Beers Criteria Flashcards
antihistamines to avoid
1st generation:
benadryl
brompheniramine, chlorpheniramine
cyproheptadine
dimenhydrinate
doxylamine
hydroxyzine
promethazine
meclizine
antihistamine harms
dry mouth
constipation
falls, delirium, dementia
infective agents to avoid
nitrofurantoin -pulmonary toxicity, hepatotoxicity, peripheral neuropathy avoid in CrCl <30ml/min
bactrim - kidney damage, hyperK
avoid which blood thinners?
warfarin - DOAC’s are better
ASA - unless for 2nd prevention, don’t use
rivaroxaban - higher bleed risk than other DOACs
dipyridamole - orthostatic hypotension
avoid which HTN meds?
a1 blockers - doxazosin, terazosin, prazosin, clonidine, guanfacine
nifedipine IR - hypoTN
which heart meds to avoid?
amiodarone - avoid 1st line unless HF or LVH due to more ADR than other agents
dronedarone - avoid in permanent Afib or HF - worse ADR than others
digoxin - avoid >0.125mg/day - safer meds on the market
avoid which antidepressants?
amitriptyline, desipramine, doxepin >6mg/day, imipramine, nortriptyline, paroxetine
highly anticholinergic
which anti-parkinson’s to avoid?
benztropine and trihexyphenidyl
too many extrapyramidal symptoms
which anti-psychotics to avoid?
aripiprazole, haloperidol, olanzapine quetiapine, risperidone - increased risk of stroke, more cognitive decline and mortality than others
phenobarbital/primidone - physical dependence, greater risk of OD
benzos - avoid if possible
avoid which sleep drugs
benadryl - anticholinergic
lunesta/zolpidem/benzos - OD, delirium, falls, fractures
avoid which hormones?
testosterone and estrogen increased cardiac risk and hormonal cancers
megestrol - increased thrombotic events
growth
avoid which anti-diabetic agents?
insulin, sulfonylureas, SGLT2’s
avoid which GI meds?
PPIs - increased risk of cdiff, PNA, GI malignancy, bone loss and fx
metoclopramide - extrapyramidal, TD
atropine, clidinium/chlordizepoxide, dicyclomine, hyoscyamine, scopolamine - too anticholinergic
mineral oil PO - aspiration risks
avoid which pain meds?
regular NSAIDs, indomethacin, ketorolac- bleed risk
meperidine - neurotoxicity
muscle relaxers (flexeril, methocarbamol, carisoprodol) - anticholinergic ADR (baclofen and tizanidine best)
avoid which meds in HF
cilostazol, diltiazem, verapamil, dextromethorphan/quinindine, NSAIDs, pioglitazones
best antiplatelet med
clopidogrel
best muscle relaxer
tizanidine or baclofen
SSRI to avoid
paroxetine
slowed GI motility increases risk of ulceration by which meds?
NSAIDs
bisphosphonates
potassium chloride
decreased first pass metabolism increases [x] of which meds?
morphine
propranolol
Geriatric Depression Scale
0 - 5 is normal
>5 thorough psych evaluation
MMSE/SLUMS Scores
0 to 30 is the scoring
25+ is normal function
20 - 24 is mild dementia
13 - 19 is moderate dementia
<12 is severe dementia
causes of risk of falls
Vit D deficiency
poor balance, weakness
orthostatic hypotension
hypoglycemia, natremia
psychotic meds
Lewy Body dementia
avoid typical antipsychotics, may use cholinesterase inhibitors
how to treat frontotemporal dementia
trazodone or SSRI’s
donepezil
all levels of alzheimer’s disease
acetylcholinesterase inhibitors
5mg daily initially
rivastigmine
for alzheimer’s disease and parkinson’s disease
acetylcholinesterase inhibitor
1.5mg PO BID or 4.6mg patch at 1st
galantamine
mild Alzheimer’s
acetylcholinesterase and nicotine
4mg BID or 8mg ER daily
renal dose necessary, take with food
memantine
moderate to severe alzheimer’s
NMDA antagonist
can be used with acetylcholinesterase inhibitors
5mg daily up to 10mg BID or 7mg ER
donepezil/memantine
may go to once stable on memantine and donepezil separately
10/28mg HS
acetylcholinesterase and NMDA
cholinesterase inhibitor side effects
nausea, vomiting, diarrhea,
elevated risk of GI bleeding
HA, insomnia, dizziness
bradycardia, orthostatic hypotension, syncope
incontinence, anorexia, weight loss, falls, hip fx
tx for dementia in AD
mild - galantamine, donepezil, rivastigmine
moderate - galantamine/donepezil/rianvastigmine, memantine, or both
anti-amyloid monoclonal antibodies
