Categories Questionable Drug In The Elderly

Some categories of products (eg. As analgesics, anticoagulants, antihypertensives, anti-Parkinson drugs, diuretics, blutzuckersnekende drugs, psychotropic drugs) pose particular risks for elderly patients. Some drugs which, although put to good use in younger adults, are so risky that they should be considered for the elderly as inappropriate. The Beers criteria are used most often to identify such inappropriate medication (s. Potentially inappropriate drug in the elderly (after American Geriatrics Society 2012 Beers Criteria Update)). share the 2012 update of the American Geriatrics Society Beers criteria potentially inappropriate medications in three groups: Potentially always avoid unreasonable: Inappropriate to prevent certain diseases or syndromes with caution apply: The benefits can compensate for the risk in some patients ( see table: Potentially inappropriate drug in the elderly unreasonable (for American Geriatrics Society 2012 Beers Criteria update)) Potentially drug (in the elderly by American Geriatrics Society 2012 Beers Criteria update) drug prescribing basic / recommendations anticholinergics * First generation antihistamines as a single agent or as a combination of active ingredient (brompheniramine, carbinoxamine, chlorpheniramine, clemastine, cyproheptadine, dexbrompheniramine, dexchlorpheniramine, diphenhydramine [oral], doxylamine, hydroxyzine, promethazine, triprolidine) Stark anticholinergic; greater risk of confusion, dry mouth, constipation and other anticholinergic effects and toxicity with advanced age, clearance decreases; when used as hypnotics to tolerance Avoid developed, but use of diphenhydramine in certain situations (such as severe allergic reaction.) may be suitable anti-Parkinson’s drugs (benztropine [oral], trihexyphenidyl) Not recommended for the prevention of extrapyramidal symptoms with antipsychotics; more effective means of treatment of Parkinson’s disease are available antispasmodics (belladonna alkaloids, Clidinium-chlordiazepoxide, dicyclomine, hyoscyamine, propantheline, scopolamine) Strongly anticholinergic, unsecured effectiveness Avoid except as short-term use in palliative care to reduce oral secretions anti-infectives nitrofurantoin may cause pulmonary toxicity; safer alternatives are available; lack of efficacy in patients with creatinine clearance <60 ml / min due to insufficient drug concentration in the urine; Do not use for long-term suppression or in patients with creatinine clearance <60 ml / min dipyridamole anticoagulants, oral short-effectively † (not applicable to Retardkombination with aspirin) Possible orthostatic hypotension; effective alternatives are available; avoid, but an intravenous administration in cardiac stress testing is acceptable ticlopidine † Safer effective alternatives are available; Cardiovascular drugs avoid alpha 1-blockers (doxazosin, prazosin, terazosin) High risk of orthostatic hypotension; alternative medicines have a better risk-benefit ratio; avoid use as an antihypertensive alpha agonists, central (clonidine, guanabenz †, † guanfacine, methyldopa †, reserpine [> 0.1 mg / day] †) High risk of unwanted CNS effects; can cause bradycardia and postural hypotension; Avoid clonidine Erstlinienhypertensivum; other not recommended antiarrhythmics, class Ia, Ic and III (amiodarone, dofetilide, dronedarone, flecainide, ibutilide, procainamide, propafenone, quinidine, sotalol) frequency control is preferably the rhythm control; avoid the first-line treatment of atrial fibrillation in amiodarone increased risk for thyroid disease, lung disease and QT interval prolongation disopyramide † Potent negative inotropic (cardiac failure can induce); strong anticholinergic; avoid other antiarrhythmic agents are preferred dronedarone have deteriorated condition in patients with atrial fibrillation or heart failure andauerndem; avoid frequency control is the rhythm control preferably atrial fibrillation digoxin (> 0.125 mg / day) in patients with heart failure low creatinine clearance and / or higher doses without added value and with an increased risk of toxicity; Avoid nifedipine immediate release † risk of hypotension and myocardial ischemia; avoid spironolactone (> 25 mg / day) in patients with heart failure, risk of hyperkalemia in particular with the additional