Per policy, orders for these non-formulary agents will be changed to formulary equivalents.
Non-Formulary Agent
Formulary Equivalent
flurbiprofen (Ansaid) 50 mg
ibuprofen (Motrin) 400 mg
flurbiprofen (Ansaid) 100 mg BID, TID
ibuprofen (Motrin) 600 mg QID
flurbiprofen (Ansaid) 100 mg daily
ibuprofen (Motrin) 600 mg BID
2023 American Geriatrics Society Beers Criteria® for potentially inappropriate medication use in older adults.
Medication:
flurbiprofen (Ansaid, Ocufen)
Criteria 1: Potentially inappropriate medication use in older adults. (Table 2)
Drug(s)
non-COX-2-selective NSAIDs, oral
Rationale
Increased risk of GI bleeding or peptic ulcer disease in high-risk groups, including those >75 years old or taking oral or parenteral corticosteroids, anticoagulants, or antiplatelet agents; use of proton-pump inhibitor or miSOPROStol reduces but does not eliminate risk. Upper GI ulcers, gross bleeding or perforation caused by NSAIDs occur in ~1% of patients treated for 3-6 months and in ~2%-4% of patients treated for 1 year; these trends continue with longer duration of use. Also can increase blood pressure and induce kidney injury. Risks are dose-related.
Recommendation
Avoid chronic use unless other alternatives are not effective and the patient can take a gastroprotective agent (proton-pump inhibitor or miSOPROStol). Avoid short-term scheduled use in combination with oral or parenteral corticosteroids, anticoagulants or antiplatelet agents unless other alternatives are not effective and the patient can take a gastroprotective agent (proton-pump inhibitor or miSOPROStol).
Quality of evidence: Moderate, Strength of Recommendation: Strong
Criteria 2: Potentially inappropriate medication use in older adults due to drug–disease or drug–syndrome interactions that may exacerbate the disease or syndrome. (Table 3)
Drug(s) ⇆ disease or syndrome
NSAIDs and COX-2 inhibitors ⇄ Heart failure
Rationale
Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation
Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: Moderate, Strength of Recommendation: Strong
Drug(s) ⇆ disease or syndrome
non-COX-2 selective NSAIDs ⇄ History of gastric or duodenal ulcers
Rationale
May exacerbate existing ulcers or cause new/additional ulcers
Recommendation
Avoid unless other alternatives are not effective and the patient can take a gastroprotective agent (i.e., proton-pump inhibitor or miSOPROStol).
Quality of evidence: Moderate, Strength of Recommendation: Strong
Criteria 5: medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults. (Table 6)
CrCl (mL/min) at which action is required
<30
Rationale
NSAIDs (oral and parenteral) may increase the risk of acute kidney injury and a further decline in kidney function.
Recommendation
Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong
Avoid short-term scheduled use in combination with oral or parenteral corticosteroids, anticoagulants or antiplatelet agents unless other alternatives are not effective and the patient can take a gastroprotective agent (proton-pump inhibitor or miSOPROStol).