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• 他のClCr推定方法Table 1. Formulas available for estimating creatinine clearance1,14,15,17,18 Southern Medical Journal 2012;105:437-445Creatinineclearance estimate Formula CommentsCockcroft-Gault formula Estimated creatinine clearance (mL/min) = Widely used; Cockroft-Gault equation is used to make dosage adjustments, [140 j age (y) Â weight (kg)]/(72 Â SCr) because this is how drug manufacturers establish their dosing recommendations. This is mandated by the FDA. Multiply by 0.85 if female Use ideal body weight: The process of rounding the SCr concentration up by 1.0 mg/dL is not Men = 50 + (2.3 Â number of inches over 5 ft) supported by medical evidence. Women = 45.5 + (2.3 Â number of inches over 5 ft)Abbreviated Estimated glomerular ﬁltration rate May be most effective in patients with diabetic kidney disease, patients MDRD equation (mL/min/1.73 m2) = 186 Â serum creatinine with chronic kidney disease in middle age (average age 51 y), black (mg/dL) Y 1.154 Â age (y) Y 0.203: patients with hypertensive chronic kidney disease, and patients with & Â (0.742 if female) preexisting kidney disease. The MDRD equation is often used to stage patients’ degree of kidney dysfunction. & Â (1.210 if African American)Actual 24-h Time-consuming and increases work for nursing Pregnant women, patients with extremes of age and weight, patients with creatinine collection malnutrition, patients with skeletal muscle diseases, patients with paraplegia or quadriplegia, patients consuming a vegetarian diet and with rapidly changing kidney functionCircumstances under which these equations are not effective for estimating renal function: extreme body weight: body mass index G19 or 935 kg/m2, signiﬁcantmuscle mass abnormality (amputations, loss of muscle mass, muscle disease, or paralysis), acute kidney failure, pregnancy, severe hepatopathy, generalized edema,or ascites.FDA, Food and Drug Administration; MDRD = modiﬁcation of diet in renal disease; SCr = serum creatinine.commonly used calculation, although many practitioners prefer what would provide the most accurate estimation of a patient’sthe MDRD formula, which may prove to be more accurate than creatinine clearance.20,21other formulas even though it has not been used for as long as In summary, the altered pharmacokinetics observed inCockroft-Gault. In elderly adults, a low serum creatinine is not most elderly patients signiﬁcantly affect the particular phar-always indicative of normal renal function. Because older adults macokinetics of a drug. These changes are summarized inhave lower muscle mass than younger people, low serum cre- Table 2. Although drug absorption is probably least affected
Table 1 (continued from page 1)AGS BEERS CRITERIA TABLE 1: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Organ System/ Recommendation, Rationale,FOR POTENTIALLY INAPPROPRIATE Therapeutic Category/Drug(s) Quality of Evidence (QE) & Strength of Recommendation (SR) Antispasmodics Avoid except in short-term palliative care to decreaseMEDICATION USE IN OLDER ADULTS n Belladonna alkaloids oral secretions. n Clidinium-chlordiazepoxideFROM THE AMERICAN GERIATRICS SOCIETY n Dicyclomine Highly anticholinergic, uncertain effectiveness. n HyoscyamineThis clinical tool, based on The AGS 2012 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older n Propantheline QE = Moderate; SR = StrongAdults (AGS 2012 Beers Criteria), has been developed to assist healthcare providers in improving medication safety in n Scopolamineolder adults. Our purpose is to inform clinical decision-making concerning the prescribing of medications for olderadults in order to improve safety and quality of care. Antithrombotics Dipyridamole, oral short-acting* (does not Avoid.Originally conceived of in 1991 by the late Mark Beers, MD, a geriatrician, the Beers Criteria catalogues medications apply to the extended-release combination with May cause orthostatic hypotension; more effective alternativesthat