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High Risk Medication Alternative Table

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High Risk Medication Alternative Table High Risk Medication Alternative Table Description High Risk Medication Rationale for risk* Alternatives Anticholinergics brompheniramine3, Highly anticholinergic, clearance Allergy: levocetirizine, desloratadine, montelukast, carbinoxamine3, reduced with advanced age, and azelastine, intranasal steroid (e.g., fluticasone4), OTCs chlorpheniramine3, tolerance develops when used as such as cetirizine, loratadine, fexofenadine, or clemastine3, cyproheptadine1, hypnotic; greater risk of confusion, dry intranasal normal saline (member to pay out of dexbrompheniramine3, mouth, constipation, and other pocket) dexchlorpheniramine3, anticholinergic effects and toxicity. Cough: OTCs such as guaifenesin, dextromethorphan diphenhydramine (oral)3, (member to pay out of pocket) dimenhydrinate3, Anti-emetic: ondansetron-oral1, granisetron-oral1, doxylamine3, hydroxyzine1, aprepitant-oral1 meclizine, promethazine1, triprolidine3 benztropine (oral)1, Not recommended for prevention of carbidopa & levodopa, carbidopa & levodopa & trihexyphenidyl1 extrapyramidal symptoms with entacapone, ropinirole, pramipexole, amantadine antipsychotics; more-effective agents available for treatment of Parkinson's disease. Antithrombotics dipyridamole - oral short May cause orthostatic hypotension; dipyridamole & aspirin4, clopidogrel acting1 (does not apply to ER more effective alternatives available; combination with aspirin) intravenous form acceptable for use in cardiac stress testing. Anti-infective nitrofurantoin Potential for pulmonary toxicity; safer For UTI Treatment, use alternatives available; lack of efficacy sulfamethoxazole/trimethoprim, fluoroquinolone in patients with CrCl < 60 mL/min due (i.e., ciprofloxacin), cephalosporins (i.e., cephalexin), to inadequate drug concentration in amoxicillin-clavulanate the urine. For UTI Prophylaxis, consider methenamine hippurate Cardiovascular digoxin In heart failure, higher dosages are not Limit use to no more than 0.125 mg of digoxin per associated with additional benefit and day. Ensure patient is adherent prior to increasing may increase risk of toxicity; dose of digoxin. decreased renal clearance may lead to risk of toxic effects. disopyramide1 Disopyramide is a potent negative Consider other antiarrhythmic agents or re-evaluate inotrope and therefore may induce the need for this medication. heart failure in older adults; strongly anticholinergic; other antiarrhythmic drugs preferred. guanfacine, methyldopa1, High risk of adverse CNS effects; may Multiple antihypertensive formulary alternatives reserpine3 (>0.1mg/day), cause bradycardia and orthostatic available: thiazide or thiazide-type diuretics, ACE guanabenz3 hypotension; not recommended as inhibitor/ARB, beta blocker, calcium channel blocker routine treatment for hypertension. Reserpine doses greater than 0.1 mg/day increase risk of adverse effects for 65 and older. nifedipine - immediate Potential for hypotension; risk of nifedipine er, felodipine er, nisoldipine er release1 precipitating myocardial ischemia. Central Nervous amoxapine, amitriptyline1, Highly anticholinergic, sedating, and Neuropathic pain: gabapentin, duloxetine, System clomipramine1, desipramine, causes orthostatic hypotension; safety pregabalin, lidocaine patch1, lidocaine doxepin (>6mg/day) , profile of low-dose doxepin (6 topical/ointment4, capsaicin topical (OTC – member imipramine1, nortriptyline, mg/day) is comparable with that of to pay out of pocket) paroxetine, protriptyline, placebo. OCD: fluoxetine, sertraline, fluvoxamine trimipramine1 Depression: citalopram, escitalopram, fluoxetine, sertraline, venlafaxine, desvenlafaxine er2 amobarbital3, butabarbital3, High rate of physical dependence; Sedative/Insomnia: ramelteon4, doxepin (≤ 6mg butalbital3, mephobarbital3, tolerance to sleep benefits; risk of /day), trazodone pentobarbital3, secobarbital3 overdose at low dosages. 