Medications to Avoid in the Elderly

The American Geriatrics Society (AGS) just released their 2012 update to their Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (65+ years old).

Quick summary: Medications to Avoid in the Elderly

Drug	Rationale	Recommend	Quality of Evidence	Str of Rec
Nitrofurantoin	Pulmonary tox Alternatives Lack of efficacy <60 mL/min	Avoid long term suppression; avoid if CrCl <60 mL/min	Moderate	Strong
Antipsychotics (conventional or atypical)	Increase CVA and CV mortality in dementia	Avoid unless danger to self/others and non pharm has failed	Moderate	Strong
Insulin, sliding scale	Hypoglycemia risk	Avoid	Moderate	Strong
Chlorpropamide Glyburide	Hypoglycemia risk	Avoid	High	Strong
Benzodiazepines (Short and long acting)	Risk cognitive effects and injury (fall/MVA); rare use appropriate eg benzo withdrawal	Avoid for treatment of insomnia, agitation, or delirium	High	Strong
Megestrol	Minimal effect on weight; risk of thrombotic events and death	Avoid	Moderate	Strong
Metoclopramide	EPS and TD	Avoid, unless gastroparesis	Moderate	Strong
Non-COX NSAIDs, oral	GI bleeding; Protection w/ PPIs or misoprostol	Avoid chronic use	Moderate	Strong
Non-BZD Hypnotics      (“z” drugs like ambient, soma, sonata)	Risk cognitive effects and injury (fall/MVA); same ADE as benzo’s	Avoid chronic use, >90 days	Moderate	Strong
Estrogens with or w/o progestin	Carcinogenic potential, lack of efficacy in dementia/CV dz prevention	Avoid oral and topical patch. Topical cream safe and effective for vaginal symptoms	High	Strong
Muscle Relaxants	Ineffective at tolerated doses, antichol, falls	Avoid	Moderate	Strong

Full List - Worth Reviewing

Acute Bacterial Sinusitis in Children

• The most common predisposing factors for acute bacterial sinusitis are:
• viral upper respiratory tract infection (URI)
• allergy
• Approximately 80% of episodes of acute bacterial sinusitis are preceded by a viral URI infection
• Children who attend day care are twice as likely to have sinusitis after a URI
• Diagnosis

• Treatment
• High-dose amoxicillin–clavulanate (90 mg/kg/d, divided bid) is first-line therapy for children
• in penicillin-resistant areas w/ resistance rates are of 10% or higher
• in day care
• > 2 years of age
• who have been hospitalized or treated with abx in the past month
• If the above risk factors are not present, standard-dose amoxicillin–clavulanate (40 mg/kg/d divided bid) is recommended
• Macrolides and TMP-SMX (bactrim) not recommended d/t high national rates of resistance
• Levofloxacin is recommended for children with h/o type I hypersensitivity reaction to PCN
• Recommended duration of therapy w/ amoxicillin–clavulanate or levofloxacin is 10-14 days in children

Reference: NEJM

AAP Says Benefits of Circumcision Outweigh Harms
A new policy statement from the AAP says the benefits of circumcision outweigh the harms

The benefits include:

• Lower risk for UTI before age 1 
• Reduced risk for STIs (e.g., HIV, HSV, HPV)
• Reduced risk for penile cancer 

The group says the procedures benefits justify access to those parents who desire it and warrants third-party payment for circumcision of male newborns.

The AAP did, however, stop short of recommending routine circumcision, saying that decision is best left to parents.  ACOG also endorses this policy statement.

Reference: AAP Policy Statement

New CDC recommendations about Hep C screening

One time hepatitis C screening for all patients born from 1945 to 1965

Guideline

• The Centers for Disease Control and Prevention recommends that all Americans born between 1945 and 1965 should have a one-time screening for hepatitis C virus (HCV), according to new finalized guidelines

• The CDC also recommends that all persons identified with HCV should receive a brief alcohol screening and intervention and be referred to the appropriate care and treatment services for HCV

Rationale

• About 2.7 to 3.9 million people in the U.S. are infected with HCV and approximately 45% to 85% of those with HCV are unaware that they are infected

• A CDC review found that hepatitis C mortality increased significantly from 1999 to 2007

• Nearly three quarters of these deaths occurred in baby boomers

• In addition, an NHANES study found a 3.25% prevalence in this age group

Reference: MMWR

CDC Updates Gonorrhea Treatment Guidelines

Bottom Line:

• The CDC no longer recommends cefixime (suprax) as a first-line treatment for gonorrhea 
• The only first line therapy now is ceftriaxone 250mg IM x1
• If ceftriaxone is unavailable, the updated guidelines allow use of cefixime (400 mg PO x1), but recommend a test-of-cure at 1 week.
  

The change was based on evidence that susceptibility to cefixime decreased among U.S. Neisseria gonorrhoeae isolates between 2006 and 2011.

In its 2010 treatment guidelines, the CDC recommended combination therapy with a cephalosporin (ceftriaxone or cefixime) plus oral azithromycin or doxycycline.

Reference: MMWR Article

Guidelines for Breast Cancer Screening

Reference:  http://www.nejm.org/doi/full/10.1056/NEJMcp1101540

Identify the Image

What's the diagnosis?

A 2-year-old girl was referred for an abnormal whitening (leukocoria) of the left pupil, as well as a divergent squint (Panel A). Her visual acuity was markedly impaired. Ophthalmologic examination revealed retinal detachment. Computed tomography showed left intraocular calcification (Panel B, arrow).