cause adverse drug events in older adults due to their pharmacologic properties and the physiologic changes of aspirin) available; IV form acceptable for use in cardiac stress testing.aging. In 2011, the AGS undertook an update of the criteria, assembling a team of experts and funding the develop- QE = Moderate; SR = Strongment of the AGS 2012 Beers Criteria using an enhanced, evidence-based methodology. Each criterion is rated (qual- Ticlopidine* Avoid.ity of evidence and strength of evidence) using the American College of Physicians’ Guideline Grading System, which Safer, effective alternatives available.is based on the GRADE scheme developed by Guyatt et al. QE = Moderate; SR = StrongThe full document together with accompanying resources can be viewed online at www.americangeriatrics.org. Anti-infective Nitrofurantoin Avoid for long-term suppression; avoid in patients withINTENDED USE CrCl <60 mL/min.The goal of this clinical tool is to improve care of older adults by reducing their exposure to Potentially Inappropri- Potential for pulmonary toxicity; safer alternatives available; lack ofate Medications (PIMs). n This should be viewed as a guide for identifying medications for which the risks of use in older adults outweigh concentration in the urine. QE = Moderate; SR = Strong n These criteria are not meant to be applied in a punitive manner. n This list is not meant to supersede clinical judgment or an individual patient’s values and needs. Prescribing and Cardiovascular managing disease conditions should be individualized and involve shared decision-making. Alpha1 blockers Avoid use as an antihypertensive. n These criteria also underscore the importance of using a team approach to prescribing and the use of non- n Doxazosin High risk of orthostatic hypotension; not recommended as routine n Prazosin treatment for hypertension; alternative agents have superior risk/ pharmacological approaches and of having economic and organizational incentives for this type of model. n Implicit criteria such as the STOPP/START criteria and Medication Appropriateness Index should be used in n Terazosin a complementary manner with the 2012 AGS Beers Criteria to guide clinicians in making decisions about safe QE = Moderate; SR = Strong medication use in older adults. Alpha agonists - n Clonidine ers as listed.The criteria are not applicable in all circumstances (eg, patient’s receiving palliative and hospice care). If a clinician is n Guanabenz* High risk of adverse CNS effects; may cause bradycardia and n Guanfacine* orthostatic hypotension; not recommended as routine treatmentof the medication as potentially inappropriate can serve as a reminder for close monitoring so that the potential for n Methyldopa* for hypertension.an adverse drug effect can be incorporated into the medical record and prevented or detected early. n Reserpine (>0.1 mg/day)* QE = Low; SR = Strong Antiarrhythmic drugs (Class Ia, Ic, III) n AmiodaroneTABLE 1: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults n Dofetilide n Dronedarone Organ System/ Recommendation, Rationale, n Flecainide harms than rhythm control for most older adults. Therapeutic Category/Drug(s) Quality of Evidence (QE) & Strength of Recommendation (SR) n IbutilideAnticholinergics (excludes TCAs) n Procainamide Amiodarone is associated with multiple toxicities, including thyroidFirst-generation antihistamines (as single Avoid. n Propafenone disease, pulmonary disorders, and QT interval prolongation.agent or as part of combination products) n Quinidine QE = High; SR = Strongn Brompheniramine Highly anticholinergic; clearance reduced with advanced age, and n Sotaloln Carbinoxamine tolerance develops when used as hypnotic; increased risk of confu- Disopyramide* Avoid.n Chlorpheniramine sion, dry mouth, constipation, and other anticholinergic effects/ Disopyramide is a potent negative inotrope and therefore mayn Clemastine toxicity. induce heart failure in older adults; strongly anticholinergic; othern Cyproheptadine