PHARMACOTHERAPY REVIEW CNS STIMULANTS for treatment of ...

SEDATIVE-HYPNOTICS REVISITED – GERIATRIC CONSIDERATIONSAt the August 6, 2003 P&T Committee meeting, when addressing the issue of sedativehypnoticsto be considered for preferred drug status, the P&T Committee voted to table,for further evaluation, the recommendation that “no brand name first generationbenzodiazepine or nonbenzodiazepine GABA agonist is recommended for preferred drugstatus.”P&T Committee discussion revolved around the clinical propriety of benzodiazepineGABA agonist use in the elderly in the context of the “Beers List.” The possible additionof a brand name nonbenzodiazepine GABA agonist to the recommendation for preferredstatus was discussed.The Beer’s List is a national guideline for fostering safe, appropriate and effectivemedication management in the elderly. Criteria were originally developed in 1991 (BeersMH, Ouslander JG, Rollingher I, et al. Explicit criteria for determining inappropriatemedication use in nursing home residents. Arch Intern Med. 1991;151:1825-32). Thesecriteria were updated in 1997 (Beers MH. Explicit criteria for determining potentiallyinappropriate medication use by the elderly: an update. Arch Intern Med. 1997;157:1531-36.) and are included in Attachment A for review.Table 1 of Attachment A (Beer’s List) is a list of medications to avoid or use withinspecified dose and duration ranges in elderly patients. These criteria were developedspecifically for the frail elderly patient, especially those who are residents of long-termcare facilities. The drugs in Table 1 do not represent absolute contraindications, are notabsolutely contraindicated in the elderly as per the package labeling, and may beacceptable for use in most elderly patients.Table 2 of Attachment A (Beer’s List) is a suggested list of medications to avoid inelderly patients with specific diseases. Risk severity is rated as low or high. Medicationssuggested for avoidance in the elderly under certain medical conditions are not inalignment with package labeling as they are not typically listed as absolutecontraindications in package labeling. The drug-disease recommendations in Table 2 ofthe Beer’s List (attachment A) are typically presented as warnings, precautions, riskfactors, or special considerations for special populations in the package labeling.Selection and use is then left to the clinical judgment of the prescriber.Within the specific context of sedative-hypnotic prescription drugs, the potentialproblem/relative risk is listed as the same between the benzodiazepine GABA agonists,temazepam and triazolam, and the nonbenzodiazepine GABA agonist, zolpidem (Table 1,Attachment A). Guidance in the Beer’s List is on selecting appropriate doses oftemazepam (15 mg), triazolam (0.25 mg) or zolpidem (5 mg). The Beer’s List ranks thepotential severity of risk from use of temazepam, triazolam and zolpidem as low for allthree agents.