What instead? Alternatives to Beers: Todd Semla and Mike Steinman

Eric 00:01

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:03

This is Alex Smith.

Eric 00:05

And Alex, who do we have with us today?

Alex 00:07

We are delighted to welcome back co-chairs of the AGS Beers criteria panel. First we have Todd Semla, who’s a clinical pharmacist and is at Northwestern University. Todd, welcome back to the GeriPal podcast.

Todd 00:24

Great to be here. Thank you, Alex and Eric for inviting us.

Alex 00:27

And we’re delighted to welcome Mike Steinman, who’s a geriatrician at UCSF and also a co-chair of the AGS Beers criteria panel and is co director of the U.S. deprescribing Research Network. Welcome back, Mike.

Mike 00:42

Thank you.

Eric 00:44

So we’re going to be talking about not an alternative to Beers criteria, but alternative treatments to the medications that the Beers criteria says we shouldn’t put people on. Before we go into that topic, I think who has a song request for Alex?

Mike 00:59

That was me.

Eric 01:00

Ah, Mike, what’s the song request?

Mike 01:03

How about Getting Better by the Beatles?

Eric 01:05

Why did you choose the song other than Alex likes singing the Beatles?

Mike 01:09

Well, that was one reason. Two other reasons. First is that, you know, the goal of the alternatives list is to help people get better, feel better, live longer, happier and more productive lives. And then the second thing is, you know, as clinicians and scientists, it’s been a rough few months and we can kind of hope for a note of optimism that things will get better as the months and years pass.

Alex 01:33

Love it. Here’s a little bit.

Alex 01:40

(singing)

Alex 02:22

Ah, Beatles are fun. Thank you, Mike.

Mike 02:24

You’ve got the education policy debates in there too.

Eric 02:31

Okay, so I’m going to start off with a case. We got an 80 year old patient who has a lot of medical problems, probably like many of the patients we care for. They have diabetes, they’re on a sulfuril metformin, they have insomnia, which they take Ambien pretty much daily for. They have GERD and they’ve been on a PPI for the last three years. They got lower back pain and they’re on pick your skeletal muscle relaxant that they’re on and PRN NSAIDs. They have neuropathic pain from their diabetes.

They’re on gabapentin and then they have seasonal allergies, which they take some over the counter drug you’re not 100% sure is, but you’re pretty sure it’s Benadryl. But they can’t really tell you what they’re taking. They’re just go to CVS and pick it up. Alex, any other ones that you want to throw out there? Does that sound pretty good?

Alex 03:27

You’re covering it pretty well there.

Eric 03:33

Yeah, yeah. The ambient is working pretty good. They love their ambient, though.

Todd 03:38

I just want to make sure we had delirium in there. Yeah, yeah, yeah.

Eric 03:41

Okay. When you hear about this list as a leader in the Beers criteria, what are you thinking? Well, before that, what is the Beers criteria and how does it apply to this list?

Todd 03:55

So the Beers criteria has been around since the 90s started out for nursing home patients about medications to avoid not to use or to use with extreme caution, particularly either by themselves or if the person has a comorbidity or condition that you could make worse by that medication. And. And for the past 12 or 15 years, the American Geriatric Society has been responsible for updating applies not just to nursing home patients, but to all older adults, with the exception of palliative care end of life situations.

But it really looks at medications that we really should think twice about using, maybe avoid using them at all together in older adults. Also drugs that need to be adjusted for renal function that people may forget about and drug. Drug interactions that could happen to anybody. But in an older adult, they’re more likely to cause morbidity or mortality. So they kind of rise to the top of the table. But the question’s been, what do we do instead?

Eric 05:06

If we’re going to say that we should have put somebody on this and I would push you, I actually think this applies very much in the palliative care and hospice practice too, because some of the things that we’re trying to avoid matter a ton in that population as far as maintaining cognition, deprescribing. So I love this alternative, even from this alternatives paper from a hospice and palliative care perspective as well.

Alex 05:31

And they’re frequently used with the justification that, oh, this is different at the end of life, it’s okay.

Eric 05:37

Yeah.

Alex 05:38

And maybe it’s not as okay as some of our clinicians might have been trained to think.

Todd 05:45

Well, there’s still a place for common sense.

Mike 05:48

Yeah. And it speaks to the larger issue that, you know, the breach criteria is one small slice of the larger landscape of drugs. You know, and every drug has reasons where it might be used appropriately. And every drug has reasons where it might not be the best choice for an older adult or just an adult in general. And so kind of applying common sense and clinical decision making throughout is going to be really important. Sort of of the Beers criteria as a starting point, but certainly not the ending point.

Eric 06:13

So it’s potentially inappropriate medicines. You’re not saying it’s absolutely inappropriate medicines.