antiarrhythmic drugs preferred.n Dexbrompheniramine Use of diphenhydramine in special situations such as acute treat- QE = Low; SR = Strongn Dexchlorpheniramine ment of severe allergic reaction may be appropriate.n Diphenhydramine (oral) Dronedaronen Doxylamine heart failure. QE = High (Hydroxyzine and Promethazine), Moderate (All others); SRn Hydroxyzine = Strongn Promethazine Worse outcomes have been reported in patients taking drone-n Triprolidine general, rate control is preferred over rhythm control for atrialAntiparkinson agents Avoid.n Benztropine (oral) QE = Moderate; SR = Strongn Trihexyphenidyl Not recommended for prevention of extrapyramidal symptoms Digoxin >0.125 mg/day Avoid. with antipsychotics; more effective agents available for treatment of In heart failure, higher dosages associated with no additional Parkinson disease. may increase risk of toxicity. QE = Moderate; SR = Strong QE = Moderate; SR = Strong
Table 1 (continued from page 2) Table 1 (continued from page 3) TABLE 1: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults TABLE 1: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Organ System/ Recommendation, Rationale, Organ System/ Recommendation, Rationale, Therapeutic Category/Drug(s) Quality of Evidence (QE) & Strength of Recommendation (SR) Therapeutic Category/Drug(s) Quality of Evidence (QE) & Strength of Recommendation (SR) Nifedipine, immediate release* Avoid. Nonbenzodiazepine Avoid chronic use (>90 days) hypnotics Benzodiazepine-receptor agonists that have adverse events similar Potential for hypotension; risk of precipitating myocardial ischemia. n Eszopiclone to those of benzodiazepines in older adults (e.g., delirium, falls, QE = High; SR = Strong n Zolpidem fractures); minimal improvement in sleep latency and duration. n Zaleplon QE = Moderate; SR = StrongSpironolactone >25 mg/day Avoid in patients with heart failure or with a CrCl <30 mL/min. Ergot mesylates* Avoid. Isoxsuprine* In heart failure, the risk of hyperkalemia is higher in older adults if QE = High; SR = Strong taking >25 mg/day. QE = Moderate; SR = Strong Endocrine Androgens Avoid unless indicated for moderate to severeCentral Nervous System n Methyltestosterone* hypogonadism.Tertiary TCAs, alone or in combination: Avoid. n Testosterone Potential for cardiac problems and contraindicated in men withn Amitriptyline prostate cancer.n Chlordiazepoxide- Highly anticholinergic, sedating, and cause orthostatic hypotension; QE = Moderate; SR = Weak amitriptyline Desiccated thyroid Avoid.n Clomipramine to that of placebo. Concerns about cardiac effects; safer alternatives available.n QE = Low; SR = Strongn Imipramine QE = High; SR = Strongn Perphenazine-amitriptyline Estrogens with or without progestins Avoid oral and topical patch.Topical vaginal cream: Ac-n Trimipramine management of dyspareunia, lower urinary tract infec- - tions, and other vaginal symptoms.ond- (atypical) generation (see online for full list) non-pharmacologic options have failed and patient is Evidence of carcinogenic potential (breast and endometrium); lack threat to self or others. of cardioprotective effect and cognitive protection in older women. Evidence that vaginal estrogens for treatment of vaginal dryness is Increased risk of cerebrovascular accident (stroke) and mortality in safe and effective in women with breast cancer, especially at dos- persons with dementia. QE = Moderate; SR = Strong QE = High (Oral and Patch), Moderate (Topical); SR = Strong (Oral andThioridazine Avoid. Patch),Weak (Topical)Mesoridazine Growth hormone Avoid, except as hormone replacement following pituitary Highly anticholinergic and greater risk of QT-interval prolongation. gland removal. QE = Moderate; SR = Strong Effect on body composition is small and associated with edema, arthralgia, carpal tunnel syndrome, gynecomastia, impaired fastingBarbiturates Avoid. glucose.n Amobarbital*n Butabarbital* QE = High; SR = Strongn Butalbital greater risk of overdose at low