In 1991, researchers led by Mark Beers at the University of California, Los Angeles, established the first explicit set of criteria for medications that, when used by geriatric nursing-home residents, would be of questionable appropriateness. Twice updated and independently validated, the Beers List has been documented to correlate with total health care costs, provider costs, facility costs, inpatient hospital days, outpatient visits, and emergency-department visits.22 The largest single risk factor for receiving a Beers List drug is polypharmacy, which is prominent when six or more medications are in-volved.
The Beers List identifies two categories of questionable drugs: (1) those that should be avoided by all elderly patients and (2) those that should be avoided by elderly patients with specific illnesses.
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Examples of medications to be avoided regardless of the patient’s condition are indomethacin, chlorpropamide, amitriptyline, and long-acting benzodiazepines. Examples of drugs to be avoided by geriatric patients with specific diagnoses include disopyramide for those with congestive heart failure, anticholinergics for those with cognitive impairments, metoclopramide for those with Parkinson’s disease, and bupropion for those with seizure disorders.
Elderly patients in the U.S. receive prescriptions for drugs on the Beers List in one of every 12 physician visits; that is, 16.7 million physician visits annually may include potential prescribing errors. Furthermore, in one recent study, elderly women were twice as likely as men to receive a Beers List drug, especially central nervous system agents and anal-gesics. This pattern was not explained by the influence of age or the number of prescription drugs in multivariate regression models. Women were more likely to have visits involving antidepressants, antianxiety agents, or sedative-hypnotics, but the proportion of visits with analgesic prescriptions were not significantly different for elderly women (18.9°%) and men (18.7°%) (P = .79). For visits in which a pain reliever was prescribed, the women received inappropriate pain medications more often than the men did (10.8% vs. 5.9%; P < .001).
CURRENT SOLUTIONS TO THE DILEMMA
A variety of systems currently address different aspects of the safety problems. Reason’s “Swiss Cheese Model of Defenses” suggests that multiple overlapping solutions are necessary and appropriate, given that no solution is perfect. canadian discount drugs
In many cases, pharmaceutical manufacturers first respond to newly identified postmarketing drug interactions by attempting to notify prescribers, anticipating that increased awareness will curtail prescribing for the dangerous combination. Physicians are typically adept at recalling and applying factual knowledge, but ever-increasing demands on their time and memory have contributed to the FDA’s recall or voluntary withdrawal of several medications.
As an example, the FDA withdrew cisapride (Propulsid®, Janssen), a popular prokinetic gastrointestinal motility agent, in July 2000 after more than 70 fatalities, primarily because of the drug’s association with torsades de pointes, which can lead to ventricular fibrillation and death. The problem typically occurred after cisapride was taken concurrently with another medication, a metabolic inhibitor, which was known to increase the risk of this reaction. Of the interacting medication pairs, 50% were prescribed by the same physicians, 89% were dispensed by the same pharmacies, and 17% were dispensed on the same day.
Before withdrawing cisapride from the market, the manufacturer, in concert with the FDA, made four label changes and issued a number of “Dear Doctor” letters. Although some prescribing physicians responded immediately, no sustained change in the prescribing pattern for cisapride was observed as a result of these interventions.