teach

topics that most impact better drug topics that most impact better drug choices in the aging patientchoices in the aging patient

CHAMP: Drugs and AgingCHAMP: Drugs and AgingMed Review Guidelines in Aging Inpt.Med Review Guidelines in Aging Inpt.

• >5-6 meds >5-6 meds anticipate 50% risk of ADRanticipate 50% risk of ADR• Weigh use of high-risk/low-benefit Weigh use of high-risk/low-benefit

drugsdrugsanticipate ADRsanticipate ADRs• Weigh use of CNS active RX , esp. in comboWeigh use of CNS active RX , esp. in combo• Consider dose, clearance, drug interaction, Consider dose, clearance, drug interaction,

baroreceptor reflex blunting when CV drugs baroreceptor reflex blunting when CV drugs added in comboadded in combo

• Delirium, falls, incontinence Delirium, falls, incontinence drugs in DDx drugs in DDx• Med review @ admission and D/C to avoid Med review @ admission and D/C to avoid

polypharmacy (e.g., PPI)polypharmacy (e.g., PPI)


Round Robin MAR Session


• C--Cost, complianceC--Cost, compliance• H--Hazardous interactionsH--Hazardous interactions• A--Aging pharmacologyA--Aging pharmacology• M--Medications to avoidM--Medications to avoid• P--PolypharmacyP--Polypharmacy

CHAMP: Drugs and AgingCHAMP: Drugs and AgingRound Robin MAR #1Round Robin MAR #1

Metoprolol BID POMetoprolol BID PO

Metoprolol 50 mg tab Metoprolol 50 mg tab

Enalapril mesylate BID POEnalapril mesylate BID PO

Vasotec 10 mg tabVasotec 10 mg tab

Furosemide BID *8AM 1PMFurosemide BID *8AM 1PM

Lasix 20 mg tabLasix 20 mg tab

Verapimil sust rel BID POVerapimil sust rel BID PO

Verapimil SR 120 mg capVerapimil SR 120 mg cap

Warfarin sodium QHS POWarfarin sodium QHS PO

Coumadin 5 mg tabCoumadin 5 mg tab

Potassium chloride BID POPotassium chloride BID PO

Klor Con 10 mEq tabKlor Con 10 mEq tab

Aspirin QD POAspirin QD PO

Ecotrin 325 mg tabEcotrin 325 mg tab

Isosorbide mononitrate BID PO *8AM 3PMIsosorbide mononitrate BID PO *8AM 3PM

ISMO 20 mg tabISMO 20 mg tab

85 year old man with CAD, CHF, HTN, atrial fib, admitted for chest pain. During his hospital stay, he becomes hypotensive, and INR is 5.




Amlodipine besylate DAILY POAmlodipine besylate DAILY PO

Norvasc 10 mg tabNorvasc 10 mg tab

Heparin sodium BID SCHeparin sodium BID SC

Heparin sodium 5,000 / 0.5 mL syrHeparin sodium 5,000 / 0.5 mL syr

Chlorpropamide BID POChlorpropamide BID PO

Diabenese 250 tabDiabenese 250 tab

Furosemide 120 mg Furosemide 120 mg

Dextrose 5% in water freq: BID 50 mLDextrose 5% in water freq: BID 50 mL

Ciprofloxacin HCl BID POCiprofloxacin HCl BID PO

Cipro 500 mg tabCipro 500 mg tab

Lansoprazole QAM POLansoprazole QAM PO

Prevacid 30 mg capPrevacid 30 mg cap

Spironolactone qam poSpironolactone qam po

Aldactone 25 mg tabAldactone 25 mg tab

76 yr old woman with end-stage liver disease, renal insufficiency, hepatocellular Ca, admitted with increased ascites.



Round Robin MAR #3:Round Robin MAR #3: 5 yr old woman with CAD, HTN, DM, admitted for COPD exacerbation.Theophylline BID POTheophylline BID PO