intake of NSAIDs, ACE inhibitors, angiotensin receptor blockers or potassium supplements; avoided in heart failure or creatinine clearance <30 ml / min CNS Tertiary TCAs, alone or in combination (amitriptyline, chlordiazepoxide amitriptyline, clomipramine, doxepin [> 6 mg / day], imipramine, perphenazine amitriptyline, trimipramine) Strongly anticholinergic and sedative, causing orthostatic hypotension; Avoid antipsychotics, the first (conventional) and second (atypical) generation Increased risk of stroke and mortality in patients with dementia Avoid in patients with dementia-related behavior problems, except for the ineffective non-pharmacological options and in patients for themselves and others a threat represent thioridazine mesoridazine strong anticholinergic; Risk for QT interval prolongation; avoid barbiturates (amobarbital †, † butabarbital, butalbital, mephobarbital †, † pentobarbital, phenobarbital, secobarbital †) High physical dependence and tolerance; Risk of overdose at low dosages; avoid benzodiazepines, short and intermediate-acting (alprazolam, estazolam, lorazepam, oxazepam, temazepam, triazolam) benzodiazepines, long-acting (clorazepate, chlordiazepoxide, chlordiazepoxide amitriptyline, Clidinium-chlordiazepoxide, clonazepam, diazepam, flurazepam, quazepam) Increased risk of cognitive impairment , delirium, falls, fractures and car accidents can be appropriate for a seizure disorder, REM sleep disorders, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, periprocedural anesthesia, end-of-life care use in insomnia, restlessness or delirium avoid chloral hydrate † Can only up to 3 times the recommended dose are overdosed; Tolerance occurs within 10 days; Risks outweigh benefits, meprobamate avoid high rate of physical dependence; strong sedative; avoid Nonbenzodiazepin-hypnotics (eszopiclone, Zolpidem, zaleplon) Similar to benzodiazepines (. eg Delirium, falls, fractures); minimal improvement in sleep latency and duration not use> 90 days Ergot mesylate † † isoxsuprine lack of efficacy; avoid hormonal therapy androgens (methyltestosterone †, testosterone) Potential heart problems; Exacerbation of prostate cancer avoid, except for moderate to severe hypogonadism thyroid dry extract Possible cardiac effects; safer alternatives are available; avoid estrogens with or without progestins Possible carcinogenic potential (breast and endometrial); lack of cardioprotective effect and cognitive protection in older women Topical vaginal cream low dose can be applied to dyspareunia, lower urinary tract infections and other vaginal symptoms; there is evidence that low doses can be sure with breast cancer (estradiol <25 micrograms twice / week) in women Topical Plaster and avoid oral growth hormones Low effect on body composition; associated with edema, arthralgia, carpal tunnel syndrome, gynecomastia, impaired glucose tolerance avoid, except for hormone replacement therapy after Hypophysenentfernung insulin sliding scale higher risk of hypoglycemia with no improvement in glycemic control, independently of the medical settings; avoid megestrol Minimal impact on weight; increases the risk of thrombotic events and possibly the risk of death; avoid sulfonylureas, long duration (chlorpropamide, glibenclamide), chlorpropamide: prolonged half-life; can cause prolonged hypoglycemia, syndrome of inappropriate antidiuretic hormone secretion; avoid glyburide: higher risk of severe prolonged hypoglycemia; avoid Gastrointestinal Therapy Can metoclopramide extrapyramidal effects, including tardive dyskinesia cause. Risk may be greater in frail elderly; avoid except for gastroparesis mineral oil, orally potential for aspiration; safer alternatives are available; avoid trimethobenzamide One of the least effective antiemetics; may cause extrapyramidal side effects; avoid pain meperidine (Editor's note: not approved in Germany!) No effective oral analgesic doses in common; can cause neurotoxicity; safer alternatives are available; avoid non-COX-selective NSAIDs, oral (aspirin [> 325 mg / day], diclofenac, diflunisal, etodolac, fenoprofen, ibuprofen, ketoprofen, meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin) Increased risk of gastrointestinal bleeding and stomach ulcers in high-risk groups, including those aged> 75 years or under use of oral or parenteral corticosteroids, anticoagulants