Considerations for optimal prescribing in older adults

Julia Bareham; Rae Petrucha; Michael MacFadden; Alex Crawley

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Table 1.

Indications for the use of select medications and supplements in older adults

MEDICATION OR SUPPLEMENT	POSSIBLE INDICATIONS
Calcium	Dyspepsia: Calcium as an antacid might help to neutralize stomach acid and therefore reduce mild heartburn or GERD symptoms (eg, symptoms <3 times/wk of short duration and low intensity)² Duration of therapy: Use as needed, if it provides symptom relief Osteoporosis (for treatment and prevention): Calcium and vitamin D might increase bone mineral density and reduce the risk of hip fractures in postmenopausal women² Duration of therapy: Chronic therapy, but the optimal duration unknown. Individuals taking a bisphosphonate should take a calcium supplement if their dietary intake is insufficient The maximum amount of elemental calcium that can be absorbed at once is 500 mg.² Calcium carbonate is better absorbed when taken with food. Osteoporosis Canada has a useful dietary calcium calculator found at osteoporosis.ca/bone-health-osteoporosis/calcium-calculator Hyperphosphatemia in CKD: Calcium-based phosphate binders, such as calcium supplements, are first-line therapy in individuals with CKD when the serum calcium level is not elevated.^3,4 Supplements can be used for treatment or maintenance Duration of therapy: Dependent on serum phosphate and calcium levels
Vitamin B12 or cobalamin⁵	Vitamin B12 deficiency: Stomach acid is required to cleave vitamin B12 from dietary protein and only about 50% of the ingested amount is absorbed. As such, those with malabsorption conditions, poor nutrition, or taking certain medications (eg, alcohol, aminosalicylic acid, colchicine, cotrimoxazole, histamine-2 blockers, isoniazid, metformin, neomycin, nitrofurantoin, oral contraceptives, proton pump inhibitors, sulfasalazine, tetracyclines, and triamterene) might be at risk of vitamin B12 deficiency Duration of therapy: Deficiency should resolve within 3–4 wk of therapy, but it might take more than 6 mo for neurologic improvements to occur Pernicious anemia: These individuals lack gastric intrinsic factor and are unable to cleave vitamin B12 from dietary proteins Duration of therapy: Chronic therapy
Multivitamin⁶	AMD: Might slow the progression of intermediate to severe AMD Duration of therapy: Discontinue if or when benefit uncertain Cataract prevention: Might decrease the risk of developing cataracts; does not prevent surgery Duration of therapy: Consider discontinuing if cataracts develop Chronic alcohol use: Corrects folic acid, pyridoxine, and thiamine deficiencies, which are common with alcohol dependence Duration of therapy: Insufficient evidence to recommend a duration Compromised nutritional status: Meets nutritional requirements when there is insufficient dietary intake Duration of therapy: Until dietary intake can provide the required nutrients
Low-dose ASA (ie, 75–100 mg/d)	Secondary prevention of cardiovascular disease (ie, in people who have a history of cardiovascular or cerebrovascular disease) In older adults, low-dose ASA appears to produce more harms than benefits when used for primary prevention of cardiovascular disease, and is therefore no longer recommended⁷
NSAIDs (eg, naproxen, celecoxib, ibuprofen)	Treatment of acute or chronic pain Indomethacin might be more likely than other NSAIDs to have adverse CNS effects and should be avoided in older adults⁸ The 2019 Beers Criteria recommend that chronic use of NSAIDs be avoided in older adults unless alternatives are not effective and the patient can take a gastroprotective agent such as a proton pump inhibitor⁸

AMD—age-related macular degeneration, ASA—acetylsalicylic acid, CKD—chronic kidney disease, CNS—central nervous system, GERD—gastrointestinal reflux disease, NSAID—nonsteroidal anti-inflammatory drug.