Potentially Inappropriate Medications in Older Adults According to Beers List and STOPP Criteria Note: These guidelines are not applicable in all circumstances. Avoid use when possible. Use with caution when necessary. CENTRAL NERVOUS SYSTEM CARDIOVASCULAR Beers List Beers List Anticholinergic Antidepressants (alone or in combination): Peripheral Alpha-1 Blockers: Amitriptyline, amoxapine, clomipramine, desipramine, doxepin (> 6 Doxazosin, Prazosin, Terazosin mg/d) imipramine, nortriptyline, paroxetine, protriptyline, trimipramine Central Alpha Agonists: Antipsychotics – 1st (conventional) & 2nd (atypical) generation: Clonidine for first-line treatment of hypertension (HTN) Avoid except in schizophrenia, bipolar or short-term use as antiemetic Other CNS alpha-agonists: during chemotherapy. ƒ Guanabenz Increase risk of CVA, increase rate of cognitive decline and mortality in ƒ Methyldopa people with dementia. ƒ Guanfacine Barbiturates: ƒ Reserpine (> 0.1 mg/d) Amobarbital, butabarbital, butalbital, mephobarbital, pentobarbital, Others: phenobarbital, secobarbital Disopyramide Benzodiazepines (BZDs): Dronedarone, amiodarone Short- and intermediate-acting: alprazolam, estazolam, lorazepam, Digoxin (for first-line treatment of atrial fibrillation or of heart failure) oxazepam, temazepam, triazolam Nifedipine (immediate release form) Long-acting BZDs: clorazepate, chlordiazepoxide (alone or in Acetylcholinerase inhibiters combination with amitriptyline or clidinium), clonazepam, diazepam, Tertiary tricyclic antipsychotics flurazepam, quazepam Antipsychotics: ƒ Chlorpromazine Non-BZD “Z” Drugs: ƒ Thioridazine Eszopiclone, zaleplon, zolpidem ƒ Olanzapine Others: Meprobamate, ergoloid, mesylates, isoxsuprine Trimethoprim-sulfamethoxazole (with ACE inhibitor or ARB and decreased creatinine clearance) STOPP Criteria In patients with heart failure: Tricyclic antidepressants: NSAIDs, COX-2 inhibitors, non-dihydropyridine calcium channel ƒ In patients with dementia blockers, thiazolidinediones, cilostazol, dronederone ƒ First line for depression STOPP Criteria SSRIs with Na Centrally acting anti-hypertensives: Neuroleptics: ƒ Methyldopa ƒ With anticholinergic s/e ƒ Clonidine ƒ For behavior in dementia ƒ Used as hypnotics ƒ Guanfacine Antipsychotics in Parkinsonism or Lewy Body disease: Loop diuretic for: (except quetiapine and clozapine) ƒ HTN first-line ƒ Dependent ankle edema Benzodiazepines: ƒ HTN with urinary incontinence Used > 4 weeks Others: Anticholinergic/Antimuscarinics: ƒ In dementia or delirium ƒ Digoxin for heart failure ƒ Used to treat EPS of neuroleptic medications ƒ Diltiazem and Verapamil in New York Heart Association (NYHA) class 3-4 heart failure Phenothiazines: ƒ Beta blockers when heart rate less than 50 beats/min As first-line treatment ƒ Amiodarone first-line for supraventricular tachycardia (SVT) Levodopa or Dopamine: Agonists used for benign essential tremor ENDOCRINE DRUGS THAT INCREASE RISK OF FALLS Beers List Beers List Androgens: Anticonvulsants ƒ Methyltestosterone Antipsychotics ƒ Testosterone Benzodiazepines Desiccated thyroid: Tricyclic antidepressants (TCAs) ƒ Estrogens with or without progestines (oral or transdermal – Serotonin reuptake inhibitors (SSRIs) excludes intravaginal estrogen) Serotonin norepinephrine reuptake inhibitors (SNRIs) Growth hormone Opioids Sliding scale insulin: Non-benzodiazepine, benzodiazepine receptor agonists (Non-BZD “Z” ƒ Insulin regimens