or antiplatelet agents Upper gastrointestinal ulcers, severe bleeding or perforation occur in about 1% of patients for 3-6 months were treated, and about 2-4% of the patients who were treated for 1 year, to; This trend continues with prolonged use continued avoidance of regular use, unless other alternatives ineffective and patients are able to take a proton pump inhibitor or misoprostol (which reduces the risk, but not eliminate) indomethacin ketorolac, incl. parenterally Increases Risk of gastrointestinal bleeding and stomach ulcers in high-risk groups (see above non-COX-selective NSAIDs) of all the NSAIDs, indomethacin has the most adverse effects; avoid pentazocine † Adverse CNS effects, including confusion and hallucinations, more often than other opioids; is also a combined agonist and antagonist; safer alternatives are available; avoid skeletal muscle relaxants (Carisoprodol Chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine) Because of the anticholinergic effects poorly tolerated; sedation; Risk of fractures; Efficacy at doses that are tolerated by the elderly is questionable; * Avoid TCAs are not included. † These medicines are used irregularly TZA = Tricyclic antidepressants Adapted from The American Geriatrics Society 2012 Beers Criteria Update Expert Panel: American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society 60: (after American Geriatrics Society 2012 Beers Criteria Update) use 616-631, 2012. drugs that are used with caution in the elderly drug reason for caution aspirin for primary prevention of cardiac events with caution in patients ? 80 years Absence of proof in terms of benefits vs. Risk in patients> 80 years dabigatran with caution in patients ? 75 years with creatinine clearance <30 ml / min using larger risk of bleeding than warfarin in patients ? 75 years Absence of proof in terms of efficacy and safety in patients with creatinine clearance <30 ml / min prasugrel with caution in patients ? 75 years use increased risk of bleeding; Use may increase the risk in elderly people with the highest risk compensate (eg. As in patients with a history of myocardial infarction or diabetes mellitus) antipsychotics carbamazepine carboplatin cisplatin mirtazapine Selective serotonin-norepinephrine reuptake inhibitor SSRI Tricyclic antidepressants vincristine can aggravate syndrome of inappropriate antidiuretic hormone secretion, or hyponatremia or cause closely monitored when initiating or changing the dose levels of sodium. increase vasodilators Can occurrence of syncope in patients with a history of syncope Adapted from The American Geriatrics Society 2012 Beers Criteria Update Expert Panel: American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society 60: 616-631, 2012. Analgesics NSAIDs are occupied by> 30% of patients aged 65 to 89 years, half of all NSAID prescriptions issued for> 60-year-old. Several NSAIDs are available over the counter. The elderly may be more susceptible to adverse effects of these drugs, and these effects may be more difficult for the following reasons: NSAIDs are highly lipid soluble, and as the fat tissue increases with age, the distribution of the active ingredients is extensive. The plasma protein often goes back, resulting in higher levels of unbound drug and exaggerated pharmacological effects. Renal function is reduced in many older people, which leads to decreased renal clearance and higher exposure levels. Serious adverse effects include peptic ulcers and bleeding in the upper gastrointestinal tract. If the dose of an already scheduled NSAIDs is increased, this risk is even higher. The risk of bleeding in the upper gastrointestinal tract increases when NSAIDs are given with warfarin, aspirin or other antiplatelet agents (eg. As clopidogrel). NSAIDs may increase the risk of cardiovascular events, cause fluid retention and, rarely, a nephropathy. NSAIDs may also act blood pressure-increasing; This effect may not be detected and lead to an intensification of antihypertensive treatment (Verschreibungskaskade- interactions between drugs and diseases). Therefore, doctors should keep this effect in mind when blood pressure increases in elderly patients and ask them for taking particular-counter NSAIDs. Selective COX-2 (Cylooxygenase-2) inhibitors (COXIBs) cause less gastrointestinal irritation and a lower