mild dementia or mild cognitive impairment
q4w, very expensive
iron overload, microhemorrhages in brain, edema of brain
should get repeat MRI’s PRN
problems geriatrics cannot verbalize
constipation - scheduled bowel regimen
pain - scheduled tylenol
treat geriatrics for anxiety
buspirone
SSRI/SNRI
gabapentin
limit benzos
treat geriatrics for apathy
cholinesterase inhibitors (donepezil, galantamine, rivastigmine)
methylphenidate in small doses
treat geriatrics with depression
SSRI or mirtazapine
no on paroxetine
treat geriatrics with insomnia
melatonin
mirtazapine if depression also
treat geriatrics for paranoia, hallucinations, sundowning, agitation
risperidone, olanzapine, quetiapine, aripiprazole in low doses
quetiapine is preferred in Parkinsons
pimavanserin is only for parkinsons
how to treat geriatrics with aggression or resistance to care
valproic acid most common
experimental for prazosin, nuedexta, citalopram
causes for urinary incontinence
DRIP
drugs, delirium
retention, restricted mobility
impaction, infection, inflammation
polyuria, prostatitis
drugs that cause urinary incontinence
bethanechol
donepezil, rivastigmine, galantamine
prazosin
benadryl-like drugs, CCBs, opioids
diuretics and sedation drugs
antimuscarinic agents
oxybutynin, tolterodine, fesoterodine, trospium, solifenacin, darifenacin
BEERS list for anticholinergic activity
beta-3 agonists
mirabegron, vibegron
minimal anticholinergic effects
can be used with antimuscarinics
do not use if HTN
alpha adrenergic antagonists for urinary incontinence
alfuzosin, tamsulosin, silodosin, doxazosin, terazosin, prazosin
tamsulosin is preferred in geriatrics
caution if cataract surgery soon, floppy iris syndrome
5a reductase inhibitors
finasteride, dutasteride
reduce the size of the prostate and alter PSA values, slows progression
reserve for prostate >40g as not immediately helpful, takes 6 months
long term use increases prostate cx risk
PDE5 inhibitors
tadalafil 5mg PO Daily for BPH
usually monotherapy
pelvic volume residual
measure of urine left in bladder after voiding, if > 50ml then it’s positive, increased risk of infection
urinary retention and prostate cancer risk
start dutasteride or finasteride
5-alpha reductase inhibitor
alpha 1 adrenergic blockers that reduce BP significantly
doxazosin or terazosin
what age do you prefer topical NSAIDs vs oral?
75 year or older
1st line in RA
DMARDs
methotrexate***, hydroxychloroquine (least side effects)
sulfasalazine (slow onset, DOC in pregnancy)
leflunomide
2nd line in RA
combo DMARDs or biologics…
etanercept, infliximab, abatacept or rituximab most common
If you have ________ you should avoid TNF inhibitors
HF
makes you immune compromised as well
TNF inhibitor list (5)
etanercept (Enbrel) - SQ
infliximab (Remicade) - IV
adalimumab (Humira) - SQ
certolizumab (Cimzia) - SQ
golimumab (Simponi) - SC
Non-TNF inhibitors for RA
abatacept (Orencia)
anakinra (kineret)
rituximab (rituxan)
sarilumab (Kevazara)
tocilizumab (Actemra)
gout is diagnosed with urate level of _____
> 6.8 mg/dl
hours within onset to use colchicine
within 26 hours of attack onset
cochicine gout dosing in attack
1.2mg PO immediately, then 0.6mg one hour later
continue 0.6mg BID until flare subsides
can be fatal if used with pgp inhibitors or CYP3A4 inhibitors
tx for acute gout
colchicine, steroids, NSAIDs
NSAIDs FDA approved for gout
naproxen, indomethacin, sulindac
when to do continuous gout prophylaxis
tophi on imaging study or visual
2 or more attacks in a year
damage caused by gout on bones
1st and 2nd line for gout px
allopurinol 100-300mg daily
febuxostat if intolerant or allopurinol doesn’t work
lesinurad
add on to allopurinol or febuxostat if urate levels not at goal
may increase CV events
probenecid
later line agent for gout
kidney stone, CrCl <50, not a great agent for gout
pegloticase
discontinue all other gout therapies and start here if last line
8mg IV q2w
premedicate with benadryl and steroids
allopurinol skin reaction risks
SJS/TEN
HCTZ, black or asian, HLA-B 5801, highest risk during first few months