See comments for answer.

Statin Update

• Statin Induced Myopathy
• Myalgias are reported by 10 to 20% of patients who take statins
• The incidence of severe myotoxicity (CK > 10 times the upper limit of normal, associated with muscle symptoms leading to hospitalization) is estimated at 0.1 to 1.0%, or 0.4 to 1.1 per 10,000 patient-years.
• Risk factors for the development of a statin-associated myopathy:
• Concurrent medications
• e.g., fibrates and calcium-channel blockers
• Older age
• Hypothyroidism
• Hepatic dysfunction
• High BMI
• The risk of a statin-induced myopathy is dose-dependent
• The risk among patients who receive high-dose therapy is higher by a factor of 10 than the risk among patients who receive more moderate doses
• Simvastatin may be particularly notorious in this regard (high dose [greater than 40mg daily] = high risk of myopathy)
• Drugs that compete with the cytochrome P-450 system could augment statin myotoxicity
• Amlodipine, doxazosin, and finasteride all use this pathway and thus render patients vulnerable to the myotoxic effects of simvastatin
• Gemfibrozil poses an additional problem, since it may interfere with the hepatic uptake of simvastatin
• Concurrent therapy with statins and gemfibrozil has been associated with an increased risk of myopathy; in one study, the average incidence of rhabdomyolysis per 10,000 patient-years increased from 0.49 to 18.73

Reference: http://www.nejm.org/doi/full/10.1056/NEJMcpc1110052?query=BUL

• No More Routine Monitoring of LFTs for patients on Statins
• New FDA guidelines for statins released last week
• Recommendation for routine monitoring of LFTs in patients taking statins was removed.
• Labels now recommend that LFTs be checked before starting statin therapy and as clinically indicated thereafter.
• The FDA has concluded that serious liver injury with statins is rare and unpredictable in individual patients, and that routine periodic monitoring of liver enzymes does not appear to be effective in detecting or preventing serious liver injury.

Reference: http://www.fda.gov/Drugs/DrugSafety/ucm293101.htm

New Evidence About Osteoporosis Screening in Women - NEJM

Take home message from this study: Older women with BMD testing T scores greater than −1.50 have a low likelihood to develop osteoporosis and can defer retesting for 15 years, researchers concluded.

Women 65 and older are recommended to have bone mineral density (BMD) testing to screen for osteoporosis., but the evidence on appropriate intervals between testing is lacking.

This study followed 4957 women, 67 years of age or older, with normal BMD (T score at the femoral neck and total hip, −1.00 or higher) or osteopenia (T score, −1.01 to −2.49) and with no history of hip or clinical vertebral fracture or of treatment for osteoporosis, prospectively for up to 15 years.

The BMD testing interval was defined as the estimated time for 10% of women to make the transition to osteoporosis before having a hip or clinical vertebral fracture, with adjustment for estrogen use and clinical risk factors. Transitions from normal BMD and from three subgroups of osteopenia (mild, moderate, and advanced) were analyzed with the use of parametric cumulative incidence models.

The estimated BMD testing interval was 16.8 years (95% confidence interval [CI], 11.5 to 24.6) for women with normal BMD, 17.3 years (95% CI, 13.9 to 21.5) for women with mild osteopenia, 4.7 years (95% CI, 4.2 to 5.2) for women with moderate osteopenia, and 1.1 years (95% CI, 1.0 to 1.3) for women with advanced osteopenia.

Bottom line suggested by this study:
Osteoporosis would develop in less than 10% of older, postmenopausal women during rescreening intervals of approximately 15 years for women with normal bone density or mild osteopenia, 5 years for women with moderate osteopenia, and 1 year for women with advanced osteopenia.

Reference: http://www.nejm.org/doi/pdf/10.1056/NEJMoa1107142

ACOG Cervical Cancer Screening Guidelines

Under Age 21
- ACOG doesn't recommend pelvic examinations for girls < 21 unless they have been sexually active or have a medical complaint such as pelvic pain, vaginitis or irregular menstrual periods
- If a younger girl is sexually active, ACOG recommends a pelvic exam, Pap smear, and STD testing (including for chlamydia and gonorrhea) within three years following first intercourse

- All women between ages 19 and 64 who are sexually active should be tested for human immunodeficiency virus (HIV)

Age 21 to 30
- Pelvic examinations with Pap smears should begin at age 21 for women who have not been sexually active
- Thereafter, annual screening should continue up to age 30 (given higher risk for HPV in this group)
- Screen sexually active women 25 and under for chlamydia.  Urine based testing is adequate.

Over 30
- Screening can be cut back to every two or three years whenever a woman has three consecutive test results that were normal (provided she has no conditions that affect the immune system, was not exposed to the drug diethylstilbestrol (DES) while in utero (before birth), and has no other medical problems that require annual or semi-annual examinations)
- Routine physical pelvic exams should continue annually.

65 and Older
- Although routine pelvic exams should continue after age 65, under certain conditions, Pap smears can be discontinued at this point
- If three consecutive Pap smears are normal and there have been no abnormal results during the previous 10 years (with no history of cervical cancer, HIV or other conditions that affect the immune system, is at no risk of acquiring STDs, and was not exposed to DES) Pap smears can be eliminated from the annual exam

Exceptions
If a woman of any age has a complete hysterectomy for reasons other than cancer and has never had cervical cancer or abnormal Pap smears, Pap testing may be eliminated from routine pelvic exams, according to ACOG guidelines.