012021 SCAN Health Plan Description High Risk Medication Rationale for risk* Alternatives Central Nervous phenobarbital1 High rate of physical dependence; Seizure: levetiracetam, ethosuximide, gabapentin, System (continued) tolerance to sleep benefits; risk of divalproex sodium, valproic acid, lamotrigine, overdose at low dosages. topiramate, felbamate, carbamazepine, Dilantin, phenytoin, oxcarbazepine, pregabalin meprobamate1 High rate of physical dependence; buspirone very sedating. eszopiclone3, zaleplon3, Benzodiazepine-receptor agonists that Consider short-term use (< 90 days); suggest sleep zolpidem have adverse events similar to those hygiene techniques; re-evaluate the need for this of benzodiazepines in older adults medication after 90 days; ramelteon4, doxepin (≤ 6mg (e.g., delirium, falls, fractures); /day), trazodone minimal improvement in sleep latency and duration. ergoloid mesylates1, Lack of efficacy. Consider ChEI's (donepezil, rivastigmine4, isoxsuprine3 galantamine4), memantine Endocrine estrogens** with or without Evidence of carcinogenic potential Premarin vaginal cream, estradiol vaginal cream, progesterone (oral and (breast and endometrium); lack of yuvafem tablet, OTC lubricants such as KY Jelly or topical patch products only) cardioprotective effect and cognitive Astroglide (member to pay out of pocket) protection in older women. Evidence that vaginal estrogens for treatment Bone density: calcium with vitamin D (OTC), of vaginal dryness is safe and alendronate, risedronate2, ibandronate-oral, effective; women with a history of raloxifene4, Prolia1 breast cancer should discuss risks and benefits of low-dose vaginal estrogen Hot flashes: venlafaxine er, paroxetine er, sertraline, (estradiol < 25 mcg twice weekly) with fluoxetine, gabapentin, clonidine their provider. Avoid oral and topical patch. Vaginal cream or vaginal tablets: acceptable to use low-dose intravaginal estrogen for the management of dyspareunia, recurrent lower urinary tract infections, and other vaginal symptoms. chlorpropamide3, Prolonged half-life in older adults; can glipizide, glipizide er glyburide3, glimepiride cause prolonged hypoglycemia. megestrol acetate Minimal effect on weight; increases Depressed patients - mirtazapine; treatment of risk of thrombotic events and possibly cachexia associated with AIDS - oxandrolone and death in older adults. dronabinol1 Desiccated thyroid3 Concerns about cardiac effects; safer levothyroxine, levoxyl, liothyronine, Synthroid, alternatives available. unithroid, Cytomel Pain Medications meperidine HCl3 Not an effective oral analgesic in Multiple formulary opioid analgesics available. Use dosages commonly used; may cause the lowest effective dose of opioid and small quantity neurotoxicity; safer alternatives for the shortest duration possible. Avoid long- available. duration, sustained release opioids in opioid naïve individuals. indomethacin1, ketorolac1 Increases risk of GI bleeding and Short term use of etodolac, meloxicam, nabumetone, (includes oral and injectable peptic ulcer disease in high-risk ibuprofen, naproxen, sulindac. If these alternatives routes only) groups. are used chronically, consider adding a PPI or misoprostol. Skeletal Muscle carisoprodol3, Most muscle relaxants are poorly Spasticity: baclofen (start with a low dose and titrate Relaxants chlorzoxazone1, tolerated by older adults because of slowly up and down), tizanidine cyclobenzaprine1, anticholinergic adverse effects, Muscle spasm: NSAID (use with PPI or misoprostol for metaxalone3, sedation, risk of fracture; long term use), massage therapy, physical therapy methocarbamol1, effectiveness at dosages tolerated by orphenadrine3 older adults is questionable. 1 = Prior Authorization required, 2 = Step Therapy required, 3 = Non-Formulary, 4 = Quantity Limit. Refer to formulary for tier placement of all drugs. *American Geriatrics Society. American Geriatrics Society 2019 Updated Beers Criteria for Potential Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 2019. ** Conjugated estrogens, esterified estrogens, estradiol, estropipate (including combination products, oral and transdermal routes). Some estrogen products will require Prior Authorization. Abbreviations: OTC- over the counter; ER- extended release; TCAs- tricyclic antidepressants; OCD- obsessive compulsive disorder; ChEI’s- cholinesterase inhibitors; PPI- proton pump inhibitor; NSAID- nonsteroidal anti-inflammatory drug 012021 SCAN Health Plan .
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