Medications to Avoid in the Elderly

Medications to Avoid in the Elderly Adapted from NCQA’s HEDIS® measure, Use of High-Risk Medications in the Elderly

Description Prescription Adverse Side Formulary Alternatives1 Effects/Concerns Anti-anxiety  aspirin-meprobamate  meprobamate Addictive and sedating Low-dose short-acting (includes anxiolytic benzodiazepines, combination drugs) lorazepam, buspirone Anti-emetics  scopolamine  trimethobenzamide Extra pyramidal adverse Ondansetron, dolasetron effects (Anzemet) Analgesics  ketorolac Potential for GI bleeding, Acetaminophen, (includes renal failure, high blood Trisalicylate (Trilisate), combination drugs) pressure and heart failure Topicals (capsaicin) Antidepressant  amitriptyline  perphenazine-amitriptyline Anti-cholinergic and Condition dependent:  Chlordiazepoxide  doxepin sedative effects; SSRIs, bupropion, amitriptyline increased risk of falls and mirtazapine, nortriptyline, fractures desipramine Weight management: diet and lifestyle modifications Antihistamines  APAP/dextromethorphan/  dexchlorpheniramine/ Anti-cholinergic effects Fexofenadine, azelastine (includes diphenhydramine methscopolamine/PSE and sedation, weakness, (Astelin) combination drugs)  APAP/diphenhydramine/  dexchlorpheniramine- blood pressure changes, phenylephrine pseudoephedrine dry mouth, urinary  APAP/diphenhydramine/  dextromethorphan- retention pseudoephedrine promethazine  acetaminophen-  diphenhydramine diphenhydramine  diphenhydramine/  carbetapentane/diphen- hydrocodone/phenylephrine hydramine/phenylephrine  diphenhydramine-  codeine/phenylephrine/ magnesium salicylate promethazine  diphenhydramine-  codeine-promethazine phenylephrine  cyproheptadine  diphenhydramine-  dexchlorpheniramine pseudoephedrine  dexchlorpheniramine/  hydroxyzine hydrochloride dextromethorphan/PSE  hydroxyzine pamoate  dexchlorpheniramine/  phenylephrine-promethazine guaifenesin/PSE  promethazine  dexchlorpheniramine/ hydrocodone/phenylephrine Antipsychotic,  thioridazine Central nervous system olanzapine (Zyprexa), typical (CNS) and extra quetiapine (Seroquel), pyramidal effects risperidone (Risperdal), pimozide (Orap), Printed with permission from National Committee for Quality Assurance (NCQA) – HEDIS measure 651ALL0111-E Medications to Avoid in the Elderly Adapted from NCQA’s HEDIS® measure, Use of High-Risk Medications in the Elderly

trifluoperazine Description Prescription Adverse Side Formulary Alternatives1 Effects/Concerns Amphetamines  amphetamine-  methamphetamine Addictive properties, angina, Condition dependent: dextroamphetamine  methylphenidate hypertension and Depression: SSRIs,  benzphetamine  phendimetrazine myocardial infarction bupropion, mirtazapine,  dexmethylphenidate  phentermine nortriptyline, desipramine  dextroamphetamine  diethylpropion Barbiturates  butabarbital  phenobarbital Condition-dependent  mephobarbital  secobarbital Insomnia: zolpidem  pentobarbital Long-acting  amitriptyline-  chlordiazepoxide-clidinium Causes prolonged sedation, Low-dose short–acting benzodiazepines chlordiazepoxide  diazepam increased risk of falls and benzodiazepines, if they (includes  chlordiazepoxide  flurazepam fractures must be used combination drugs) Calcium channel  nifedipine  short-acting only Potential for hypotension. Felodipine, nifedipine- blockers Use long-acting formulation long-acting (nifedipine to avoid adverse effects. ER) Cardiovascular  amiodarone Anti-arrhythmia Metoprolol, Atenolol; (amiodarone) associated Sotalol with prolonged QT intervals; possible torsades de pointes, bradycardia and thyroiditis Gastrointestinal  dicyclomine  propantheline Anti-cholinergic effects Duodenal ulcer: anti-spasmodics omeprazole Constipation: psyllium, PEG, stool softener, lubiprostone (Amitiza) Diarrhea: loperamide, aluminum hydroxide Belladonna  atropine  atropine-edrophonium Anti-cholinergic effects Constipation: psyllium, alkaloids (includes  atropine/CPM/hyoscyamine/  belladonna PEG, stool softener, combination drugs) PE/scopolamine  belladonna/ergotamine/ lubiprostone (Amitiza)  atropine/hyoscyamine/PB/ phenobarbital Diarrhea: loperamide, scopolamine  butabarbital/hyoscyamine/ aluminum hydroxide  atropine-difenoxin phenazopyridine  atropine-diphenoxylate  digestive enzymes/hyoscyamine/phenyltoloxamine