containing only short- or rapid-acting insulin drugs): dosed according to current blood glucose levels without ƒ Eszopiclone concurrent use of basal or long-acting insulin ƒ Zaleplon Long-acting Sulfonylureas: ƒ Zolpidem ƒ Chlorpropamide ƒ Glimepiride STOPP Criteria ƒ Glyburide (aka glibenclamide) Benzodiazepines (BZDs) STOPP Criteria Neuroleptic drugs ƒ Sulfonylureas with prolonged duration of action in type 2 diabetes Vasodilator drugs with persistent postural hypotension: mellitus: ƒ Alpha-1 receptor blockers ū Chlorpropamide ƒ Calcium channel blockers ū Glimepiride ƒ Nitrates (long-acting) ƒ Thiazolidenediones in persons with heart failure ƒ ACE inhibitors ū Rosiglitazone ƒ ARBs ū Pioglitazone ƒ Minoxidil ƒ Beta blockers in persons with diabetes mellitus with frequent ƒ Hydralazine hypoglycemic episodes Hypnotic Non-benzodiazepine, benzodiazepine receptor agonists ƒ Estrogens in people with history of breast cancer or venous (Non-BZD “Z” drugs): thromboembolism ƒ Eszopiclone ƒ Estrogens without progesterone in women with an intact uterus ƒ Zaleplon ƒ Androgens in the absence of primary or secondary hypogonadism ƒ Zolpidem

ANALGESICS MUSCULOSKELETAL Beers List Beers List Non-cyclooxygenase-2 (Non-COX-2) NSAIDs: Carisoprodol, cyclobenzaprine, chlorzoxazone, metaxalone, Aspiring > 325 mg/day, diclofenac, diflunisal, etodolac, fenoprofen, methocarbamol, orphenadrine ibuprofen, ketoprofen, meclofenomate, mefenamic acid, meloxicam, nabumetone naproxen, oxaprozin, piroxicam, sulindac, tolmetin, STOPP Criteria indomethacin, ketorolac (includes parenteral) ƒ Non-COX-2 selective NSAIDs without concurrent proton pump Other: inhibitor (PPI) or H2 antagonist in persons with history of peptic Meperidine ulcer disease or gastrointestinal bleeding ƒ NSAID with established hypertension or heart failure STOPP Criteria ƒ Long-term use of NSAIDs (> 3 months) for relief of osteoarthritis ƒ Use of oral or transdermal “strong” opioids as first-line therapy for symptom pain where paracetamol has not been tried (use simple mild pain: analgesics first) ū Morphine ƒ Long-term corticosteroid use (> 3 months) as monotherapy for ū Oxycodone rheumatoid arthritis ū Fentanyl ƒ Oral corticosteroid use for osteoarthritis ū Buprenorphine ƒ Long-term NSAID or colchicine use for prevention of gout relapse ū Methadone (use xanthine-oxidase inhibitors first-line if not contraindicated) ū Tramadol ƒ COX-2 NSAIDs in concurrent cardiovascular disease ƒ Use of regular, scheduled opioids without a scheduled laxative ƒ NSAID with corticosteroids without PPI ƒ Use of long-acting opioids without short-acting opioids for break- ƒ Oral bisphosphonates in persons with history of upper through pain gastrointestinal disease ANTICHOLINERGICS GASTROINTESTINAL AND GENITORURINARY Beers List Beers List – Gastrointestinal First Generation Antihistamines: Aspirin (> 325 mg) Brompheniramine, carbinoxamine, chlorpheniramine, clemastine, Non-COX-2 selective NSAIDS cyproheptadine, dexbrompheniramine, dexchlorpheniramine, Metoclopramide (unless for gastroparesis with duration of use not to dimenhydrinate, diphenhydramine (oral), doxylamine, hydroxyzine, exceed 12 weeks except in rare cases) meclizine, promethazine, pyrilamine, triprolidine Mineral oil, administered orally Antiparkinsonian Agents: PPIs (avoid scheduled use > 8 weeks unless person at high risk) Benztropine, trihexyphenidyl STOPP Criteria – Gastrointestinal Antispasmodics: ƒ Prochlorperazine