Mike 06:19

Yeah, exactly. Every drug in the Beer’s criteria might have a reasonable use in a given individual. And lots of drugs not on the Beers criteria might not be the best choice for your older adult for other reasons.

Alex 06:29

Yeah, I really liked in our last podcast with you, I think it was 20, 23 when you last updated the criteria. You said that these criteria should be like a stop sign. Like you come up to it and you pause, you stop, you come to a complete stop and you look around for alternatives. And maybe you don’t, maybe you go with one of the alternatives and maybe not, and maybe you continue on with that. But this should be a wait check.

Mike 06:53

Hold on.

Alex 06:54

Before we continue, let’s really think about this.

Todd 06:57

Yeah. And Alex, I’ve updated my analogy. You know. Oh, I say that it’s like you’re driving down the street and there’s a pothole and you’ve got a choice. I can swerve and avoid the pothole, but I’m going to hit the person on the bicycle. Or I can just go right over the pothole and hope for the. Hope for the best. So, you know, the word avoid was kind of legacy language with the Beerus criteria, but, you know, you try to avoid the potholes.

Eric 07:26

Well, I’m not sure about that analogy because I don’t think I want to. Todd does not like bicyclists.

Alex 07:34

I think as a cyclist, As a.

Eric 07:36

Cyclist, stay away from Todd.

Todd 07:39

No, you don’t want to hit the bicycle, so you gotta hit the pot. You gotta hit the pothole. You gotta take the pothole.

Alex 07:43

These are your choices.

Eric 07:46

Always choose the bicyclist. I care about my car too much.

Alex 07:55

I kind of like the first analysis better.

Eric 08:01

Well, let’s move away from cyclists. Alex has PTSD from car accidents in the past.

Alex 08:08

I’m not driving around Evanston, Illinois. I mean, biking around Evanston anytime soon. That Chicago century off my list.

Eric 08:18

Alternatives, alternatives. So we have this 80 year old that we’re seeing. They have diabetes, insomnia, GERD, lower back pain, neuropathic pain. They have all this stuff. I’m going to start off with insomnia. Is there what’s the pothole here they’re on, they’re doing great. They love their Ambien, they feel great about it. You’re, you’re coming up to the pothole, you see Alex to the side on his bike. What do you do here? What’s, what’s the issue here?

Mike 08:51

Well, there are a lot of issues, you know, so the first thing to keep in mind is this person is suffering because they have insomnia. So, you know, our sort of foremost goal should be to help that person manage their insomnia and to do so in a way that’s most likely to be effective and most likely to be safe. And the reason that there’s a bunch of drugs on the beers criteria that are commonly used to treat insomnia, which often cause more harm than good, is because those drugs either are sort of, sort of effective but cause a lot of harms, or maybe they’re not very effective and they also cause harms.

And so can we find a better both pharmacologic or non pharmacological alternative to help manage that patient’s symptoms, which is the ultimate goal? The ultimate goal is not to, like, start any specific drug or stop any specific drug, is to help the patient with the symptom and do so in a way that’s safe and effective. So, like the different meds we might avoid, like in this case and others, include the benzodiazepines, include the Z drugs.

Eric 09:48

Which have Z drugs like Zolpidem, the ones that starts with Z’s, not for ZZ Sleep Easies.

Mike 09:55

Thank you. Exactly. Zolpidem, Zoloplon, Zopiclone, all the ones that are used to be.

Eric 09:59

Wow, that’s impressive, Mike.

Mike 10:01

I know, really. And then. But also, like, you know, first generation antihistamines, you know, your diphenhydramine, Benadryl, Advil, pms, tricyclic, antidepressants like amitriptyline and barbiturates, which are used less commonly but still, you know, are used sometimes. So those are the meds that we say, you know, most people don’t use because they cause more harm than good. But there are a bunch of things that we can do instead.

Eric 10:24

What are the things that we can do? So this person’s on Ambien we’re worried about. Or Zolpidem. Sorry for using the trade name, but I’m using the trade name in, in a way, you should take it off Zolpidem. What, what should you do? What’s the alternative here?

Mike 10:42

Well, it’s important. This is true. For a lot of the different alternative criteria, it just goes back to basic principles in good medicine, which is before you treat the symptom, try to figure out what’s causing the symptom in the first place and manage your therapy according to that. So the first step is to kind of evaluate that person for healthcare conditions and factors that are contributing to their poor sleep. Is it the environment in which they’re sleeping that’s causing problems? Are they having pain that’s trimming their sleep or nocturia? Are they having sleep apnea? Are they taking other medicines which are interrupting their sleep?

So before we even start thinking about therapy, just think about what’s the actual cause and can we direct our treatment to the cause? Once you get past that and it becomes more garden variety insomnia disorder without any obvious precipitant or other environmental factor you can fix? You know, the first widely recommended treatment, which is recommended by pretty much all the clinical practice guidelines for sleep, is non pharmacologic, which is cognitive behavioral therapy for insomnia. It’s safe, it’s effective, it is unambiguously first line treatment for management of insomnia.