dosages. Insulin, sliding scale Avoid.n Mephobarbital* Higher risk of hypoglycemia without improvement in hyperglyce-n Pentobarbital* QE = High; SR = Strong mia management regardless of care setting.n Phenobarbital QE = Moderate; SR = Strongn Secobarbital* Megestrol Avoid.Benzodiazepines - Minimal effect on weight; increases risk of thrombotic events andShort- and intermediate-acting: nia, agitation, or delirium. possibly death in older adults. n Alprazolam QE = Moderate; SR = Strong n Estazolam Older adults have increased sensitivity to benzodiazepines and Sulfonylureas, long-duration Avoid. n decreased metabolism of long-acting agents. In general, all ben- n Chlorpropamide Chlorpropamide: prolonged half-life in older adults; can cause nOxazepam zodiazepines increase risk of cognitive impairment, delirium, falls, n Glyburide prolonged hypoglycemia; causes SIADH nTemazepam fractures, and motor vehicle accidents in older adults. Glyburide: higher risk of severe prolonged hypoglycemia in older nTriazolam adults.Long-acting: May be appropriate for seizure disorders, rapid eye movement QE = High; SR = Strong n Chlorazepate sleep disorders, benzodiazepine withdrawal, ethanol withdrawal, n Chlordiazepoxide severe generalized anxiety disorder, periprocedural anesthesia, Gastrointestinal n Chlordiazepoxide-amitriptyline end-of-life care. Metoclopramide Avoid, unless for gastroparesis. n Clidinium-chlordiazepoxide Can cause extrapyramidal effects including tardive dyskinesia; risk n Clonazepam QE = High; SR = Strong may be further increased in frail older adults. n Diazepam QE = Moderate; SR = Strong n Flurazepam n Quazepam Mineral oil, given orally Avoid. Potential for aspiration and adverse effects; safer alternatives avail-Chloral hydrate* Avoid. able. QE = Moderate; SR = Strong light of overdose with doses only 3 times the recommended dose. Trimethobenzamide Avoid. QE = Low; SR = Strong One of the least effective antiemetic drugs; can cause extrapyrami-Meprobamate Avoid. dal adverse effects. High rate of physical dependence; very sedating. QE = Moderate; SR = Strong QE = Moderate; SR = Strong
Table 1 (continued from page 4) Table 2 (continued from page 5) TABLE 1: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults TABLE 2: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to Drug- Organ System/ Recommendation, Rationale, Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome Therapeutic Category/Drug(s) Quality of Evidence (QE) & Strength of Recommendation (SR) Disease or Drug(s) Recommendation, Rationale, Quality of Evidence Syndrome (QE) & Strength of Recommendation (SR) Pain Medications Syncope Acetylcholinesterase inhibitors (AChEIs) Avoid. Meperidine Avoid. Peripheral alpha blockers Not an effective oral analgesic in dosages commonly used; may n Doxazosin Increases risk of orthostatic hypotension or brady- cause neurotoxicity; safer alternatives available. n Prazosin cardia. QE = High; SR = Strong n Terazosin QE = High (Alpha blockers), Moderate (AChEIs,TCAs andNon-COX-selective NSAIDs, oral Avoid chronic use unless other alternatives are not effec- Tertiary TCAs antipsychotics); SR = Strong (AChEIs and TCAs),Weakn Aspirin >325 mg/day tive and patient can take gastroprotective agent (proton- (Alpha blockers and antipsychotics)n Diclofenac Chlorpromazine, thioridazine, and olan-n zapinen Etodolac Increases risk of GI bleeding/peptic ulcer disease in high-risk Central Nervous Systemn Fenoprofenn Ibuprofen corticosteroids, anticoagulants, or antiplatelet agents. Use of pro- Chronic Bupropion Avoid.n Ketoprofen ton pump inhibitor or misoprostol reduces but does not eliminate seizures or Chlorpromazinen Meclofenamate risk. Upper GI ulcers, gross bleeding, or perforation caused by epilepsy Clozapinen Mefenamic acid Maprotiline patients with well-controlled seizures in whom alter-n Meloxicam months, and in about 2%–4% of patients treated for 1 year. These Olanzapine native agents have not been effective.n Nabumetone trends continue with longer duration