Treating Insomnia in Older Adults: Doxepin Highlights

The American Geriatrics Society recently published their Alternative Treatments to Selected Medications in reference to the most recent update to the AGS Beers Criteria in 2023.  This guidance is helpful because while the 2023 AGS Beers Criteria warned about which medications were "potentially inappropriate" in older adults, they left clinicians guessing by not offering suggestions as to which medications should alternatively be used.

Beers Criteria Update 2023 - Seven Changes

The American Geriatrics Society (AGS) 2023 updated AGS Beers Criteria® for potentially inappropriate medication (PIM) use in older adults was released during the AGS annual meeting in May 2023.  This is the sixth update to the criteria which are currently designed to identify potentially inappropriate medications (PIMs) that are best avoided in older adults in general or in specific circumstances.  The criteria were first intended to be applied to the nursing home population but were expanded to apply to all adults 65 years old and older (except for end-of-life settings). 

Nitrofurantoin in renal impairment

A 74 year old female patient presents to clinic describing dysuria and urinary frequency that started within the last few days.  She has no vaginal discharge or irritation and has no CVA tenderness, fevers, chills, flank pain, nausea, or vomiting.  The diagnosis of uncomplicated UTI is made based on clinical suspicion and you decide to prescribe some antibiotics.  She weighs 72 kg and her SCr is 1.4 mg/dL.  Using the Cockcroft-Gault equation,

Pneumococcal vaccine: Which, when, and why?

The pneumococcal vaccine was developed to reduce the disease burden of streptococcus pneumoniae, a gram-postive bacteria that has more than 90 serotypes that can cause diseases in humans.  Some of these infections include pneumonia, meningitis, bacteremia, otitis media, and sinusitis.  There are currently two vaccines on the market to raise immunity against pneumococcal infections - PCV13 (Prevnar 13 - which covers 13 serotypes) and PPSV23 (Pneumovax 23 - which covers 23 serotypes).  The 23-valent vaccine covers all of the serotypes in the

Essentials from the 2016 American Diabetes Association guidelines

The 2016 American Diabetes Association diabetes guidelines is a lengthy document outlining many aspects of diabetes care including evaluation, diagnosis, prevention, management of glycemia, and management of nonglycemic issues.  Here are some of the more common elements that come up in the internal medicine setting regarding glycemic control.

Management of acute gout - Guideline update

A new guideline from the American College of Physicians for the management of acute and recurrent gout makes a few recommendations based on updated data through March 20161.  Some recommendations and strengths differ from the 2012 recommendations from the American College of Rheumatology.  Here are the main recommendations from the updated guideline:

Metformin in kidney dysfunction - restriction revised

Metformin is the preferred initial pharmacologic therapy in every patient with type 2 diabetes mellitus who does not have a contraindication or intolerance.  It is recommended as monotherapy after diagnosis, continued when adding other medications (including insulin regimens), and should even be considered to prevent diabetes in certain patients (see who at the bottom).  

Old labeling

From approval, the restriction on metformin related to kidney function was as follows

Aspirin for primary prevention of cardiovascular disease and predicting risk of first cardiovascular event

The benefit of aspirin in reducing cardiovascular (CV) events or mortality in those patients with known CV disease (secondary prevention) is well established.  However, the benefit of aspirin in those without CV disease (primary prevention) is less clear.  Various organizations have differing opinions and recommendations regarding who, if anyone, should receive aspirin in this capacity, and their recommendations are summarized further below.  To go straight to the current recommendations, skip down to 'Current Recommendations'.

Changes to FDA Pregnancy and Lactation Labeling

On December 3, 2014, the FDA issued a new rule revising the current regulations pertaining to the pregnancy, labor and delivery, and nursing mother sections of the prescribing information for prescription drugs and biologic products. Initiation of this amendment was prompted by the FDA’s goal to provide women and their healthcare providers with sufficient information when deciding which medications to prescribe in pregnant and breastfeeding patients.

^{Why the change?}

Recent data indicate that about 90% of pregnant women take at least one medication and 70% take one or more prescription drugs, potentially putting the fetus at high risk for drug-induced developmental abnormalities. Many pregnant women may also be on medications to control chronic disease states such as hypertension or to manage acute conditions developed during pregnancy such as gestational diabetes.  It is also necessary to consider that about half of all pregnancies are unexpected, leading to unintended drug exposure.

The questionable role of digoxin in atrial fibrillation

Let's start with a patient case.  An elderly patient is admitted to the hospital with complaints of intermittent shortness of breath and a fluttering feeling in his chest.  He has a past medical history of hypertension, atrial fibrillation, and heart failure (EF 6 months ago = 30%).  He is currently taking ramipril 10 mg daily, metoprolol succinate 50 mg daily, and warfarin 6 mg M/W/F and 3 mg the rest of the week.  Other findings include a BP of 106/56 mm Hg, a creatinine clearnace of 40 mL/minute, an INR of 1.28, and atrial fibrillation with a heart rate in the 80s but a rapid ventricular response intermittently into the 120s bpm.  What should be recommended at this time to control this patient's atrial fibrillation and what is the role of digoxin, if any?

Update to anticoagulation in atrial fibrillation

Let’s start with a patient case. A 72 year old female presents to the hospital with fatigue, palpitations, and shortness of breath that has occurred intermittently over the last two weeks.  Her PMH is significant for anxiety, seasonal allergies, and PAD which is rarely symptomatic and not lifestyle-limiting.  She is admitted to the hospital with the diagnosis new-onset atrial fibrillation.  What anticoagulation strategy is recommended for someone like this?

This pharmacy pearl highlights just a few of the key points regarding anticoagulation from the 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation which was just published in April of this year.¹  There are several differences between this newest guideline and the most recent version of the Chest guidelines from 2012 (which only addressed warfarin and dabigatran since it was the only new oral anticoagulant approved at the time).  Note that this entire summary will be referring to nonvalvular atrial fibrillation.

Update on steroid recommendations for COPD exacerbations

Let’s start with a patient case.  An elderly patient is admitted through the emergency department with markedly worsening dyspnea and purulent sputum production over the last three days.  When reviewing his history, you find that he has GOLD grade 4 (very severe) COPD and experiences roughly one exacerbation per year that requires hospitalization.  His home medications for COPD include tiotropium (Spiriva) 18 mcg/inhalation once daily, albuterol MDI (Proventil HFA, ProAir HFA, or Ventolin HFA) 90 mcg/inhalation 2 inhalations every 4-6 hours as needed for dyspnea, and fluticasone/salmeterol (Advair Diskus) 250/50 mcg inhaled twice daily.  You are now deciding what steroid regimen should be initiated to manage this exacerbation.