American Society of Consultant Pharmacists
View all recommendations from this societyReleased June 8, 2022
Don’t use three or more CNS-active medications (antidepressants, benzodiazepines, Z-drugs, opioids, gabapentinoids, antipsychotics, antiepileptics), especially in older adults.
There is strong evidence linking the use of multiple CNS-active medications with serious adverse drug events in older adults. Specifically, older adults taking multiple CNS-active medications are at an increased risk for falls and fractures. Furthermore, the combined use of opioids with gabapentinoids increases the risk of opioid-related death. There is high quality of evidence for avoiding combined use of benzodiazepine receptor agonists (benzodiazepines or Z-drugs defined as zopiclone, eszopiclone, zaleplon) and moderate evidence for avoiding combinations of other CNS-active medications. Despite these medications being considered potentially inappropriate in older adults who have a history of falls, many continue to take them after a serious injury.
Benzodiazepines and Z-drugs have minimal effectiveness for sleep and safer alternatives are available (e.g. for anxiety, consider SSRIs; for insomnia, consider treatment of underlying conditions interrupting sleep, and cognitive behavioral therapy). Maintaining patients on the lowest effective dose and evaluating periodically for deprescribing are prudent strategies to mitigate harm from CNS-active medications.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.
How The List Was Created
(1–5)
A deprescribing task force led by chair (Manju T. Beier, Pharm D, BCGP, FASCP) was created by ASCP in November 2018. Members comprised of pharmacists practicing in academia, community and long-term care settings. The chair also invited pharmacists from international countries (Canada and Australia) where deprescribing initiatives have a strong focus and literature base. The collective experience and knowledge represent a focus on medication management, medication selection and reconciliation, and monitoring for drug-drug interactions (DDIs). The emphasis is on older adults no matter where they reside in step with ASCP’s mission.
Definition wise, deprescribing is a stepwise reduction of unnecessary or potentially inappropriate medications in concert with patient and family goals and wishes. We recognize that even with the best of intentions, many older adults are left on unnecessary and potentially dangerous or duplicative medications that might precipitate adverse events and other negative outcomes.
The task force prioritized formulation of the Choosing Wisely (CW) List, since the goals of CW intersect and overlap with deprescribing initiatives. The list was created to address general medication regimen review statements, and more importantly to address the paucity of statements that address DDIs with several incriminating medication therapeutic classes prescribed for older adults. After a review of published CW statements on www.choosingwisely.org and also a review of CW statements published by international countries, it was decided by consensus to have a strong emphasis on DDIs.
After several virtual meetings, the CW workgroup was divided into subgroups to formulate DDIs that have a strong evidence base in the literature and those that focus on CNS therapeutic classes, anticholinergic burden, heightened bleeding risk, and other pivotal pharmacokinetic and pharmacodynamic DDIs. For each statement the group formulated a rationale that was evidence-based accompanied with several recent, pertinent references. The compiled list (after several virtual meetings and email discussion) was further reduced to top ten statements with the strongest evidence base and practice trends on medication management in older adults.
The top five list was selected by consensus for initial submission.
Attached is a recently published guest editorial in ASCP’s journal that highlights the emphasis on DDIs.
Beier MT. Vigilance of Drug-Drug Interactions to Mitigate ADRs: Front and Center for Pharmacists (Guest Editorial). Sr Care Pharm 2020; 35:336-7.
(6–10)
A deprescribing task force led by chair (Manju T. Beier, Pharm D, BCGP, FASCP) was created by ASCP in November 2018. Members comprised of pharmacists practicing in academia, community and long-term care settings. The chair also invited pharmacists from international countries (Canada and Australia) where deprescribing initiatives have a strong focus and literature base. The collective experience and knowledge represent a focus on medication management, medication selection and reconciliation, and monitoring for drug-drug interactions (DDIs). The emphasis for all our statements is on older adults no matter where they reside in step with ASCP’s mission. Our first 5 CW statements were published in May 2021.
As previously addressed, the rationale for the new 2022 list (statements 6–10) includes one medication review statement in older adults with limited life expectancy, and three statements emphasizing the adverse combination of CNS medications that have a strong evidence base in the literature including tramadol’s potential for greater harm than benefit for pain relief, especially in older adults. We had previously highlighted pharmacodynamic DDIs for heightened bleeding risk, and this time our statement addresses the complexity of pharmacokinetic DDIs with Direct Oral Anticoagulants (DOACs).
Sources
Maust DT, Strominger J, Bynum JPW, et al. Prevalence of Psychotropic and Opioid Prescription Fills Among Community-Dwelling Older Adults with Dementia in the US. JAMA. 2020;324(7):706–708.
Kurdi A. Opioids and gabapentinoids utilisation and their related-mortality trends in the United Kingdom primary care setting, 2010–2019: a cross-national, population-based comparison study. Front Pharmacol. 2021;12:732345.
Chen C, Lo-Ciganic WH, Winterstein AG, Tighe P, Wei YJJ. Concurrent use of prescription opioids and gabapentinoids in older adults. American Journal of Preventive Medicine. 2022;62(4):519-528.
By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 2019;67(4):674-694.
Hart LA, Phelan EA, Marcum Z, Yi JY, Gray SL. Use of Fall-Risk-Increasing Medications After a Fall in Older Adults: A Systematic Review. J Am Geriatr Soc 2020;68(6):1334-1343.
Hart LA, Walker R, Phelan EA, et al. Change in central nervous system-active medication use following fall-related injury in older adults. J American Geriatrics Society. 2022;70(1):168-177.
Bykov K, Bateman BT, Franklin JM, Vine SM, Patorno E. Association of gabapentinoids with the risk of opioid-related adverse events in surgical patients in the United States. JAMA Netw Open. 2020;3(12):e2031647.
Sutton EL. Insomnia. Ann Intern Med. 2021 Mar;174(3):ITC33-ITC48.
Maust DT, Strominger J, Kim HM, et al. Prevalence of Central Nervous System-Active Polypharmacy Among Older Adults With Dementia in the US. JAMA 2021;325(10):952-961.