of use. Thioridazinen Naproxen Thiothixene QE = Moderate; SR = Strongn Oxaprozin QE = Moderate; SR = Strong Tramadoln Piroxicam Delirium All TCAs Avoid.n Sulindac Anticholinergics (see online for full list)n Tolmetin Benzodiazepines Avoid in older adults with or at high risk of delirium Chlorpromazine because of inducing or worsening delirium in olderIndomethacin Avoid. Corticosteroids adults; if discontinuing drugs used chronically, taper toKetorolac, includes parenteral Increases risk of GI bleeding/peptic ulcer disease in high-risk H2-receptor antagonist avoid withdrawal symptoms. groups (See Non-COX selective NSAIDs) Meperidine Of all the NSAIDs, indomethacin has most adverse effects. Sedative hypnotics QE = Moderate; SR = Strong QE = Moderate (Indomethacin), High (Ketorolac); SR = Strong ThioridazinePentazocine* Avoid. Dementia Anticholinergics (see online for full list) Avoid. Opioid analgesic that causes CNS adverse effects, including confu- & cognitive Benzodiazepines Avoid due to adverse CNS effects. sion and hallucinations, more commonly than other narcotic drugs; impairment H2-receptor antagonists Avoid antipsychotics for behavioral problems of is also a mixed agonist and antagonist; safer alternatives available. Zolpidem dementia unless non-pharmacologic options have QE = Low; SR = Strong Antipsychotics, chronic and as-needed use failed and patient is a threat to themselves or others.Skeletal muscle relaxants Avoid. Antipsychotics are associated with an increased riskn Carisoprodol Most muscle relaxants poorly tolerated by older adults, because of of cerebrovascular accident (stroke) and mortality inn Chlorzoxazone anticholinergic adverse effects, sedation, increased risk of fractures; persons with dementia.n Cyclobenzaprine effectiveness at dosages tolerated by older adults is questionable. QE = High; SR = Strongn Metaxalone QE = Moderate; SR = Strong History Anticonvulsants Avoid unless safer alternatives are not avail-n Methocarbamol of falls or Antipsychoticsn Orphenadrine fractures Benzodiazepines*Infrequently used drugs. Table 1 Abbreviations: ACEI, angiotensin converting-enzyme inhibitors; ARB, angiotensin Nonbenzodiazepine hypnotics Ability to produce ataxia, impaired psychomotor n Eszopiclone function, syncope, and additional falls; shorter-actingreceptor blockers; CNS, central nervous system; COX, cyclooxygenase; CrCl, creatinine clearance; GI, gastroin- n Zaleplon benzodiazepines are not safer than long-acting ones. n Zolpidemsecretion; SR, Strength of Recommendation; TCAs, tricyclic antidepressants; QE, Quality of Evidence QE = High; SR = Strong TCAs/SSRIsTABLE 2: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to Drug-Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome Insomnia Oral decongestants Avoid. n PseudoephedrineDisease or Drug(s) Recommendation, Rationale, Quality of Evidence n Phenylephrine Stimulants CNS stimulant effects.Syndrome (QE) & Strength of Recommendation (SR) n AmphetamineCardiovascular n Methylphenidate QE = Moderate; SR = StrongHeart failure NSAIDs and COX-2 inhibitors Avoid. n Pemoline Theobromines n Theophylline Nondihydropyridine CCBs (avoid only for - n Caffeine systolic heart failure) bate heart failure. Parkinson’s All antipsychotics (see online publica- Avoid. n Diltiazem disease tion for full list, except for quetiapine and Dopamine receptor antagonists with potential to n Verapamil QE = Moderate (NSAIDs, CCBs, Dronedarone), High (Thia- clozapine) worsen parkinsonian symptoms. zolidinediones (glitazones)), Low (Cilostazol); SR = Strong Pioglitazone, rosiglitazone Antiemetics Quetiapine and clozapine appear to be less likely to n Metoclopramide precipitate worsening of Parkinson disease. Cilostazol n Prochlorperazine Dronedarone n Promethazine QE = Moderate; SR = Strong