Theo-Dur 300 mg SR tabTheo-Dur 300 mg SR tab

Azithromycin DAILY POAzithromycin DAILY PO

Zithromax 250 MG tabZithromax 250 MG tab

Aspirin chewable dailyAspirin chewable daily

Bayer 81 MG tabBayer 81 MG tab

Hydrochlorothiazide DAILY POHydrochlorothiazide DAILY PO

Oretic 25 mg tabOretic 25 mg tab

Lisinopril DAILY POLisinopril DAILY PO

Prinivil 10 mg tabPrinivil 10 mg tab

Atorvastatin DAILY POAtorvastatin DAILY PO

Lipitor 20 mg tabLipitor 20 mg tab

Metoclopramide HCl QID POMetoclopramide HCl QID PO

Reglan 10 mg tabReglan 10 mg tab

Metformin BID POMetformin BID PO

Glucophage 500 MG tabGlucophage 500 MG tab

Estazolam QHS POEstazolam QHS PO

Prosom 1 mg tabProsom 1 mg tab

Prednisone DAILY POPrednisone DAILY PO

Deltasone 20 mg tabDeltasone 20 mg tab

Albuterol nebulizing soln Q6H INHAAlbuterol nebulizing soln Q6H INHA

Ipratropium nebulizing soln Q6H INHAIpratropium nebulizing soln Q6H INHA




Exelon BID POExelon BID PO

Exelon 6 mg tabExelon 6 mg tab

Triamterene/HCTZ DAILY POTriamterene/HCTZ DAILY PO

Dyazide 37.5/25 mg cap Dyazide 37.5/25 mg cap

Seroquel DAILY POSeroquel DAILY PO

Seroquel 25 mg capSeroquel 25 mg cap

Levothyroxine DAILY POLevothyroxine DAILY PO

Synthroid 50 mcg tabSynthroid 50 mcg tab

Trazodone QHS POTrazodone QHS PO

Desyrel 50 mg tabDesyrel 50 mg tab

Alprazolam QHS POAlprazolam QHS PO

Xanax 0.25 mg tabXanax 0.25 mg tab

Colchicine DAILY POColchicine DAILY PO

Colchicine 0.6 mg tabColchicine 0.6 mg tab

90 yr old man with advanced Alzheimer’s dementia, dysphagia, CRI with baseline Cr 3.0, agitation, psychosis, and gout, admitted with N/V and refusing po, with increased BUN/Cr on admit




Levothyroxine sodium QD POLevothyroxine sodium QD PO

Synthroid 25 mcg tabSynthroid 25 mcg tab

Metoprolol QD POMetoprolol QD PO

Toprol XL 25 mg tabToprol XL 25 mg tab

Fludrocortisone QD POFludrocortisone QD PO

Florinef 0.1 mg tabFlorinef 0.1 mg tab

Atorvastatin QD POAtorvastatin QD PO

Lipitor 20 mg tabLipitor 20 mg tab

Aspirin QD POAspirin QD PO

Ecotrin 325 mg tabEcotrin 325 mg tab

Celecoxib QD POCelecoxib QD PO

Celebrex 200 mg capCelebrex 200 mg cap

87 year old woman with CHF, CAD, CRI, dementia, hypothyroidism, and weight loss, admitted with hyperkalemia; after work up and treatment, medication changes are made prior to d/c.




Levetiracetam Q12 H POLevetiracetam Q12 H PO

Keppra 500 MG tabKeppra 500 MG tab

Escitalopram QD POEscitalopram QD PO

Lexapro 10 mg tabLexapro 10 mg tab

Cotrimoxazole DS Q12H POCotrimoxazole DS Q12H PO

Bactrim DS tabBactrim DS tab


Heparin Sodium 5,000 / 0.5 mL syrHeparin Sodium 5,000 / 0.5 mL syr

Primidone QAM PO 400 MG = 8 tabPrimidone QAM PO 400 MG = 8 tab

Mysoline 50 MG tabMysoline 50 MG tab

Topiramate BID POTopiramate BID PO

Topamax 100 MG tabTopamax 100 MG tab

Carbamazepine XR BID POCarbamazepine XR BID PO

Tegretol XR 400 MG XR tabTegretol XR 400 MG XR tab

Lorazepam TID POLorazepam TID PO

Ativan 0.5 MG tabAtivan 0.5 MG tab

Primidone QHS PO 200 MG = 4 tabPrimidone QHS PO 200 MG = 4 tab

Mysoline 50 MG tabMysoline 50 MG tab

69 year old woman with h/o CVA and seizure disorder, recent UTI with antibiotic treatment, admitted with increased seizures.




