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PIMs+

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ClassGeneric
Monograph(s)

FDA drug monographs (aka, labels, sheets etc.) include "information about drugs, including biological products, approved for human use in the United States (see FAQ), but does not include information about FDA-approved products regulated by the Center for Biologics Evaluation and Research (for example, vaccines, allergenic products, blood and blood products, plasma derivatives, cellular and gene therapy products). For prescription brand-name drugs, Drugs@FDA typically includes the most recent labeling approved by the FDA (for example, Prescribing Information and FDA-approved patient labeling when available), regulatory information, and FDA staff reviews that evaluate the safety and effectiveness of the drug.

PIMs+

This list of Potentially Inappropriate Medicines (PIMs+™) has been developed to assist in optimal medication management and improved health outcomes for all older adults.  PIMs+™ is the result of a multidisciplinary collaborative effort of TaperMD, Department of Family Medicine McMaster University, and the American Society of Consultant Pharmacists. The PIMs+™ is updated on a continuous basis and is currently in beta testing and a collaborative team is reviewing the content. While we are in our beta version, the 2019 PIMs+™ is open to all at no cost.

We welcome your feedback on how to improve this resource.

Details

Our screens are based on single generic components.

Details links to both single generic products and products which contain the generic component.

Prescrire

From Prescrire's annual list of “drugs to avoid.” It contains references and suggestions for alternative medications. Prescrire is a non-profit continuing education organization, committed to better patient care.[http://english.prescrire.org/en/Summary.aspx]
For more information and references click here.

Black Box Warnings (BBW)

A boxed warning (often called a"black box warning") appears on a prescription drug’s label and is designed to call attention to serious or life-threatening risks.

If a medication has a black box warning, RxISK provides a quick summary of the warning. However, for full details, users must refer to the product data-sheet.[Food and Drug Administration (FDA)]

For more information and references click here.

Anticholinergic Burden (ACB)

Adverse effects of anticholinergic medications may contribute to events such as falls, delirium, and cognitive impairment in older patients.

Other adverse effects include blurred vision, confusion, constipation, dry mouth, increased body temperature, increased heart rate, increased intraocular pressure, pupil dilation, urinary retention.

Medicines are assigned an ACB score of no ACB (= 0 (shown as blank)) to definite (= 3). The ACB is cumulative.

If an older adult is taking one medication with an ACB score greater than 2 or having a total ACB score of 3 or more for all medications, consider reducing or changing medications. Where this is not possible, reduce doses as much as possible.

For more information and references click here.

Serotonin Syndrome (SS)

Serotonin syndrome is a consequence of excess serotonin on the CNS and/or peripheral nervous system.

Symptoms include cognitive (such as anxiety, agitation), autonomic (such as sweating and tachycardia), and somatic effects (such as tremor or shivering). These may range from barely perceptible to fatal, so should be considered when these symptoms are present in patients with polypharmacy.

For more information and references click here.

Hypotension Risk (HTON)

Medications that may increase hypotension.

  • Symptoms include falls, dizziness or lightheadedness
  • Falls, blurred vision, nausea, fatigue

For more information and references click here.

Chronic Kidney Disease (CKD)

These screens incorporate various sources, but the primary sources are a 2020 Paper:  Medications Used Routinely in Primary Care to be Dose-Adjusted or Avoided in People With Chronic Kidney Disease: Results of a Modified Delphi Study. https://journals.sagepub.com/doi/10.1177/1060028019897371

This paper reflects a consensus-based approach and shows similarities and differences from previous guidelines, including Hanlon et al and the American Geriatric Society.

Prolong QT & Induce TdP (QT)

General guidelines and screens from CredibleMeds®

This list contains drugs categorized by their potential to cause QT prolongation and/or torsades de pointes (TdP), a lethal arrhythmia. General guidelines from CredibleMeds® include:

  • If possible, do not prescribe QT-prolonging drugs to anyone with a QT > 440ms (female) or 420ms (male).
  • Do not allow the QT to exceed 500ms during titration with these drugs.
  • Be aware of drug interactions that could result in greater exposure to the QT- prolonging drugs by blocking their metabolism or delaying clearance.
  • Electrolyte abnormalities, age and female sex increase the risk.

Categories of risk:

  • Drugs with known risk of TdP.
  • Drugs with possible risk of TdP.
  • Drugs with conditional risk of TdP - i.e., can cause TdP under certain conditions.
  • Drugs to be avoided by congenital Long QT patients.

The cumulative burden is important - you can also click on an individual drug to see if the FDA label recommends ECG monitoring

For more information and references click here to visit the CredibleMeds® web site.

Dementia

The Medication Appropriateness Tool for Comorbid Health conditions in Dementia (MATCH-D) criteria provides expert consensus guidance about medication use for people with dementia. Click here to view.

The following are the definitions of the three stages of dementia used in the MATCH-D study along with the consensus guidance.

Early-stage dementia:mild cognitive impairment with a preserved ability to self‐care and undertake activities of daily living.”

Mid-stage dementia:moderate cognitive impairment with physical function often preserved. People with mid‐stage dementia may be living with support in the community or a low‐care residential aged care setting.”

Late-stage dementia:severe cognitive impairment and declining function (inability to recognize loved ones, unable to ambulate independently, incontinent of urine or feces).”

Early-stage

  • continue annual influenza vaccines indefinitely

Mid-stage

  • continue annual influenza vaccines indefinitely
  • use less stringent targets for blood pressure
  • use less stringent targets for blood glucose
  • cease lipid-lowering medications
  • cease medications that have a longer potential time to benefit than the person’s likely prognosis

Late-stage

  • use less stringent targets for blood glucose
  • only use diuretics for symptomatic management of heart failure
  • cease anti-hypertensive agents
  • cease lipid-lowering medications
  • cease medications to manage osteoporosis
  • cease anti-platelet, anti-coagulants and anti-thrombotic agents
  • cease all medications that do not also provide tangible symptom relief
  • cease medications that have a longer potential time to benefit than the person’s likely prognosis

For personal or professional use only. For commercial use, contact Peter.Wood@TaperMD.com.