Table 2 (continued from page 6) Table 2 (continued from page 7) TABLE 2: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to Drug- TABLE 2: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to Drug- Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome Disease or Drug(s) Recommendation, Rationale, Quality of Evidence Disease or Drug(s) Recommendation, Rationale, Quality of Evidence Syndrome (QE) & Strength of Recommendation (SR) Syndrome (QE) & Strength of Recommendation (SR) Gastrointestinal Inhaled anticholinergic agents Avoid in men. Chronic Oral antimuscarinics for urinary inconti- Avoid unless no other alternatives. urinary tract constipation nence symptoms, Strongly anticholinergic drugs, except - n Darifenacin Can worsen constipation; agents for urinary incon- benign antimuscarinics for urinary incontinence tion. n Fesoterodine tinence: antimuscarinics overall differ in incidence of prostatic (see Table 9 for complete list). n Oxybutynin (oral) constipation; response variable; consider alternative hyperplasia QE = Moderate; SR = Strong (Inhaled agents),Weak (All n Solifenacin agent if constipation develops. others) n Tolterodine Stress or Alpha-blockers Avoid in women. n Trospium QE = High (For Urinary Incontinence), Moderate/Low (All mixed n Doxazosin Others); SR = Strong urinary in- n Prazosin Aggravation of incontinence. Nondihydropyridine CCB continence n Terazosin n Diltiazem QE = Moderate; SR = Strong n Verapamil Table 2 Abbreviations: CCBs, calcium channel blockers; AChEIs, acetylcholinesterase inhibitors; CNS, central ner- First-generation antihistamines as single - agent or part of combination products tion; SSRIs, selective serotonin reuptake inhibitors; TCAs, tricyclic antidepressants; QE, Quality of Evidence n Brompheniramine (various) n Carbinoxamine n Chlorpheniramine TABLE 3: 2012 AGS Beers Criteria for Potentially Inappropriate Medications to Be Used with Caution in n Clemastine (various) Older Adults n Cyproheptadine Drug(s) Recommendation, Rationale, Quality of Evidence (QE) & Strength of Recommenda- n Dexbrompheniramine tion (SR) n Dexchlorpheniramine (various) Aspirin for primary preven- n Diphenhydramine tion of cardiac events n Doxylamine n Hydroxyzine QE = Low; SR = Weak n Promethazine n Triprolidine Dabigatran Anticholinergics/antispasmodics (see online for full list of drugs with strong anticholinergic properties) QE = Moderate; SR = Weak n Antipsychotics Prasugrel n Belladonna alkaloids n Clidinium-chlordiazepoxide n Dicyclomine risk older patients (eg, those with prior myocardial infarction or diabetes). n Hyoscyamine QE = Moderate; SR = Weak n Propantheline n Scopolamine Antipsychotics Use with caution. n Tertiary TCAs (amitriptyline, clomip- Carbamazepine Carboplatin May exacerbate or cause SIADH or hyponatremia; need to monitor sodium level ramine, doxepin, imipramine, and trimip- Cisplatin closely when starting or changing dosages in older adults due to increased risk. ramine) MirtazapineHistory of Aspirin (>325 mg/day) Avoid unless other alternatives are not ef- SNRIs QE = Moderate; SR = Stronggastric or Non–COX-2 selective NSAIDs fective and patient can take gastroprotective SSRIsduodenal TCAsulcers Vincristine May exacerbate existing ulcers or cause new/addi- Vasodilators Use with caution. tional ulcers. QE = Moderate; SR = Strong May exacerbate episodes of syncope in individuals with history of syncope.Kidney/Urinary Tract QE = Moderate; SR = WeakChronic kid- NSAIDs Avoid. Table 3 Abbreviations: CrCl, creatinine clearance; SIADH, syndrome of inappropriate antidiuretic hormoneney disease secretion; SSRIs, selective serotonin reuptake inhibitors; SNRIs, serotonin–norepinephrine reuptake inhibitors;stages IV May increase risk of kidney injury. SR, Strength of Recommendation; TCAs, tricyclic antidepressants; QE, Quality of Evidenceand V Triamterene (alone or in combination) May increase risk of acute kidney injury. The American Geriatrics Society gratefully acknowledges the support of the John A. Hartford Foundation, QE = Moderate (NSAIDs), Low (Triamterene); SR = Strong Retirement Research Foundation and Robert Wood Johnson Foundation. (NSAIDs),Weak (Triamterene) AGSUrinary Estrogen oral and transdermal (excludes Avoid in women.incontinence intravaginal estrogen) THE AMERICAN GERIATRICS SOCIETY(all types) in Aggravation of incontinence. Geriatrics Health Professionals.women QE = High; SR = Strong www.americangeriatrics.org