Eric 11:46

It’s easily available.

Mike 11:48

Yes.

Todd 11:49

Multiple delivery methods.

Mike 11:51

Exactly. So it can be hard to get, you know, a trained cbti, sort of health psychologist or other trained provider. If you’re in the va, it’s more accessible. If you’re outside the va, you might be more out of luck. But like Todd was saying, there’s a bunch of different modalities. There’s a lot of digital apps, website based programs which have been shown to be effective and can really be tremendously useful for people who don’t have easy access to a trained therapist, I have.

Alex 12:21

To say, because we just recorded a podcast with Victor Montori, who is really worried about the burden of care that we place on our patients outside of clinic. You know, we’re asking him to do more and more and more and now he’s really concerned about the digital burden. You know, there’s an app for that. Well, there’s an app for everything. And they’re all of different interfaces and you have different passwords and you got two factor login. And it’s a lot for our older adults who are complex conditions and are probably delirious from this list of medications that they’re taking. And now you wanted to start an app.

I don’t know. I hear him and I worry about that. At the same time, I understand that there’s a shortage of trained therapists. And the answer maybe shouldn’t be always that there’s an app. Maybe it should be. We need more therapists. That’s me. I’ll get off my soapbox.

Mike 13:12

Well, but that’s true. That would be great. I ain’t holding my breath until that happens. So the patient comes to me tomorrow and you know, insomnia tends to really bother people. Like it is not a small thing for most people or many people at least. And so if I still gotta work.

Eric 13:28

Tomorrow, I still gotta do these things.

Mike 13:30

Yeah. If the framing is this symptom is really bothering you, we have a very effective safe solution that’s worked for a lot of people. It takes some work on your part, but it’s worth it because it will really help you. If people have motivation to improve their symptom, that can go a long way. And a lot of these apps are designed for people who aren’t super tech savvy. So totally hear what you’re saying.

But at the same time, like we should be helping people help themselves. It’s the same thing. Might be you could say the same thing true for exercise. Like it’s a pain in the ass to go out and exercise several times a week. You know, a lot of people don’t like it. It’s challenging, you know, but like it’s worth it. So I don’t think we should be shying away from encouraging sort of self help either.

Eric 14:16

Okay. So if you want to learn more about insomnia, we have an insomnia podcast we’ll have links to in our show notes. But when would you consider pharmacological therapies and what would the alternative be to the Z drugs or to the benzos?

Todd 14:29

So there, that gets to be a bit of a question. But the medications that. Which may be safer but not completely safe because that, that, that doesn’t exist are things such as low dose doxepin. And we’re talking up to 6 milligrams per dose. It comes as a 3 and 6 milligram formulation capsule. The dual orexin receptor antagonists are another option. And ramelteon. But we’re also looking at short term use for all these agents. They’re not necessarily chronic medications.

Eric 15:05

All right, I got to dive. I’m going to dive quickly into each one of them. Again, this doesn’t want to turn into an insomnia pod, but I got to say, doxepin, isn’t that a TCA anticholinergic, anti histaminergic, A promiscuous drug as far as receptors are concerned, medication like promiscuous it likes a lot of different receptors. Why Doxypan?

Todd 15:32

Yeah, it’s, it’s, it’s what we sometimes call a dirty drug. But we’re talking about very low doses. We’re talking three, six milligrams doses. It’s been studied in two studies in older adults and shown to be effective and safe. Where I think we get into trouble is when we have people trying to sort of cheat the system. And I fought this in the VA and I lost to try to get the 3 and 6 milligrams on formulary, but because people, people just want to use the 10 and they don’t realize that the 10 is more than three times the three.

Eric 16:10

And I heard, correct me if I’m wrong, Todd, I heard that its promiscuousness is only at the higher doses, but it’s exceptionally good at just targeting the H1 receptors, histaminergic receptors, at the very low dose. Is that right? Does that sound right?

Todd 16:25

That sounds right.

Eric 16:26

So not so anticholinergic at the low doses, maybe at the high doses, but at the low doses seems to work fairly well.

Todd 16:35

You know, you see the same thing with mirtazapine, you know, which is not one that really made the cut in terms of a recommended alternative, but it’s, you know, has its histaminic effects are at lower doses, but they get overridden by the alpha adrenergic effects at higher doses. So once you go above 30 milligrams per day, you’re, you’re, you’re losing the sedating property of mirtazapine.

Mike 16:59

Yeah. And then it kind of, it begs the question, why not trazodone? Why not melatonin? Why aren’t those things that.

Todd 17:04

Todd?

