High-Risk Medication Pocket Guide

Therapeutic Class High-Risk Medication Potential Risks Alternative Medication Option

Antihistamines Brompheniramine, Carbinoxamine, Highly anticholinergic (can cause dry mouth, flushing, dry Allergies: Cetirizine, Fexofenadine, Loratadine,

Chlorpheniramine, Clemastine, skin, confusion, or difficulty urinating); Sedation. Levocetirizine (as a single agent or as Cyproheptadine, Dexbrompheniramine, Anxiety: Buspirone, SSRIs (Fluoxetine, Paroxetine), part of a combination Dexchlorpheniramine, Diphenhydramine SNRIs (Venlafaxine, Cymbalta) product) - excludes (oral), Doxylamine, Hydroxyzine, OTC products Promethazine, Triprolidine Insomnia: Melatonin, low-dose Trazodone Anti-Infectives Nitrofurantoin (when cumulative day supply Potential for pulmonary toxicity or peripheral neuropathy Infection: Ciprofloxacin, Trimethoprim/ is >90 days during plan year) (numbness, tingling, or pain in the hands, feet, or toes. Sulfamethoxazole, Amoxicillin/Clavulanate, Muscle weakness. Cephalexin Difficulty walking and/or problems with balance or coordination).

Antiparkinson Agents Benztropine (oral), Trihexyphenidyl Highly anticholinergic (can cause dry mouth, flushing, Parkinson Disease: Selegiline, dry skin, confusion, or difficulty urinating); Carbidopa/Levodopa, Ropinirole, Pramipexole, Not recommended for prevention of extrapyramidal Entacapone symptoms with antipsychotics due to potential Antipsychotic induced Extrapyramidal Symptoms: hallucinations. Quetiapine, Clozapine Antipsychotics Thioridazine Highly anticholinergic (can cause dry mouth, Behavioral problems in dementia: (conventional) flushing, dry skin, confusion, or difficulty urinating); Abilify, Olanzapine, Saphris, Haloperidol, Risk of extremely low blood pressure and heart rhythm Fanapt, Latuda, Invega, Quetiapine, Risperidone, changes. Ziprasidone Antithrombotics Dipyridamole (oral, short acting; does not May cause extremely low blood pressure; Platelet Aggregation: Aspirin, Clopidogrel apply to the extended-release combination More effective alternatives available. with aspirin), Ticlopidine Barbiturates Amobarbital, Butabarbital, Butalbital, High dependency rate; Risk of overdose at low dosages; Insomnia: Melatonin, low-dose Trazodone Pentobarbital, Phenobarbital, Secobarbital Increased risk of falling and confusion. Seizures: Divalproex, Levetiracetam, Lamotrigine, Carbamazepine

Cardiovascular Agents Guanfacine, Methyldopa, Reserpine Increased risk of heart attack or stroke due Hypertension: ACE Inhibitors (Lisinopril, (>0.1mg/day), Nifedipine (immediate to rapid decrease in blood pressure. Ramipril), ARBs (Losartan), Beta Blockers release) (Atenolol, Metoprolol), Calcium Channel Blockers (Amlodipine), Thiazides (Hydrochlorothiazide)

Digoxin (>0.125mg/day) Increased risk of toxicity with higher doses Heart Failure: ACE Inhibitors (Lisinopril, Ramipril), due to slow elimination from the body. Beta Blockers (Atenolol, Metoprolol)

Disopyramide Highly anticholinergic (can cause dry mouth, flushing, dry Atrial Fibrillation: Beta Blockers skin, confusion, or difficulty urinating); May induce heart (Atenolol, Metoprolol), Calcium Channel Blockers failure in older adults. (Amlodipine)

Central Nervous Chloral hydrate Increased risk of daytime sedation and falls. Insomnia: Melatonin, low-dose Trazodone System Meprobamate High dependency rate; Sedation. Anxiety: Buspirone, SSRIs (Fluoxetine, Paroxetine), SNRIs (Venlafaxine, Cymbalta)

Endocrine Desiccated Thyroid Concerns about cardiac effects; Hypothyroidism: Levothyroxine safer alternatives available.