Mupirocin !qwH TOPMupirocin !qwH TOP

Bactroban 2% 22 GMBactroban 2% 22 GM

Vancomycin HCL 1 GMVancomycin HCL 1 GM

Freq: Q 12 H Freq: Q 12 H

Famotidine Q12H POFamotidine Q12H PO

Pepcid 20 mg tabPepcid 20 mg tab


Heparin Sodium 5,000 / 0.5 mL syrHeparin Sodium 5,000 / 0.5 mL syr

Rofecoxib QD PORofecoxib QD PO

Vioxx 25 MG tabVioxx 25 MG tab

Promethazine HCL Q6H PRN INJPromethazine HCL Q6H PRN INJ

Phenergan 25 MG/ML 1 MlPhenergan 25 MG/ML 1 Ml

Diphenhydramine HCL QHS PRN insomnia PODiphenhydramine HCL QHS PRN insomnia PO

Benadryl 25 MG capBenadryl 25 MG cap

Acetaminophen/Oxycodone Q4-6H PRN POAcetaminophen/Oxycodone Q4-6H PRN PO

Percocet tab Dose = 1-2 tabsPercocet tab Dose = 1-2 tabs

Morphine sulfate PRN Q4-6H IVMorphine sulfate PRN Q4-6H IV

Morphine INJ Dose = 2-4 mgMorphine INJ Dose = 2-4 mg

75 yr old woman with h/o breast CA and OA admitted for cellulitis after a burn injury on her foot.

CHAMP: Drugs and AgingCHAMP: Drugs and AgingOther teaching toolsOther teaching tools

• Case Chart AuditCase Chart Audit• Census Chart AuditCensus Chart Audit

CHAMP: Census AuditCHAMP: Census AuditSampleSample

• Choose a medication to avoid in Choose a medication to avoid in the elderly: the elderly: BenadrylBenadryl

• Audit the use of Benadryl by Audit the use of Benadryl by reviewing the MAR reviewing the MAR

• Teach about drugs to avoid, Teach about drugs to avoid, focusing on Benadryl and focusing on Benadryl and anticholinergic effects anticholinergic effects

• Audit Benadryl use after teaching Audit Benadryl use after teaching • Feedback in statistical termsFeedback in statistical terms

Census Audit: Census Audit: Drugs to Avoid in Aging Drugs to Avoid in Aging PatientsPatients

• Drug for review: List drug_______Drug for review: List drug_______• Drug ordered: List # of Y,N ___Y, ___NDrug ordered: List # of Y,N ___Y, ___N• Summary:Summary:

– Proportion of patients _(drug)_ ordered ___%Proportion of patients _(drug)_ ordered ___%• Patient Safety Issues/Systems Issues ThemesPatient Safety Issues/Systems Issues Themes

– Consider drug-drug interaction/ drug-disease Consider drug-drug interaction/ drug-disease interaction risk, issues of aging pharmacologyinteraction risk, issues of aging pharmacology

– Safer Alternative/s? List:Safer Alternative/s? List:• Plan for changePlan for change• Plan for reevaluationPlan for reevaluation

CHAMP: Drugs and AgingCHAMP: Drugs and AgingSummarySummary

• Teaching about drugs and aging in the Teaching about drugs and aging in the hospitalized elderly important:hospitalized elderly important:– ADRs are common, costly & many preventable.ADRs are common, costly & many preventable.– Elderly at risk for ADRs due to # of meds, multiple Elderly at risk for ADRs due to # of meds, multiple

comorbid conditions & age-related changes.comorbid conditions & age-related changes.

• Admit drug list/MAR clinical trigger for teachingAdmit drug list/MAR clinical trigger for teaching• Teaching Tools:Teaching Tools:

– CHAMP teaching toolCHAMP teaching tool– Teach on topic—polypharmacy, meds to avoid, aging Teach on topic—polypharmacy, meds to avoid, aging

pharmacology, hazardous interactions, cost/compliancepharmacology, hazardous interactions, cost/compliance– Teach about a drug—CV, CNS active drugsTeach about a drug—CV, CNS active drugs– Audit toolsAudit tools

CHAMP: Drugs and AgingCHAMP: Drugs and AgingGoals for Course ModuleGoals for Course Module

• End year #1End year #1As the As the teachingteaching attending: attending:

• teach medication review from the MARsteach medication review from the MARs• teach about polypharmacy, aging pharmacology, teach about polypharmacy, aging pharmacology,

better drug choices in the aging hospitalized patientbetter drug choices in the aging hospitalized patient• use CHAMP acronym as aid to teachinguse CHAMP acronym as aid to teaching• use audits as teaching tooluse audits as teaching tool

As the As the practicing practicing attending:attending:• reduce #s of unnecessary drugsreduce #s of unnecessary drugs• choose drug/class from high risk/low benefit drug choose drug/class from high risk/low benefit drug

group to target for review, e.g., demerol, group to target for review, e.g., demerol, anticholinergic drugsanticholinergic drugs

CHAMP: Drugs and AgingCHAMP: Drugs and AgingBibliographyBibliography

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Documents

CHAMP Drugs and Aging Paula M. Podrazik, MD Paula M. Podrazik, MD University of Chicago University of Chicago