Eric 17:05

Oh, yeah, why not melatonin, you got.

Alex 17:08

Or Trazodone, which are probably far more prescribed.

Eric 17:12

Melteon. That’s like, that’s basically the pharma version of melatonin.

Mike 17:17

Right, right. And the difference is evidence, you know, like we, you know, there’s just really limited evidence for a lot of these things, including for trazodone, low dose potazepine, melatonin, other drugs of that ilk. You know, there’s just really limit evidence. It doesn’t mean they absolutely don’t work. Yeah, but we don’t have much evidence that they do work.

And particularly for melatonin, the evidence does not suggest it’s not super effective. They’re probably reasonably safe, but they’re not going to help people so much, except through maybe placebo effect for, for, for sort of you know, just general insomnia disorder. We’re not talking about more sort of specialized forms of insomnia. Go ahead, Don.

Todd 17:56

I think this gets back to the methodology of how we did the alternatives, which we haven’t really talked about yet. So we didn’t look for the primary evidence because we have a hard enough time with the Beers criteria finding primary evidence to support what we’re doing. It’s mostly observational cohort type studies. But to go out and find clinical trials for the alternatives that show that they’re in older adults is pretty rare.

Mike 18:23

Yeah.

Todd 18:24

So what we ended up, our subgroups, our panel ended up doing is looking at what are the recommendations from other societies and other clinical practice guidelines. And specifically we’re hoping to find those recommended for older adults. So when we start looking at, through the sleep recommendations, this is what other organizations and sleep guidelines were recommending.

Alex 18:46

And is it possible. I know we don’t want to turn it into an insomnia podcast. We got a lot of other topics we want to get to. And is it possible that some of those society guidelines were influenced by pharmaceutical industry conflicts of interest?

Mike 19:02

Yes, for sure. You know, it’s true for any, any guideline for members sort of have conflicts of interest, many of them.

Eric 19:09

So the Beers criteria alternative list, we.

Mike 19:13

Do have a series of disclosures. Most of our panelists do not have any, any conflicts to disclose. Some do. They tend to not directly be from drug manufacturers, but make your own judgment based on the description.

Eric 19:25

I got another question real quick. Insomnia. If you had somebody insomnia in the hospital, you try to do all those things, you can avoid the insomnia, us waking them up, all of that. You’re probably not going to be doing CBTI in them in the hospital. Like, is there a drug that you would use in this alternative list for them? Todd, are you thinking doxepin here, low dose, 3 milligrams, if you can get it.

Todd 19:48

Yeah, if you can get it. That’s. That’s the issue.

Eric 19:50

Yeah, yeah.

Todd 19:53

You know, you could also be looking at a dual orexion receptor antagonist, one of those agents, as well as another. Another possibility. The, the evidence from the clinical trials, the minimum, the effect on sleep latency and sleep length is pretty small compared to placebo. But you know, it may work well enough in those situations.

Eric 20:17

So I’m gonna refer all of our guests to the insomnia podcast. We’ll talk more about that in the insomnia podcast. But I wanna get into this 80 year old again. I think we’ve talked about his insomnia. Mike said, oh, you wanna make sure that nothing else is bothering them. Their sleep, you know, good history and exam. And they say, yeah, you know, it’s my pain. I got this neuropathic pain in my feet. I take gabapentin. I got lower back pain. I’m taking Flexeril or cyclobenzaprene for maybe they’re, I don’t know if they’re really working. They say, where are we now? We’re still, we’re seeing more potholes now. Alex is still next to us biking. Who wants to take that one?

Mike 21:01

I can maybe start. Paint’s really easy. We, we all have the easy solution.

Eric 21:06

Yeah, you tell us not to use anything.

Todd 21:07

Exactly.

Mike 21:08

I know the exact answer.

Eric 21:09

I’m just gonna not tell skeletal muscle relaxants. I mean you kind of avoid gabapentin.

Mike 21:16

Right.

Eric 21:16

And.

Mike 21:18

Right. So I mean, so I mean first thing like is setting realistic expectations about what you realistically can and can’t do and kind of helping to, you know, this I’m as palliative care experts not telling you anything you haven’t taught me, you know, 10 times over. You know, focus on, you know, understanding what’s a reasonable outcome for the pain, focusing on function, functional outcomes rather than expecting your pain’s going to get to zero. But you know, once we get beyond that, you know, it gets back to what we were talking about before about insomnia. It’s like, let’s see if there are underlying triggers of pain that we can address.

Probably not the only thing that we need to do, but at least it’s a good start. So looking at those environmental, other kind of contextual factors, other drugs, other conditions, lifestyle modifications, things like that, that can help with that pain. And then the other thing is there are other kind of non pharmacologic therapies. You know, pain, of course it’s a, you know, a lot of it lives in the head. You know, it’s, it’s how we process pain, how emotional reaction to pain.