Megestrol Concerns about cardiac effects; Weight Gain: Mirtazapine Avoid use due to minimal effect on weight gain.

Estrogens Conjugated Estrogens (PREMARIN, Increased risk of Cardiovascular Disease (CVD) and cancer Osteoporosis: PREMPRO), Esterified Estrogens, in older adults. Calcium and Vitamin D, Alendronate, Evista (with or without Estradiol, Estrogen Patch progesterone; Hot flashes: SSRIs (Fluoxetine, Paroxetine), (VIVELLE-DOT), Estropipate oral and topical patch Gabapentin, Venlafaxine products only) Vaginal symptoms: Estrace Vaginal Cream, Premarin Vaginal Cream High-Risk Medication Pocket Guide

Therapeutic Class High-Risk Medication Potential Risks Alternative Medication Option

Gastrointestinal Trimethobenzamide Highly anticholinergic (can cause dry mouth, flushing, dry Nausea/Vomiting: Granisetron, Ondansetron, skin, confusion, or difficulty urinating); Sedation. Prochlorperazine

Narcotic Analgesics Meperidine, Pentazocine CNS adverse effects leading to increased Mild to Moderate Pain: Acetaminophen, NSAIDs

risk of toxicity; May cause confusion; (Ibuprofen), Capsaicin, Codeine/Acetaminophen, (Includes oral Safer alternatives available. Topical NSAIDs (Voltaren) and injectable routes only) Moderate to Severe Pain: Capsaicin, Hydrocodone/ Acetaminophen, Oxycodone/Acetaminophen

Non-Benzodiazepine Eszopiclone (LUNESTA), Zaleplon (SONA- Increased risk of daytime sedation and falls. Insomnia: Melatonin, low-dose Trazodone Hypnotics TA), Zolpidem (AMBIEN)

(when cumulative day supply for any of the listed HRMs is >90 days during plan year)

Non-Narcotic Ketorolac, Indomethacin Increased risk of GI toxicity. Mild to Moderate Pain: Acetaminophen, NSAIDs Analgesics (Ibuprofen), Capsaicin, Codeine/Acetaminophen, Topical NSAIDs (Voltaren) (includes oral and injectable Moderate to Severe Pain: Capsaicin, Hydrocodone/ routes only) Acetaminophen, Oxycodone/Acetaminophen Skeletal Muscle Carisoprodol, Chlorzoxazone, Highly anticholinergic (can cause dry mouth, flushing, dry Pain/Muscle spasm: Baclofen, Tizanidine Relaxants Cyclobenzaprine, Metaxalone, skin, confusion, or difficulty urinating); Sedation leading to Methocarbamol, Orphenadrine extremely low blood pressure; Increased risk of falling.

(as a single agent or as part of a combination product) Sulfonylureas Chlorpropramide, Glyburide Risk of prolonged hypoglycemia. Diabetes: Glimepiride, Glipizide (long-duration)

Tertiary TCAs Amitriptyline, Clomipramine, Doxepin Highly anticholinergic (can cause dry mouth, flushing, dry Depression: Desipramine, Nortriptyline, low-dose

(>6mg/day), Imipramine, Trimipramine skin, confusion, or difficulty urinating); Sedation; Increased Trazodone, SSRIs (Sertraline), SNRIs (Venlafaxine), (as a single risk of falling Mirtazapine, Bupropion agent or as part and confusion. Nerve Pain: Capsaicin, Desipramine, Nortriptyline, of a combination Cymbalta, Lyrica, Gabapentin, Lidoderm product)

Insomnia: Melatonin, low-dose Trazodone

Vasodilators Ergoloid Mesylates, Isoxsuprine Lack of efficacy. Platelet Aggregation: Aspirin, Clopidogrel

Peripheral Vascular Disease: Cilostazol

Dementia: Galantamine, Rivastigmine, Donepezil

This list of high-risk medications is provided by Blue Cross and Blue Shield of Alabama as recommendations to improve medication management with elderly patients. It is not intended to substitute the clinical judgment of the attending physician.

This is not a comprehensive list of alternative options. Please refer to the current formulary for other possible alternatives.

An independent licensee of the Blue Cross and Blue Shield Association