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Medications to avoid in the elderly

Description Medications to avoid1 Adverse side effects/concerns Formulary alternatives2,3 Alpha , • guanabenz • methyldopa High risk of central nervous lisinopril, enalapril, losartan, felodipine, central • • reserpine system (CNS) effects; may cause nifedipine-long acting (nifedipine ER) (doses greater than bradycardia and orthostatic 0.1mg/day) hypotension; not recommended for routine treatment of hypertension. Analgesics • indomethacin Potential for gastrointestinal acetaminophen, trisalicylate (Trilisate), • ketorolac bleeding, renal failure, high blood topicals (capsaicin) pressure and heart failure Androgen • methyltestosterone Prostatic hypertrophy and cardiac danazol concerns Anti-anxiety • aspirin- Addictive and sedating anxiolytic Anxiety: buspirone, citalopram, duloxetine, • meprobamate escitalopram, fluvoxamine, sertraline, venlafaxine : See the section for insomnia alternatives , • Highly effects; may : Selective serotonin reuptake tricyclic • clomipramine cause orthostatic hypotension inhibitors (SSRIs) – citalopram, escitalopram, • fluvoxamine, sertraline; Serotonin and (doses greater than 6mg/day) norepinephrine reuptake inhibitors (SNRIs) – • imipramine duloxetine, venlafaxine • Insomnia: See the nonbenzodiazepine hypnotic section for insomnia alternatives Neuropathic pain: Anti-emetics • trimethobenzamide Extrapyramidal adverse effects ondansetron, dolasetron (Anzemet)

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GHHH1R5HH 0214 Medications to avoid in the elderly

Description Medications to avoid1 Adverse side effects/concerns Formulary alternatives2,3 • • Highly anti-cholinergic effects, Pruritus/urticaria: fexofenadine, fluticasone (includes single • carbinoxamine (oral) sedation, weakness, blood pressure Insomnia: See the nonbenzodiazepine entity or as part • chlorpheniramine • changes, dry mouth, urinary hypnotic section for insomnia alternatives of a combination • • retention; clearance reduced in product) • hydrochloride advanced age. Nausea/vomiting: ondansetron • dexbrompheniramine • hydroxyzine pamoate Tolerance develops when used as Allergic rhinitis: fexofenadine, azelastine, • dexchlorpheniramine • hypnotic fluticasone • Anxiety: SSRIs (citalopram, escitalopram, fluvoxamine, sertraline); SNRIs (duloxetine, venlafaxine); buspirone Anti-infectives • nitrofurantoin Potential for pulmonary toxicity; Dependent on the : (when cumulative • nitrofurantoin macrocrystals nitrofurantoin causes renal sulfamethoxazole/trimethoprim, days’ supply impairment. Avoid in persons with a ciprofloxacin, cephalexin greater than CrCl < 60mL/min due to inadequate 90 days) drug concentration in the urine.

Anti-parkinson • benztropine (oral) Not recommended for prevention (Requip), amantadine, agents • of extrapyramidal symptoms with (Mirapex) . Antipsychotics • Highly anti-cholinergic; CNS and (Zyprexa), (Seroquel), extrapyramidal effects; greater (Risperdal), pimozide (Orap), risk of QT interval prolongation; trifluoperazine associated with tremors, slurred Note: All antipsychotics have been associated speech, bradykinesia, dystonia, with increased mortality when used to treat muscle rigidity and akathisia psychosis related to dementia Anti-thrombotics • dipyridamole, oral short-acting only Dipyridamole may cause orthostatic aspirin/dipyridamole extended-release • ticlopidine hypotension; more effective capsules, low-dose aspirin alternatives are available.

Printed with permission from National Committee for Quality Assurance (NCQA) – HEDIS measure 1429ALL0214

GHHH1R5HH 0214 Medications to avoid in the elderly Description Medications to avoid1 Adverse side effects/concerns Formulary alternatives2,3 • • High rate of physical dependence; Anxiety: SSRIs (citalopram, escitalopram, • • patients develop tolerance, which fluvoxamine, sertraline); SNRIs (duloxetine, • • reduces benefits; risk of venlafaxine); buspirone • mephobarbital overdose at low dosage due to Insomnia: See nonbenzodiazepine hypnotic tolerance and patient choice to section for insomnia alternatives over-medicate to achieve therapeutic effect

Belladonna • //phenobarbital/ Anti-cholinergic effects Constipation: psyllium, PEG, stool softener, alkaloids lubiprostone (Amitiza) (includes single • belladonna/ / phenobarbital Diarrhea: loperamide, aluminum hydroxide entity or as part • butabarbital/hyoscyamine/ phenazopyridine of a combination product) Calcium channel • nifedipine − short-acting only Potential for hypotension; risk of Use long-acting formulation to avoid adverse blockers causing myocardial ischemia effects: felodipine, nifedipine-long-acting (nifedipine ER) Cardiovascular • digoxin (doses greater than 0.125mg/day) Digoxin: in heart failure, higher Heart failure: digoxin 0.125mg, ACEI • disopyramide doses have increased risk of toxicity; (lisinopril, quinapril, enalapril) or ARB decreased renal clearance (losartan) and/or a beta blocker (metoprolol Disopyramide: potent negative XL, bisoprolol, carvedilol) instead of digoxin inotrope that may induce heart failure in older adults; anti-cholinergic effects Endocrine • megestrol Increases risk of thrombotic event Consider nutritional support and treatment and possibly death in older adults of potential cause (e.g., depression, certain medications); consider dronabinol for anorexia associated with weight loss in patients with AIDS or for nausea and vomiting in chemotherapy patients who failed to respond adequately to conventional treatments