Eric 22:17

It’s all in the head. Right. You don’t have a head, you don’t have pain. You have. No, exactly. Fiber’s going up. But pain is an experience.

Mike 22:24

Right. So what can we do with the non pharmacologic therapies that kind of help with these sort of our, are the way our brain processes pain. So education, intervention, exercise, and this is all evidence based stuff from the guidelines. Like Todd said, you know, we didn’t try to reinvent the wheel by reviewing every single primary Evidence.

We went back to the guidelines and saw what the guidelines said, you know, and so some effective things that tend to work across a variety of causes of different types of pain education, exercise therapy of different types, aerobic, aquatic strengthening, yoga, physical therapy, cognitive behavioral therapy, and then some other kind of non pharmacologic medical interventions like peripheral electric or magnetic stimulation, acupuncture, things like that. So those are things we should be thinking about rather than saying, okay, here we have a bad drug, let’s take off the bad drug, let’s find a better drug to put in place of the bad drug.

Eric 23:18

Not as bad, but still think that way.

Mike 23:20

Yeah, yeah. You know, go back to first principles. We remember very, we very well might need another drug, but that shouldn’t be our first reflex.

Eric 23:28

Yeah. So for like, lower back pain, there’s a lot of non pharmacological interventions that we can do to manage lower back pain.

Mike 23:36

Exactly.

Eric 23:37

And depending on the cause of the lower back pain too.

Todd 23:41

Right.

Mike 23:41

And one other thing to kind of keep in mind is that, you know, I think we’ve. The Beers criteria and other sort of guidance in older adults has sometimes led to an irrational fear of NSAIDs.

Eric 23:51

Yeah.

Mike 23:51

Like guidance in the AGS. Beers criteria basically says don’t use NSAIDs regularly for more than a month. If someone needs to take NSAIDs every once in a while, like to manage their pain, like, and it works like, that’s a pretty safe regimen. And if it works for you, it’s effective for you, then by all means. So it’s not like we should never use NSAIDs.

Todd 24:11

We just be cautious about using them regularly for long term and maybe be careful which NSAID you use.

Eric 24:17

Yeah, how so?

Todd 24:19

Well, you just don’t want to use ones that are more likely to cause ulcerogenic problems. So maybe stick with a COX2 inhibitor, which is less likely. Or if you need to put somebody on some type of gastroprotective regimen like an hidden histamine antagonist or even a PPI for short term use, you know, that’s, that’s okay.

Eric 24:39

All right, where are we with the COX2 inhibitors? You know, was that a decade ago? Weren’t they bad?

Alex 24:46

I feel like that was 15 years.

Mike 24:51

Well, the, the, the ones that were the highest risk.

Eric 24:56

Yeah, yeah.

Mike 24:57

I mean, so celecoxib is, you know, has a, is, has less specific affinity for the COX1 receptor. So it tends to have less of the problems that you got from adrenaline for coxidibiotics that had more affinity. You know, I think the, my understanding is that the evidence of, of heart, you know, benefits are certainly similar between sort of COX2 inhibitors and NSAIDs. And then the harms, you know, if you take a gastroprotective agent, they’re generally similar between the, the NSAIDs and the COX2 inhibitors, so. Which are still in the market. So take your pick. As long as you don’t, you avoid stuff like, like indomethacin, which is particularly risky.

Todd 25:35

And don’t forget we have another delivery system for NSAIDs, and that’s through the topical. So depending on, you know, is this the right knee that’s bothering this individual? And can you localize that treatment? And there are other topical agents that may also be helpful when the pain is lessened. You know, maybe you need the NSAID oral NSAIDS for flare ups.

Eric 25:56

Yeah. Or if this person, we said this person has diabetic neuropathy in bilateral legs. Capsaicin, lidocaine combo likes lidocaine, capsaicin.

Todd 26:08

They’re, they’re all pretty safe as long as you don’t put it in your eye or open wound, you know.

Eric 26:13

Yeah.

Todd 26:15

Worth a try.

Eric 26:16

Yeah. I, I got a question though. So this person is on a PPI for the last three years for a history of gerd. So we’re safe. Right. But I think PPI is maybe on the beers list too. Are they?

Todd 26:31

They are.

Eric 26:32

What are they on the beers list for? Because everybody’s on them.

Todd 26:35

Well, they’re on them specifically for things like gerd, in particular for chronic conditions like Barrett’s, esophagitis and other things. We don’t refer to them in the beers criteria. We recognize that they have a role there, but we’re really trying to avoid them because of the long term safety issues that can occur with these agents. Sets people up for C. Difficile infections, perhaps pneumonia. What else am I missing, Mike?

Mike 27:04

I think atypical femur fractures.

Todd 27:13

Side effects.