or metoclopramide with Parkinsonian symptoms Atropine (excludes ophthalmic), belladonna alkaloids, clindinium- ƒ PPIs for uncomplicated peptic ulcer disease or erosive peptic chlordizepoxide, dicyclomine, homatopine (excludes ophthalmic), esophagitis at full therapeutic dosage for > 8 weeks hyoscyamine, methscopolamine, propantheline, scopolamine ƒ Drugs likely to cause constipation in persons with chronic Antidepressants: constipation where non-constipating alternatives are appropriate Amitriptyline, amoxapine, clomipramine, desipramine, doxepin (> 6mg), ū Antimuscarinic/anticholinergic drugs imipramine, nortriptyline, paroxetine, protriptyline, trimipramine ū Opioids Antimuscarinics: ū Verapamil Darifenacin, fesoterodine, flavoxate, oxybutinin, solifenacin, tolterodine, ū Aluminum antacids trospium ƒ Oral elemental iron doses greater than 200 mg/day – examples: ū Ferrous fumarate Antipsychotics: ū Ferrous gluconate Chlorpromazine, clozapine, loxapine, olanzapine, perphenazine, ū Ferrous sulfate thioridazine, trifluoperazine ū Polysaccharide-iron complex (PIC) Skeletal muscle relaxants: ū PIC plus folic acid Vitamin B12 Cyclobenzaprine, orphenadrine ū Antiarrhythmic: Beers List – Genitourinary Disopyramide Desmopressin for nocturia or nocturnal polyuria Antiemetics: Metoclopramide, prochloroperazine, promethazine STOPP Criteria – Genitourinary ƒ Selective alpha-1 blockers in persons with symptomatic orthostatic STOPP Criteria hypotension or micturition syncope ƒ Concomitant use of two or more drugs with antimuscarinic/ ƒ Antimuscarinic drugs for overactive bladder in persons with: anticholinergic properties – examples: ū Dementia or chronic cognitive impairment ū Bladder antispasmodics ū Narrow-angle glaucoma ū Intestinal antispasmodics ū Chronic prostatism ū Tricyclic antidepressants ū First generation antihistamines

ANTITHROMBOTIC Beers List (Avoid) Aspirin: ƒ > 160 mg daily long-term use Dipyridamole – oral, short-acting (does not apply to the extended- ƒ With history of peptic ulcer disease without concomitant PPI release combination with aspirin) ƒ Plus clopidogrel as secondary stroke prevention Warfarin used with amiodarone Warfarin used with NSAIDs Vitamin K antagonist, direct thrombin inhibitor or factor Xa inhibitors: Warfarin used with ciprofloxacin ƒ With antiplatelet agents in patients with stable coronary, Warfarin used with macrolides (excluding azithromycin) cerebrovascular or peripheral arterial disease without a clear Warfarin used with trimethoprim-sulfamethoxazole indication for anticoagulant therapy ƒ In combination with aspirin in patients with chronic atrial Beers List (Use With Caution) fibrillation Aspirin for primary prevention of cardiac disease and colorectal cancer ƒ For > 6 months for first deep venous thrombosis (DVT) or > 12 Dabigatran months for first pulmonary embolus without continuing risk factors Prasugrel Ticlopidine in any circumstance Rivaroxaban NSAIDs: STOPP Criteria ƒ In combination with vitamin K antagonist, direct thrombin inhibitor or factor Xa inhibitors Aspirin, clopidogrel, dipyridamole, vitamin K antagonist, direct thrombin ƒ In combination with antiplatelets without inhibitor, factor Xa inhibitors in patients with a high risk for bleeding PPI prophylaxis RENAL MISCELLANEOUS Beers List Beers List NSAIDs (non-COX and COX- selective, oral and parenteral, Drugs that exacerbate or cause SIADH or hyponatremia: nonacetylated salicylates) in