Thrombozytenaggreagtionshemmung than other NSAIDs. Nevertheless involve coxibs still a risk of gastrointestinal bleeding, especially for patients taking warfarin or aspirin (even at low doses), and for patients with already had taken place gastrointestinal bleeding. The class of coxibs appears to increase the risk of cardiovascular events, but this can vary depending on the drug; Coxibs should be used with caution. Coxibs have renal effects that are comparable to those of other NSAIDs. It should be used if possible lower risk alternatives (eg. As paracetamol). If NSAIDs are used in elderly patients, the lowest effective dose should be used and the more need to be checked often. With long-term use of NSAIDs serum creatinine and blood pressure should be closely monitored, particularly in patients with other risk factors (eg. As heart failure, kidney damage, cirrhosis with ascites, fluid removal, use of diuretics). Anticoagulants With age, the sensitivity may increase compared to the anticoagulant effect of warfarin. Cautious dosing and routine monitoring to the increased risk of bleeding in elderly patients taking warfarin, largely limit. It is also therefore a stronger monitoring is required because interactions with warfarin often occur when new drugs on or be discontinued old; computer-assisted programs to drug interactions should be consulted when patients are taking multiple medications. Patients should also be monitored for Warfarinwechselwirkungen with food components, alcohol and non-prescription drugs and dietary supplements. The newer anticoagulants (dabigatran, rivaroxaban, apixaban) may be easier to dose, and they have fewer drug interactions and food-drug interactions than warfarin, but increase still the risk of bleeding in the elderly, especially those with impaired renal function. Antidepressants Tricyclic antidepressants are effective but should be used only rarely in the elderly. SSRI and combined reuptake inhibitors, such as serotonin-norepinephrine reuptake inhibitor (SNRI), are as effective as tricyclic antidepressants and cause less toxicity; However, there are regarding some of these drugs concerns. paroxetine: This ingredient is more sedating than other SSRIs, has anticholinergic effects and may, like some other SSRIs inhibit the hepatic cytochrome P-450-2D6 enzyme activity, possibly numerous metabolism drugs, incl. tamoxifen, some antipsychotics, antiarrhythmics, and tricyclic antidepressants interfere. Citalopram doses should be limited because of possible QT prolongation to a maximum of 20 mg / day in the elderly. Venlafaxine This medicine can increase blood pressure. Mirtazapine: This medicine may be sedating and stimulate appetite / weight gain. Antidiabetic agents in patients with diabetes mellitus, the Antidiabetikadosen should be carefully titrated. The risk of hypoglycemia by sulfonylurea may increase with age. As described below, see Table: Potentially inappropriate drug in the elderly (after American Geriatrics Society 2012 Beers Criteria Update), chlorpropamide is not recommended in the elderly because of increased risk of hypoglycemia and hyponatremia due to the syndrome of inappropriate antidiuretic hormone secretion (SIADH). The risk of hypoglycemia is also greater with glyburide as with other oral antidiabetic agents, since the renal clearance is reduced in the elderly. Metformin, a biguanide, which is excreted through the kidneys, increases the sensitivity of peripheral tissues to insulin may be used alone or in combination with sulfonylurea be effective. The risk of lactic acidosis, a rare but serious complication increases with the degree of renal impairment and the patient’s age. Heart failure is a contraindication. Antihypertensives Many elderly patients may be necessary to reduce the risk of adverse reactions lower initial doses of antihypertensive drugs; but are necessary for most elderly patients with hypertension to achieve the target blood pressure standard doses and a multi-drug therapy. comprising the initial treatment of hypertension in the elderly, depending on comorbidities, usually a diuretic type diuretics, ACE inhibitors, angiotensin II receptor blocker, or a calcium antagonist of the dihydropyridine type. ?