Printed with permission from National Committee for Quality Assurance (NCQA) – HEDIS measure 651ALL0111-E Medications to Avoid in the Elderly Adapted from NCQA’s HEDIS® measure, Use of High-Risk Medications in the Elderly

 hyoscyamine  hyoscyamine/methenam/ m-blue/phenyl salicylate Description Prescription Adverse Side Formulary Alternatives1 Effects/Concerns Skeletal muscle  ASA/caffeine/orphenadrine  chlorzoxazone Anti-cholinergic effects, Baclofen, tizanidine relaxants (includes  ASA/carisoprodol/codeine  cyclobenzaprine sedation and weakness. combination drugs)  aspirin-carisoprodol  metaxalone Poorly tolerated  aspirin-methocarbamol  methocarbamol  carisoprodol  orphenadrine Oral estrogens  conjugated estrogen  esterified estrogen Cardio-protective properties Hot flashes: nondrug (includes  conjugated estrogen-  esterified estrogen- are absent; high comfort therapy, SSRIs, combination drugs) medroxyprogesterone methyl-testosterone carcinogenic effects (breast venlafaxine  estropipate cancer and endometrial Bone density: calcium, cancer) vitamin D, alendronate Oral hypoglycemics  Chlorpropamide Prolonged half-life causing Glipizide prolonged hypoglycemia. Causes syndrome of inappropriate anti-diuretic hormone secretion (SIADH) Narcotics (includes  ASA/caffeine/propoxyphene  meperidine-promethazine  Pentazocine produces high Hydrocodone, morphine combination drugs)  acetaminophen-pentazocine  naloxone-pentazocine CNS adverse effects oxycodone, fentanyl  acetaminophen-  pentazocine  Propoxyphene produces transdermal patch, propoxyphene  propoxyphene similar effects as other acetaminophen (not in  belladonna-opium hydrochloride narcotic medications combination product)  meperidine  propoxyphene napsylate Respiratory  theophylline Delirium, seizures and status Inhaled corticosteroid (e.g., epilepticus Flovent HFA or QVAR) with or without Serevent. Note: Long-acting beta agonists (LABAs) should be used in combination with ICS, for asthma maintenance therapy. LABAs are NOT indicated as monotherapy for asthma. Vasodilators  Dipyridamole  short-acting  isoxsuprine Orthostatic hypotension Aspirin/Dipyridamole only extended-release  ergot mesyloid capsules, low-dose Printed with permission from National Committee for Quality Assurance (NCQA) – HEDIS measure 651ALL0111-E Medications to Avoid in the Elderly Adapted from NCQA’s HEDIS® measure, Use of High-Risk Medications in the Elderly

aspirin

Description Prescription Adverse Side Formulary Alternatives1 Effects/Concerns Others (including  methyltestosterone  nitrofurantoin Prostatic hypertrophy and Danazol androgens and  nitrofurantoin macrocrystals- cardiac concerns; anabolic steroids,  nitrofurantoin macrocrystals monohydrate nitrofurantoin causes renal thyroid drugs,  thyroid desiccated impairment urinary anti- infectives)

1Source: Potentially Harmful Drugs in the Elderly: Beers List and More. Pharmacist's Letter/Prescriber's Letter 23.9. (2007):230907.

Printed with permission from National Committee for Quality Assurance (NCQA) – HEDIS measure 651ALL0111-E