chronic kidney disease (CKD) stage IV or Antipsychotics1, carbamazepine, diuretics, mirtazapine, SNRIs, SSRIs, creatinine clearance < 30 ml/min TCAs, tramadol Reduce dose if CrCl: Drugs that can induce or worsen delirium: Dofetilide 20-59 ml/min Anticholinergics Edoxaban 15-50 ml/min Antipsychotics1 Enoxaparin < 30 ml/min Benzodiazepines Rivaroxaban 15-50 ml/min for nonvalvular atrial fibrillation Corticosteroids (oral or parenteral2) Gabapentin < 60 ml/min Levetiracetam < 80 ml/min H2-receptor antagonists: Pregabalin < 60 ml/min ƒ Cimetidine Tramadol immediate release < 30 ml/min ƒ Famotidine Cimetidine < 50 ml/min ƒ Nizatidne Famotidine < 50 ml/min ƒ Ranitidine Nizatidine < 50 ml/min Meperidine Ranitidine < 50 ml/min Non-benzodiazepine, benzodiazepine receptor agonist hypnotics Colchicine < 30 ml/min (non-BZD “Z” drugs): Avoid use if CrCl: ƒ Eszopiclone Amiloride < 30 ml/min ƒ Zaleplon Apixaban < 25 ml/min ƒ Zolpidem Dabigatran < 30 ml/min Drugs that worsen dementia or cognitive impairment: Dofetilide < 20 ml/min Anticholinergics Edoxaban < 15 or > 95 ml/min Antipsychotics1, chronic and as-needed use Fondaparinux < 30 ml/min Rivaroxaban < 30 ml/min Non-benzodiazepine, benzodiazepine receptor agonist Spironolactone < 30 ml/min hypnotics (non-BZD “Z” drugs): Triamterene < 30 ml/min ƒ Eszopiclone Duloxetine < 30 ml/min ƒ Zaleplon Tramadol extended-release form ƒ Zolpidem Probenecid < 30 ml/min Dextromethorphan/quinidine (does not apply to Pseudobulbar Affect) Nitrofurantoin < 30 ml/min Drugs that worsen Parkinson’s Disease: Ciprofloxacin < 30 ml/min Antiemetics: Trimethoprim-Sulfamethoxazole < 30 ml/min ƒ Metoclopramide STOPP Criteria ƒ Prochlorperazine ƒ Promethazine Avoid use if eGFR: All antipsychotics (except clozapine, pimavanserin, quetiapine - Digoxin < 30 ml/min/1.73 m2 none of these are ideal in efficacy or safety) Direct thrombin inhibitors < 30 ml/min/1.73 m2 Factor Xa inhibitors < 15 ml/min/1.73 m2 STOPP Criteria NSAIDs < 50 ml/min/1.73 m2 Respiratory: Colchicine < 10 ml/min/1.73 m2 ƒ Theophylline as monotherapy for COPD Metformin < 30 ml/min/1.73 m2 ƒ Systemic corticosteroids instead of inhaled corticosteroids for maintenance therapy in moderate-severe COPD ƒ Anti-muscarinic bronchodilators with history of glaucoma or bladder outlet obstruction ƒ Benzodiazepines with acute or chronic respiratory failure

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Sources: American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, Journal of the American Geriatrics Society 63:2227-2246, 2015; STOPP/START Criteria for Potentially Inappropriate Prescribing in Older People version 2; Mahoney, Denis et.al. Age and Ageing, volume 44, Issue 2, 1 March 2015, pages 213-218, supplemental data pages 1-23. 1May be required to treat concurrent schizophrenia, bipolar disorder and other selected mental health conditions, but should be prescribed in the lowest effective dose and shortest possible duration. 2Oral and parenteral corticosteroids may be required for conditions such as exacerbation of COPD, but should be prescribed in the lowest effective dose and for the shortest possible duration. This material was originally prepared by Healthcare Quality Strategies, Inc., Delmarva Foundation – Maryland, and Delmarva Foundation – District of Columbia, and modified by TMF Health Quality Institute, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 11SOW-QINQIO-C3.6-18-16 Published 8/2018; Revised 05/2020