Printed with permission from National Committee for Quality Assurance (NCQA) – HEDIS measure 1429ALL0214

GHHH1R5HH 0214 Medications to avoid in the elderly

Description Medications to avoid1 Adverse side effects/concerns Formulary alternatives2,3 Narcotics • acetaminophen- Meperidine may not be effective , , , fentanyl • belladonna-opium at commonly prescribed doses; transdermal patch, acetaminophen (not in • meperidine side effects include , combination product) • meperidine-promethazine falls, fractures, dependency and • naloxone-pentazocine withdrawal. • pentazocine Pentazocine produces CNS-adverse effects, including confusion and and is a mixed and antagonist; safer alternatives are available.

Nonbarbiturate or • hydrate : Tolerance develops • Consider only short-term or intermittent nonbenzodiazepine • Lunesta (eszopiclone) within 10 days; risks outweigh use (less than 90 days per year). hypnotic • Sonata () benefits: delirium, overdose (narrow • Discuss sleep hygiene and avoidance of (when cumulative • Ambien () therapeutic window) caffeine, , nicotine and medications days’ supply is All others: -receptor that cause insomnia. greater than agonists have adverse events similar • Evaluate for depression, a common cause 90 days) to those of in older of insomnia in the elderly. Secondary adults (e.g., delirium, falls, fractures); insomnia can be treated with 50 they produce minimal improvement mg (may cause orthostatic hypotension) or 4 in sleep latency and duration.1 doxepin (less than 6 mg per day). • Over-the-counter option: , if appropriate; regarded as safe in recommended doses (up to 15 mg daily) for up to two years.5

Printed with permission from National Committee for Quality Assurance (NCQA) – HEDIS measure 1429ALL0214

GHHH1R5HH 0214 Medications to avoid in the elderly

Description Medications to avoid1 Adverse side effects/concerns Formulary alternatives2,3 Oral estrogens • conjugated estrogen • esterified estrogen- Cardio-protective properties are Hot flashes: nondrug comfort therapy and estradiol • conjugated estrogen- methyl- absent; high carcinogenic SSRIs: citalopram, escitalopram, fluvoxamine, transdermal patch medroxyprogesterone • estropipate effects (breast cancer and sertraline; SNRIs: venlafaxine; • drospirenone-estradiol • estradiol endometrial cancer) • esterified estrogen • estradiol- Vaginal dryness: Premarin vaginal cream norethindrone Bone density: calcium, vitamin D, • estradiol- alendronate, raloxifene levonorgestrel Oral hypoglycemics • chlorpropamide Prolonged half-life causing glimepiride, glipizide • glyburide prolonged hypoglycemia; also causes syndrome of inappropriate anti-diuretic hormone secretion (SIADH) Skeletal muscle • ASA/caffeine/ • Anti-cholinergic effects, sedation, , relaxants • weakness and increased risk of Nonpharmacologic treatment for muscle • ASA// • fractures spasms: heat, massage, stretching/exercise codeine • orphenadrine Poorly tolerated; effectiveness at • aspirin-carisoprodol doses tolerated by older adults is • carisoprodol questionable • Thyroid • Thyroid desiccated Cardiac concerns levothyroxine

Vasodilators • dipyridamole − short-acting only Orthostatic hypotension Stroke prevention: aspirin/dipyridamole • ergot mesyloid extended-release capsules, low-dose aspirin • isoxsuprine Alzheimer’s disease/dementia: galantamine, rivastigmine, donepezil

This document was last updated in January 2014.

Printed with permission from National Committee for Quality Assurance (NCQA) – HEDIS measure 1429ALL0214

GHHH1R5HH 0214 Medications to avoid in the elderly

References: 1. The American Geriatric Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf. Accessed Dec. 19, 2013. 2. Source: Potentially Harmful Drugs in the Elderly: Beers List and More. Pharmacist’s Letter/Prescriber’s Letter 23.9. (2007):230907. 3. STARTing and STOPPing Medications in the Elderly. Pharmacist’s Letter/Prescriber’s Letter. (2011):270906. 4. Mendelson WB. A review of the evidence for efficacy and safety of trazodone in insomnia. The Journal of Clinical Psychiatry, 2005; 66:469-76. Buscemi N, Vandermeer B, Friesen C, et al. The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs. The Journal of General Internal Medicine, 2007; 22:1335-5. Zavesicka L, Brunovsky M, Horacek J, et al. Trazodone improves the results of cognitive behaviour therapy of primary insomnia in non-depressed patients. Neuroendocrinology Letters, 2008; 29:895-901. 5. Jellin JM, Gregory PJ, et al. Clinical management series. Natural medicines in the clinical management of insomnia. Pharmacist’s Letter/Prescriber’s Letter Natural Medicines Comprehensive Database. www.naturaldatabase.com (Accessed Dec. 19, 2013) Zhdanova IV, Wurtman RJ, Regan MM, et al. Melatonin treatment for age-related insomnia. The Journal of Clinical Endocrinology & , 2001; 86:4727-30. Garfinkel D, et al. Improvement of sleep quality in elderly people by controlled-release melatonin. Lancet, 1995; 346:541-44.

Printed with permission from National Committee for Quality Assurance (NCQA) – HEDIS measure 1429ALL0214

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