You'll see renewed focus on appropriate med use in patients 65 and older...due to new Beers Criteria from the American Geriatrics Society.

Continue to think of these guidelines as a "warning light" to be cautious with certain meds...NOT a "stop sign" to always avoid them.

PPIs are new to the list. Discourage using PPIs for over 8 weeks without a good reason, such as chronic oral steroid use. Explain PPIs are linked to a higher risk of C. difficile, fractures, pneumonia, etc.

Help patients taper off a PPI if needed. Advise lowering the dose, then taking it every OTHER day for a week or more before stopping.

"Z drugs" (zolpidem, zaleplon, eszopiclone) are a concern now when used for ANY duration...not just over 90 days. Potential harms...such as delirium, falls, and fractures...seem to outweigh any benefit.

Keep in mind not to turn to benzos...they're still on the list and aren't safer for sleep. Instead, emphasize nondrug strategies. Or consider suggesting low doses of trazodone or doxepin...or ramelteon.

Nitrofurantoin used to be discouraged for UTIs if CrCl < 60 mL/min. But now feel comfortable suggesting it short-term if CrCl ≥ 30 mL/min...since new evidence supports its safety and efficacy in these patients.

Digoxin should now be saved for atrial fib or heart failure patients only when other options aren't enough...since it may increase mortality. If digoxin must be used, recommend a max of 0.125 mg/day.

Warfarin with amiodarone, anticholinergic combos, and other interactions can be riskier in seniors. Suggest avoiding if possible.

Direct oral anticoagulants (dabigatran, etc), famotidine, gabapentin, and others may cause more side effects in renal impairment. Advise reducing the med's dose or avoiding it...based on renal function.

Expect the Star Ratings high-risk med list to catch up eventually.

Diabetes patients will need your help sticking with metformin...since about 1 in 3 patients will have GI problems with it.

We know metformin is our go-to med for type 2s due to well-established safety and efficacy...possible CV benefits...and low cost. Plus it seems safer than previously thought in stable kidney disease.

But GI side effects can lead to poor adherence...impacting glucose control AND Star Ratings.

Be ready to help patients give metformin a fair trial.

Set the stage for what to expect. Explain that GI problems such as diarrhea are usually short-lived...especially with a slow titration.

Recommend starting with 500 mg daily...or even just 250 mg daily for some. Suggest titrating by 250 to 500 mg every 1 or 2 weeks as tolerated.

Advise backing off to the previous dose if GI side effects are a problem...and trying another dose increase after about 2 weeks.

It's okay if it takes weeks or months to reach the target dose of 2 g/day. And don't feel compelled to aim for doses higher than this...they don't lower glucose much more, but may increase GI side effects.

Consider REtitrating if a patient stops metformin for even a couple of days...especially if GI problems occurred when it was started.

Avoid administration pitfalls. For example, suggest taking metformin during or right after a large meal to improve tolerability.

If needed, suggest giving the ER dose BID instead of once daily.

Suggest switching metformin products if needed. Extended-release forms often need less frequent dosing...and seem to cause fewer GI side effects. Plus, some of the ER generics now cost as little as $10/month.

Discourage Glumetza. It's the only metformin ER product without a generic, and it costs about $6700 per month...and that's not a typo. Plus, there's no good evidence any ER product is better tolerated than another.

Also consider a different generic if pill odor is a problem. Odor varies between products...and ER tabs may not smell as bad.

This PL Voices episode is a clip from one of our many editorial discussions.

This one took place on February 17, 2016 and is led by our Editor, Sherri Boehringer, PharmD, BCPS. You’ll hear the voices of preventive medicine expert JoAnn E. Manson, MD, DrPH, FAHA, Harvard Medical School, Massachusetts; and guest panelist Barbara P. Yawn, MD, MSc, MPSH, FAAFP, University of Minnesota. You can read our brief, to-the-point Recommendation and dive into the evidence-based details if you wish.

To learn more, visit pharmacistsletter.com.

This PL Voices episode is a clip from one of our many editorial discussions.

This one took place on February 17, 2016 and is led by our Editor, Sherri Boehringer, PharmD, BCPS. You’ll hear the voice of Editorial Board member Craig D. Williams, PharmD, FNLA, BCPS, Oregon Health and Science University. You’ll also listen to depression expert, Barbara P. Yawn, MD, MSc, MPSH, FAAFP, University of Minnesota. You can read our brief, to-the-point Recommendation and dive into the evidence-based details if you wish.

To learn more, visit pharmacistsletter.com.

This PL Voices episode is a clip from one of our many editorial discussions.

This one took place on February 17, 2016 and is led by our Editor, Sherri Boehringer, PharmD, BCPS. You’ll hear the voices of Editorial Board members Steven E. Nissen, MD, MACC, Cleveland Clinic, Ohio; and Craig D. Williams, PharmD, FNLA, BCPS, Oregon Health and Science University. You’ll also listen to cardiovascular disease expert Suzanne Oparil, MD, FACC, FAHA, FASH, FAPS, University of Alabama at Birmingham. You can read our brief, to-the-point Recommendation and dive into the evidence-based details if you wish.

To learn more, visit pharmacistsletter.com.