2017 High-Risk Medication Therapeutic Alternatives Guide

BlueAdvantage (PPO)SM BlueChoice (HMO)SM BlueCare Plus (HMO SNP)SM ii As part of ongoing efforts focused on quality and safety, BlueCross BlueShield of Tennessee would like to partner with you to avoid using medications considered high risk for those 65 years of age and older, especially when there may be safer alternatives.

High-risk medications (HRMs) are those identified by the American Geriatric Society and by the Pharmacy Quality Alliance that may cause adverse events in older adults due to their pharmacologic properties and the physiologic changes of aging.

You are in the best position to help reduce medication- associated health problems. This guide provides formulary alternatives that may be used in place of high-risk drugs.

We encourage you to use this guide to help determine a safe alternative for your patients as medically appropriate. We look forward to partnering with you to ensure optimal outcomes for them.

1 Commonly Prescribed High-Risk Clinical Medication Concerns Alternatives Allergy Anticholinergic For allergies: medications: effects such cetirizine oral solution as confusion, diphenhydramine desloratadine tablet oral elixir dry mouth and constipation desloratadine tablet, hydroxyzine hcl Clearance reduced disintegrating with advanced age levocetirizine oral Tolerance develops solution when used as levocetirizine tablet hypnotic fluticasone nasal Use of spray diphenhydramine in certain situations flunisolide such as acute nasal spray treatment of a mometasone severe allergic nasal spray reaction may be Diphenhydramine appropriate for sleep: Rozerem trazodone Hydroxyzine for anxiety: buspirone escitalopram sertraline venlafaxine 2 Commonly Commonly Prescribed Prescribed High-Risk Clinical High-Risk Clinical Medication Concerns Alternatives Medication Concerns Alternatives Allergy Anticholinergic For allergies: Antidepressant Anticholinergic For depression: medications: effects such cetirizine oral solution medications: effects, sedation SSRI (except as confusion, and orthostatic diphenhydramine desloratadine tablet amitriptyline paroxetine) oral elixir dry mouth and hypotension – citalopram, constipation desloratadine tablet, clomipramine hydroxyzine hcl escitalopram, Clearance reduced disintegrating doxepin capsule fluoxetine, sertraline >6 mg/d with advanced age levocetirizine oral SNRI–duloxetine Tolerance develops solution doxepin oral (caution with when used as levocetirizine tablet concentrate >6mg/d renal dysfunction), hypnotic imipramine Pristiq, venlafaxine, fluticasone nasal bupropion, trazodone Use of spray trimipramine diphenhydramine in certain situations flunisolide For neuropathic such as acute nasal spray pain: treatment of a mometasone SNRI severe allergic nasal spray gabapentin reaction may be Diphenhydramine appropriate (caution with renal for sleep: dysfunction) Rozerem Lyrica (caution with trazodone renal dysfunction) Hydroxyzine for lidocaine patch anxiety: buspirone escitalopram sertraline venlafaxine 3 Commonly Prescribed High-Risk Clinical Medication Concerns Alternatives Amitriptyline or imipramine for pain: duloxetine (caution with renal dysfunction) gabapentin (caution with renal dysfunction) Lyrica (caution with renal dysfunction) venlafaxine venlafaxine, extended release

Clomipramine for OCD: citalopram escitalopram fluoxetine fluvoxamine sertraline venlafaxine

4 Commonly Prescribed High-Risk Clinical Medication Concerns Alternatives Antiemetic Anticholinergic granisetron medications: effects such ondansetron promethazine oral as confusion, solution dry mouth and constipation promethazine injection solution Potential to worsen Parkinsonian promethazine tablet symptoms Antithrombotic May cause clopidogrel medications: orthostatic aspirin-dipyridamole, dipyridamole hypotension extended release (short-acting)

5 Commonly Prescribed High-Risk Clinical Medication Concerns Alternatives Antipsychotic Increases risk aripiprazole medications: of orthostatic Fanapt thioridazine hypotension or bradycardia haloperidol Caution in patients Latuda with epilepsy or paliperidone chronic seizures; lowers seizure quetiapine threshold; may risperidone be acceptable in Saphris individuals with well controlled Seroquel XR seizures in whom ziprasidone alternative agents have not been effective Anticholinergic properties Antipsychotics are associated with an increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia

6 Commonly Prescribed High-Risk Clinical Medication Concerns Alternatives Barbiturate High rate For seizures: medications: of physical carbamazepine dependence phenobarbital lamotrigine oral elixir Tolerance to sleep benefits divalproex phenobarbital tablets Greater risk of levetiracetam overdose at low (caution with renal dosages dysfunction) oxcarbazepine

7 Commonly Prescribed High-Risk Clinical Medication Concerns Alternatives Cardiovascular May be associated Potential alternatives medications: with increased should be discussed digox tablets mortality in with provider (250mcg/d) people with atrial depending on fibrillation indication for use and digitex tablets goals of care (250mcg/d) May be associated with increased digoxin tablets mortality in older (250mcg/d) adults with digoxin oral solution heart failure (250mcg/d) Higher doses in heart failure are not associated with additional benefit and may increase risk of toxicity Decreased renal clearance may lead to increased risk of toxic effects Avoid doses greater than 125mcg/d in atrial fibrillation and heart failure

8 Commonly Prescribed High-Risk Clinical Medication Concerns Alternatives Dementia Lack of efficacy donepezil medications: galantamine ergoloid memantine Namenda XR rivastigmine Hormone Carcinogenic For bone density: medications: potential (breast Bisphosphonates estrogens with and endometrium) (alendronate; or without Lack of ibandronate; progesterone – cardioprotective risedronate) oral and topical effect and cognitive raloxifene patch products protection in older ONLY (estradiol women For vaginal symptoms: tablet; estradiol Aggravation of transdermal incontinence Estrace vaginal cream patch weekly; estradiol valerate For vasomotor intramuscular; symptoms (hot estradiol- flashes): norethindrone SSRI (except acetate tablet; paroxetine) Menest oral tablet; SNRI Premarin oral tablet) gabapentin (caution with renal dysfunction)

9 Commonly Prescribed High-Risk Clinical Medication Concerns Alternatives Insomnia Risk of falls, Rozerem medications: delirium, fractures trazodone zaleplon and motor vehicle accidents zolpidem May cause ataxia, impaired psychomotor function and syncope Increased risk of ER visits and hospitalizations Minimal improvement in sleep latency and duration Muscle relaxant Anticholinergic Potential alternatives medications: effects, sedation should be discussed cyclobenzaprine and increased risk with provider of fractures depending on chlorzoxazone Dosages tolerated indication for use and by older adults may goals of care not be efficacious

10 Commonly Prescribed High-Risk Clinical Medication Concerns Alternatives Parkinson’s Anticholinergic carbidopa/levodopa disease effects entacapone medications: Not recommended pramipexole benztropine tablet for prevention of extrapyramidal ropinirole symptoms with antipsychotics

Anti-infective Avoid if CrCl is less amoxicillin- medications: than 30 mL/min clavulanate nitrofurantoin or for long-term cefaclor suppression of macrocrystal cefpodoxime capsule bacteria cephalexin nitrofurantoin Potential for monohyd/m-cryst pulmonary toxicity, ciprofloxacin capsule hepatoxicity, and peripheral levofloxacin nitrofurantoin oral neuropathy sulfamethoxazole/ suspension trimethoprim Endocrine Minimal effect on Potential alternatives medications: weight should be discussed megestrol oral Increases risk of with provider suspension thrombotic events depending on indication for use and megestrol tablet and possibly death in older adults goals of care

11 References: 1. American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63:2227-2246. 2. Hanlon JT, Semla TP, Schmader KE. Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug-Disease Interactions in the Elderly Quality Measures. J Am Geriatr Soc. 2015;63(12):e8-e18. 3. Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Available at: http://www.micromedexsolutions.com. Accessed Dec. 30, 2016.

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BlueCross BlueShield of Tennessee, Inc. is a PPO plan with a Medicare contract BlueChoice Tennessee is an HMO plan with a Medicare contract. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, copayments and coinsurance may change on January 1 of each year. Enrollment in BlueCross BlueShield of Tennessee, Inc. and BlueChoice Tennessee depends on contract renewal. BlueCross BlueShield of Tennessee, Inc. and BlueChoice Tennessee, Independent Licensees of the BlueCross BlueShield Association. 17PED100707 (3/17) High Risk Medication Guide