Eric 27:13

Yeah. So we want them off it. I also saw though that H2 blockers, maybe as a short term relief at night, aren’t H2 blockers not so great too? Or where do they fall into this?

Todd 27:28

They’re, they’re, they’re really more restricted in patients who have at risk or have a delirium. That’s what we’re more concerned with, with, with those agents.

Eric 27:38

Okay, so maybe if this is. We’re using NSAIDs, we decide to use NSAIDs. Mike. We could also consider a PPI for GI protection, but if it’s just GERD.

Mike 27:52

Yeah. If you look at the guidelines for uncomplicated GERD it’s basically treat for PPI for eight weeks and then stop. The guidelines do not say to continue forever because a lot of times your GERD symptoms will resolve or at least dramatically improve. And then you can use your either PPI as needed basis. Even though there’s some pathophysiologic theory, it doesn’t work. It seems like for some people it does work. Or just better yet, use an H2 block or an antacid or something as needed.

So if someone, you know, got started on a PPI three years ago because someone thought they were wearing GERD and then it’s kind of never stopped it like, and they don’t have an indication, they’re not taking a chronic nsaid, they don’t have Barrett’s esophagus, they’re not taking a chronic steroids. Don’t have a strong indication to keep using it. Like help to, you know, don’t stop it abruptly. Help to maybe wean that patient off of it. And there are guidelines about how to wean PPIs and other other commonly used meds.

Eric 28:43

Do you have a good place for those guidelines? Is this deprescribing.org or where are those guidelines deprescribing?

Mike 28:51

Deprescribing.org from our arch nemesis Canada.

Eric 28:55

Is there guidelines tariff now?

Todd 28:58

Yeah.

Eric 29:00

Good news. Well, you have to be 100% tariff, but 100% tariff on a free comes out free. So that’s good.

Mike 29:07

Yeah, no there. And those guidelines are super helpful because they’re very thoughtfully constructed, they’re evidence based based and they’re simple to use. They have these very simple to use kind of cheat sheet algorithms or you can just follow the algorithm down. It tells you when to deprescribe, how to do so safely and effectively, what to look out for. And it’s the kind of thing you can look at in 10 seconds and kind of know what to do and have information you can give to patients. So strongly recommended deprescribing.org and they have them for a series of different and.

Eric 29:36

We’Ll have links to that site plus our deep prescribing podcast with them on the show Notes. Go ahead, Alex.

Alex 29:43

Well, so one question that came up at the AGS session that you did, which was terrific, and we’ll include the link to it in our show notes, was one of the participants asked about the use of cannabinoids, which could be used for a variety of the topics that we’re discussing today, including say pain, insomnia, for example, thoughts about and why weren’t Cannabinoids on the alternatives list.

Todd 30:11

Well, we know that our pain group looked at that as alternatives for pain, but they couldn’t find anything in recommendations because the evidence really isn’t there. And it also goes back to the. When we talked about melatonin earlier, one of the concerns we have is the quality of products is what’s in the product on the label. Really what’s in the product. Unless it’s got like a USP seal on it, you really don’t know. And I don’t think the USP has been certifying cannabinoid products, at least not to my knowledge yet. And which, which cannabinoids? Which what, what ratio of THC to CBD do we need? Yeah, that’s also kind of under investigation right now.

Alex 30:56

And we’ll have a link to our cannabis podcast. I think that was within the last.

Todd 31:00

Year or so and it’s not available in all states. CBD even.

Eric 31:06

Yeah. All right, I got another question. This person also, this 80 year old, has been on metformin and the sulfon real for the last 20 years, doing really well with that. Per him. A1C is fantastic. 6.5.

Todd 31:22

Hi.

Eric 31:23

Is this a pothole?

Mike 31:27

Sure.

Eric 31:28

Oh, why?

Todd 31:29

Well, this kind of goes back to the original Beers criteria where I would present it at grand rounds or something and, and everybody would say, well, I’ve got patients that have been on these drugs for years and they’ve never had a problem. Well, you haven’t come up to the mile of road where that pothole is living just waiting for you. So that’s what you’re worried about?

Is this patient at some point going to start to develop hypoglycemia? Maybe they stop eating regularly or they get ill and they develop hypoglycemia or something. So it’s, it’s a concern. We have long term. Also a hemoglobin A1C of 60.5 in an 80 year old. That’s pretty low. I mean, what would it be like if they were just on metformin? I’d be curious to know.

Eric 32:15

Yeah. 6.8. Yeah.

Todd 32:20

And what’s the risk of hypoglycemia then? Yeah.

Eric 32:25

So it sounds like you’re worried not about the metformin in this case, you’re worried about the sulfonyl which is on the Beers criteria, Right?

Todd 32:31

Correct.

Mike 32:32

Yes. So it’s on the BS criteria as a medicine to avoid as first or second line treatment. Okay.