-blockers should be reserved for second-line treatment. Short acting dihydropyridines (eg., Nifedipine) may increase the risk of death and should not be used. The blood pressure in the sitting and standing can, v. a. When several antihypertensives, for Überpüfung of orthostatic hypotension, that may increase the risk for falls and fractures, can be monitored. Anti-Parkinson drug Levodopa clearance is reduced in elderly patients for adverse drug reactions, particularly orthostatic hypotension and confusion, are also susceptible. Therefore, elderly patients should receive a lower dose of levodopa and be carefully monitored for adverse effects (Parkinson’s disease: levodopa). Patients who become confused while taking levodopa, dopamine agonists may be able to (z. B. pramipexole, ropinirole) is also not tolerated. Elderly patients may be cognitively impaired with Parkinsonism drugs should be avoided with anticholinergic effects. Antipsychotics antipsychotics should be reserved for the treatment of psychosis. In nonpsychotic, agitated patients control the symptoms antipsychotics only marginally better than placebo, and they can have serious adverse effects. Studies have shown that in people with dementia increased antipsychotics in mortality and the risk of stroke, which the FDA prompted to issue a black box warning on the use in such patients. Antipsychotics act not with dementia-related behavior problems in general (eg. As wandering, crying, uncooperative behavior). If an antipsychotic is used, the Initaildosis should be about a quarter of the usual starting dose for adults and be gradually increased with regular monitoring of therapy response and adverse effects. Once the patient responds, the dose should be reduced down if possible to the lowest still effective dosage. The drug should be discontinued if it is ineffective. The data from clinical trials relating to dosage, efficacy and safety of these drugs in the elderly is limited. Antipsychotics can reduce a paranoid disorder, confusion, however deteriorate (schizophrenia: Conventional antipsychotics). Elderly patients, especially women, have an increased risk of Spätdysinesien that are often irreversible. With up to 20% of elderly patients taking an antipsychotic medication, sedation, orthostatic hypotension, anticholinergic effects, and akathisia may (subjective motor restlessness) may occur, and a drug-induced Parkinsoismus can 6-9 months after discontinuation of the drug continue. When using 2nd generation antipsychotics (eg. As olanzapine, quetiapine, risperidone) may even, especially in higher doses, cause extrapyramidal disorders. Risks and benefits of using an antipsychotic should be discussed with the patient or the person responsible for patient care. Antipsychotika sollten für Verhaltensauffälligkeiten in Betracht gezogen werden, wenn nichtpharmakologische Optionen unwirksam sind und bei Patienten, die für sich und andere eine Bedrohung darstellen Anxiolytika und Hypnotika Vor der Anwendung von Hypnotika sollten behandelbare Ursachen von Schlaflosigkeit eruiert und entsprechend behandelt werden ( Untersuchung des Patienten mit Schlafstörungen oder Störungen des Schlaf-Wach-Rhythmus : Hypnotika). Nichtpharmaologische Maßnahmen, wie kognitive Verhaltenstherapie, und Schlafhygiene (z. B. Vermeidung von koffeinhaltigen Getränken, Einschränkung von Nickerchen am Tage, Modifikation der Schlafenszeit) sollten zunächst versucht werden. Sind sie unwirksam, sind Nichtbenzodiazepinhypnotika (z. B. Zolpidem, Eszopiclon, Zaleplon) Optionen für den kurzfristigen Einsatz. Diese Arzneimittel binden hauptsächlich an einen Benzodiazepinrezeptor-Subtyp und stören das Schlafmuster weniger als Benzodiazepine. Sie haben einen schnelleren Wirkungseintritt, weniger Rebound-Effekte, wenige Hangover-Effekte und ein geringes Abhängigkeitspotenzial. Wie in siehe Tabelle: Potenziell unangemessene Arzneimittel bei Älteren (nach American Geriatrics Society 2012 Beers Criteria Update) beschrieben sind kurz-, mittel- und langwirkende Benzodiazepine bei Älteren mit einem erhöhten Risiko für kognitive Beeinträchtigung, Delirium, Stürze, Knochenbrüche und Autounfälle assoziiert und sollten in der Behandlung von Schlaflosigkeit vermieden werden. Benzodiazepine können für die Behandlung von Angstzuständen oder Panikattacken bei älteren Menschen geeignet sein. Wenn möglich, sollte die Dauer einer anxiolytischen oder hyp

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