アドヒアランスのチェック MANAGING MEDICATIONS IN CLINICALLY COMPLEX ELDERS• アドヒアランスを障害する因子 JAMA. 2010;304(14):1592-1601 g Table 1. Barriers to Medication Adherence and Targeted Solutions i Barriers Potential Solutions a Forgetting to take; Use pill organizers, medication calendars, blister limited organizational packs, electronic dispensing devices; simplify c skills regimen and reduce pill burden; encourage i active family/caregiver involvement; use Internet-linked or electronic adherence aids e and reporting systems m Patient believes drug is Work collaboratively with patient to address c not needed, is concerns and establish shared goals of care; ineffective, or that provide educational (including literacy- p too many drugs appropriate) materials using teach-back c are being taken approach; assess drug effectiveness; simplify m regimen and reduce pill burden Difficulty taking Substitute with easier-to-use medications (eg, p (eg, opening pill liquid if trouble swallowing; ordering easy-off g bottles, swallowing) caps); simplify regimen and reduce pill i burden; use pill cutters, oral dosing syringes, insulin syringe magnification, spacer for i inhalers Cost Substitute with lower-cost medications (eg, G generic vs brand name) and reduce unnecessary ones; assess prescription drug M insurance and direct patient to apply for t low-income subsidy and prescription drug assistance programs h
どの薬剤を切るべきか？creased compared with the control group. The present studytests the feasibility of applying the same algorithm in com- Discuss the following with the patient/guardian • 各患者背景,munity-dwelling elderly patients. An evidence-based consensus exists for using the Yes drug for the indication given in its current dosing rate リスク-ベネフィットを考慮し, METHODS in this patient’s age group and disability level, and the benefit outweighs all possible known adverse effects No/Not sure 中止,STUDY PARTICIPANTS 変更を決める. No Indication seems valid and relevant in this patient’s age S group and disability level TThis prospective cohort study included consecutive elderly pa- Otients referred by their family physician or family for compre- Yes P Dhensive geriatric assessments from February 2005 through June Yes R2008 and excluded patients with advanced disease (cancer or Do the known possible adverse reactions of the drug U outweigh possible benefit in old, disabled patients? Gnoncancer) in whom the initial estimate of life expectancy wasless than 3 months and patients in whom follow-up availabil- No • 入院というイベントはity was shorter than 4 months. Participants were assessed and Yesrecommendations were made on medications based on the Good Any adverse symptoms or signs that may be related to S the drug? H 薬剤調節の最も良い機会とPalliative–Geriatric Practice (GP-GP) algorithm (Figure).12 As-sessments were performed either at the day care center for se- No I F Tnior citizens in Pardes Hana or at the patient’s home in Israel. T 捉えるべし.The rationale for recommendations was then explained and dis- Is there another drug that may be superior to the one in question? Yes Ocussed in detail with each patient and/or guardian/family. They A Nwere informed of the pros and cons of each medication pre- No Oscribed, the level of evidence for a positive benefit to risk ratio T Can the dosing rate be reduced with no significant risk? Hand its possible impact on longevity and quality of life. Fol- Elowing this discussion and based on patient and/or guardian/ Rfamily preferences and consent, detailed letters were sent to the No Yes D Rfamily physicians with recommendations to stop as many “non– U Continue with the same dosing rate Reduce dose Glife saving drugs” as possible for at least 3 months. When stop-ping a Intern Med. 2010;170(18):1648-1654 appropriate, dose Arch drug therapy was not considered