High-Risk Medication Pocket Guide

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High-Risk Medication Pocket Guide 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.
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    Antihistamines in the treatment of chronic urticaria I Jáuregui,1 M Ferrer,2 J Montoro,3 I Dávila,4 J Bartra,5 A del Cuvillo,6 J Mullol,7 J Sastre,8 A Valero5 1 Service of Allergy, Hospital de Basurto, Bilbao, Spain 2 Department of Allergology, Clínica Universitaria de Navarra, Pamplona, Spain 3 Allergy Unit, Hospital La Plana, Villarreal (Castellón), Spain 4 Service of Immunoallergy, Hospital Clínico, Salamanca, Spain 5 Allergy Unit, Service of Pneumology and Respiratory Allergy, Hospital Clínic (ICT), Barcelona, Spain 6 Clínica Dr. Lobatón, Cádiz, Spain 7 Rhinology Unit, ENT Service (ICEMEQ), Hospital Clínic, Barcelona, Spain 8 Service of Allergy, Fundación Jiménez Díaz, Madrid, Spain ■ Summary Chronic urticaria is highly prevalent in the general population, and while there are multiple treatments for the disorder, the results obtained are not completely satisfactory. The second-generation H1 antihistamines remain the symptomatic treatment option of choice. Depending on the different pharmacokinetics and H1 receptor affi nity of each drug substance, different concentrations in skin can be expected, together with different effi cacy in relation to the histamine-induced wheal inhibition test - though this does not necessarily have repercussions upon clinical response. The antiinfl ammatory properties of the H1 antihistamines could be of relevance in chronic urticaria, though it is not clear to what degree they infl uence the fi nal therapeutic result. Before moving on to another therapeutic level, the advisability of antihistamine dose escalation should be considered, involving increments even above those approved in the Summary of Product Characteristics. Physical urticaria, when manifesting isolatedly, tends to respond well to H1 antihistamines, with the exception of genuine solar urticaria and delayed pressure urticaria.
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