Eric 32:37

So it’s not. Never use a sulfonyurial. There are certain indications that you may want to consider it, but because of the risk for hypoglycemia, but it has a super long track record. Like, we know the risks and benefits of this drug versus some of the newer agents. We’re just kind of figuring them out. Right.

Todd 32:54

Well, we also, and we also recognize, because this came up when we, when we released the current edition of the Beers criteria, people were really concerned. That’s what their patients can afford. And if they need a second line agent or they can’t take metformin, this is what they can afford. And we recognize that. And that’s part of your decision as to whether you hit Alex on the bike or you hit the pothole.

Eric 33:17

It’s always Alex. Poor cyclist, easy choice.

Mike 33:22

And then the other thing to keep in mind, and this is true for all these drugs, it’s got to be good. A pretty process of shared decision making. It’s not like I, I, the clinician going to unilaterally stop the drug whether you like it or not. You know, we’re going to burn bridges that way. So, you know, there’s a whole literature and, and sort of area of expertise around how to have these deep prescribing conversations. But, you know, just, we need to be really thoughtful if for all these things.

Like we, you know, the, the, the, the framing needs to be like, we want to help you, we want to manage your symptoms, we want to help you live longer, happier, better. And that is my goal. And this is why I would make this recommendation. So going to help you meet that goal. And if the patient doesn’t buy in, then might be best to come back to another day.

Eric 34:02

Shoot. I looked at the wrong patient’s chart. Even when I see it’s not 6.5, it’s 8.4, and they’ve been having some hypoglycemic episodes. Is there an alternative? Should I just put them on insulin and call it day? How should I think about this?

Mike 34:23

Well, first thing is like, what’s their dose of metformin? You know, can that be raised? You know, if they’re having hypoglycemic episodes, that certainly ups the ante to kind of be more aggressive about stopping the sulfonylurea.

Eric 34:33

Yeah.

Mike 34:34

And then, you know, you mentioned, like, there are newer therapies, but even though they’re newer, some of them are not especially new. You know, a lot of them have been around for at least a while now, and others who had a few years of experience to be pretty safe and effective in older adults. I’m talking, you know, the DPP4s, the GLP1 receptor agonists, the SGLT2 inhibitors. And so all those have a much more robust, you know, track record of safety and effectiveness than sulfonylureas at this point.

So there are cost issues for sure, which are real and serious, but at the same time, like can we find a way to get a patient if they, if they, if their A1C really is above target and with afro thoughtful consideration of what that target should be, then yeah, I would definitely sort of see if we can, you know, maybe substitute in one of those medicines instead.

Eric 35:24

How do you choose between, did you do any quick advice? How do you choose between that for the GLP1 SGL2s? Like how do you.

Mike 35:34

It’s complicated. Not. I could.

Eric 35:36

It’s a long talk.

Mike 35:38

Long talk. Comorbidities, you know, some of these ones are better for CKD or heart failure or other conditions than others. So look at guidelines, okay?

Eric 35:51

So look at guidelines, okay? So you decide to put this person on a, they switch to a glp, they’re doing well over the next two years and then palliative care gets consulted for significant weight loss and wondering, hey, can we put this person on Megestrel for their continued weight loss? Because it seems like they’re getting more frail and they’re losing weight. This is actually I heard this happening to someone pal of care getting consulted for weight loss and somebody on a ozempic. Thoughts, Todd?

Todd 36:29

Well, first of all, Magesterol is on the Beers criteria because it’s associated with increased mortality in older adults, something we try to avoid. So I guess the question would be do they still need their ozembic or whatever they were on? Is this the reason why they’ve lost so much weight or they need a further workup? Yeah, there’s all sorts of non pharmacologic interventions that we want to look at. Are they still, are they having difficulty preparing their meals or shopping for food? You know, I once had a patient who we’re trying to get her to increase her calcium intake but she avoided the dairy aisle because it was too cold. You know, so look for things like that.

Mike 37:12

Yeah.

Eric 37:13

So hypothetically different case than when we’re thinking about appetite stimulants. Is there one that’s not on the Beers criteria that we could potentially choose or is this just all non pharmacological like look at other causes for their decreased PO intake or loss of appetite. Is there anything on that list, on the alternative list?

Todd 37:36

Well, some people would say if the person has depression that you might want to try mirtazapine as something to. To stimulate their. Yeah, their appetite. I don’t recall that. This is like the only thing the person didn’t have.

Eric 37:49

Yeah, they did not have depression.

Mike 37:53

Yeah.

Todd 37:53

And we know that mirtazapine isn’t really our sleep alternative, but some people might.

Eric 37:57

Still say, well, so no evidence for sleep or appetite outside of depression. But if they’re depression, maybe it’s a good drug to use from a side effect profile. Is that a good summary?

Todd 38:09

Yeah. Yes.

Eric 38:11

All right.

Alex 38:12

Anything else?

Todd 38:13

I’m not aware of other medications? Most of our other alternatives are off.

Eric 38:19

Farm cannabinoids, I guess. We already talked about cannabinoids. Marinol. Honestly, I’ve never seen somebody get better on Marinol for appetite. That sound about right?

Todd 38:31

Yep.

Alex 38:32

Yeah.

Mike 38:32

It’s certainly not. Not in sort of evidence based guidelines for weight loss.

Eric 38:37

Alex, any other palliative care symptoms coming up that you’re.

Alex 38:39

That behavioral symptoms in this, a different case? I don’t know that we could do everything in the one case, behavioral symptoms for people with dementia. Thoughts? Recommendations? Like, of course you’re gonna say non pharmacologic first. And they’ll say, we’ve tried that, we tried that, we tried that.

Eric 39:00

Geriatricians and they’re non pharmacologic.

Mike 39:03

Yeah.

Alex 39:03

Come on, give me something. Yeah, give me something.

Mike 39:07

Yeah. Well, I mean, the other thing to think about is not just like, did you use, like get into the person’s world and try to redirect, but also like, are they having other clinical conditions which are going. This is getting back to first principles. Things which are causing them to be agitated in the first place. Are they constipated, are they in pain, are they having urinary retention? Something else going on. So kind of making sure we’re ruling that stuff out.

You know, there is a role for antipsychotics in the management of agitation or aggression of people with dementia. You know, if the person’s at risk for themselves or others and the non pharmacologic stuff has failed. So it’s not like you should never use it. But you know, it’s again, going back to. I don’t want to use the swerving to Alex analogy.

Eric 39:49

Severe distressing hallucinations.

Mike 39:52

Yeah, exactly. But there’s a risk. I mean, they increase mortality. So we should be thinking about all the things that are safer and we know to be effective. But if those aren’t working and the person is desperate for therapy and they’re willing to take those risks, then yeah, it can be a reasonable thing to do. Or recognizing that, you know, some of them have been FDA approved for treatment of this and others have not, doesn’t necessarily mean the others are ineffective, but it just means there’s limited evidence for like say breakfast pipers all compared to some of the others.

Eric 40:24

All right, I got my last question for you. You’ve both been dealing with beer’s criteria for so long. What is your pet peeve? Like, what’s your. What’s like if that. That drug on the beers criteria that you. I hate that drug. And there’s, you know, this other alternative that you think is great, is there. Do you have one? Mike, do you have one?

Mike 40:46

I don’t have a single drug. I think the thing I hate most is like just people taking overly simplistic approach to it. Like this is a list of bad drugs, we should never use them and everything else is fine, which is not true. And so applying clinical judgment and just applying good clinical common sense to how we think of these lists and just going back to first principles, like figure out what’s causing the symptom. Let’s see if we can try a non pharmacologic strategy.

This is not rocket science, but as clinicians, we’re often so busy and overwhelmed, we kind of often skip past that stuff. So the thing I always try to remind myself, easier said than done, is just take a step back and let’s just go back to first principles before I just sort of act reflexively. Any of these lists.

Eric 41:30

All right. Todd, do you have one?

Todd 41:32

Yeah, it’s similar. Similar to what Mike’s saying. I think that people over interpret or oversimplify the criteria and they see a void and they don’t read the recommendation, they don’t read the rationale and apply that. So avoid means avoid at all costs. And sometimes that comes down to third party payers and others. But, you know, you never want to hit the bicyclist. I’m just gonna close with that.

Eric 41:57

Thank you.

Alex 42:00

Thank you.

Todd 42:00

I want to be clear about that.

Eric 42:02

But what if you have a really nice car? Alex has got a nice car.

Todd 42:09

We want to keep Alex in one piece.

Eric 42:11

All right, Alex, you can sing more now. You’re not gonna get hit.

Alex 42:20

It’s getting better all the time. Me used to be angry young man Me hiding me head in the sand. You gave me the word I finally heard I’m doing the best that I can. I’ve got to admit it’s getting better. A little better all the time. I have to admit it’s getting better it’s getting better since you be mine.

Eric 43:02

Wonderful. Mike, Todd, where can we find this article that you published as of this moment?

Mike 43:09

It will imminently be published in the Journal of the American Geriatric Society. And also these should be linked from the American geriatric society website, americangeriatrics.org.

Eric 43:19

There will be a link from the GeriPal website. So take a look at that. Todd, Mike, thanks for joining us on this GeriPal Podcast.

Todd 43:26

Thank you for having us.

Mike 43:27

Thank you.

Eric 43:28

And thank you to all of our listeners for your continued support.

This episode is not CME eligible.