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Home , Amitriptyline, Butabarbital, Butalbital, Carbidopa, Carbinoxamine, Channel blocker

High-Risk in the Elderly The Centers for Medicare & Medicaid Services (CMS) contracted with the National Committee for Quality Assurance (NCQA) to develop clinical strategies to monitor and evaluate the quality of care provided to Medicare beneficiaries. The NCQA’s Geriatric Measurement Advisory Panel identified several categories of medications that have an increased risk of adverse effects to elderly patients. The enclosed chart identifies several key categories that CMS and NCQA are monitoring. In an effort to ensure patients’ safety, many of our clients have established pre-authorization protocols for those prescriptions for high risk medications in patients older than 65 years of age. Since pharmacists have a very important role in patient care, we want you to be part of this safety initiative. We strongly encourage that you contact the prescriber when your elderly patient is requesting a new or refilled prescription of a high-risk medication listed on the below chart. Category High Risk Medications Alternatives /APAP Mild : butalbital/APAP/ (ESGIC, FIORICET) acetaminophen, , short-term NSAIDs butalbital /APAP/caffeine/codeine Moderate/Severe Pain: butalbital/ASA/caffeine (FIORINAL) (ULTRAM), tramadol/APAP* (ULTRACET), butalbital/ASA/caffeine/codeine sulfate (MS CONTIN), (TORADOL) /APAP (VICODIN, etc.), indomethacin (INDOCIN) (OXYIR), oxycodone/APAP (PERCOCET), meperidina (DEMEROL) patch (DURAGESIC), OXYCONTIN (TALWIN) : pentazocine/APAP (CYMBALTA), (LYRICA), (NEURONTIN), (NORPRAMIN), (PAMELOR), topical agents (, topical ) Anti- / (EQUAGESIC) Anxiety: meprobamate (EQUINIL) SSRI, SNRI, (BUSPAR) (ELAVIL) TCAs: amitriptyline/ (LIMBITROL DS) nortriptyline (PAMELOR), desipramine /amitriptyline (ETRAFON) (NORPRAMIN), (DESYREL) (ANAFRANIL) : (> 6mg/d) (SINEQUAN) SSRI, SNRI, (REMERON, REMERON (TOFRANIL) SOLTAB), (WELLBUTRIN) (SURMONTIL) Neuropathic Pain: duloxetine (CYMBALTA), pregabalin (LYRICA), gabapentin (NEURONTIN), capsaicin : hygiene , , ROZEREM tab 8mg, low-dose doxepin (suspension), SILENOR tab 3mg and 6mg, Gastrointestinal (TIGAN) (KYTRIL), (ZOFRAN) /belladonna (DONNATAL : fiber, psyllium, polyethylene glycol (MIRALAX) : (IMODIUM), aluminum hydroxide, cholestyramine First Generation Please refer to the formulary for other options or call our clinical pharmacist at (787) 200-1689. chlorpheniramine (oral) Oral Hypoglycemic (DIABINESE, INSULASE) (AMARYL) glyburide (MICRONASE, GLYNASE, DIABETA) (GLUCOTROL) glyburide/ (GLUCOVANCE

Category High Risk Medications Alternatives Anti-Parkinson Agents benztropine (COGENTIN) Parkinson’s disease: trihexiphenidyl (ARTANE (CYCLOSET), EMSAM, levodopa/ (SINEMET) (MIRAPEX), (REQUIP), COMTAN, STALEVO

Antiplatelet Agents dipyridamole, short-acting (PERSANTINE) clopidogrel (PLAVIX), low-dose aspirin (TICLID) (MELLARIL) (HALDOL), (ZYPREXA), (RISPERDAL), ABILIFY, FANAPT, (GEODON), GEODON INJ, INVEGA, SAPHRIS, SEROQUEL XR - : sleep hygiene therapy

(BUTISOL) melatonin phenobarbital (LUMINAL) ROZEREM tab 8mg (SECONAL) low-dose doxepin (suspension) Non- (> 90 days): SILENOR tab 3mg and 6mg (AMBIEN) Temazepam (LUNESTA) (SONATA) Other: hydrate Cardiac Agents > 0.125 mg/d (LANOXIN) dose reduction, with monitoring

(NORPACE) rate control preferred for (TENEX, INTUNIV) Low dose or a second generation (ALDOMET) methyldopa/ (ALDORIL) OR (short-acting), (PROCARDIA) ACE inhibitor, ARB, beta-blocker or combination product based on specific chronic conditions conjugated (PREMARIN, CENESTIN, Bone Density: ENJUVIA) alendronate (FOSAMAX), ibandronate (BONIVA), (oral, transdermal) conjugated estrogen/medroxyprogesterone EVISTA (PREMPHASE, PREMPRO) Hot Flashes: esterified estrogen (MENEST) non- therapy with or without progestin esterified estrogen/ (COVARYX, Vaginal Symptoms: ESTRATEST) vaginal estrogen (ESTRACE, ESTROGEL, CLIMARA) estropipate (OGEN, ORTHO-EST)

estradiol/norethindrone (ACTIVELLA, COMBIPATCH) ethinyl estradiol/norethindrone (FEMHRT, JINTELI) estradiol/ (ANGELIQ) estradiol/ (CLIMARA PRO) estradiol/ (PREFEST) Skeletal Muscle Relaxants ASA/caffeine/ Physiotherapy: ASA//codeine * (LIORESAL), ASA/carisoprodol, (ZANAFLEX) (as long as no , carisoprodol (SOMA) , BPH, cognitive impairment, constipation) (PARAFON FORTE, LORZONE) (AMRIX, FEXMID, FLEXERIL) (SKELAXIN) (ROBAXIN) orphenadrine (NORFLEX) Other thyroid desiccated (ARMOUR THYROID) Hypothyroid: (thyroid drug; urinary anti-infective; progestins) nitrofurantoin (FURADANTIN) (SYNTHROID), levoxyl nitrofurantoin macrocrystals (MACRODANTIN) Urinary Tract : nitrofurantoin macrocrystals-monohydrate (CIPRO), (MACROBID) trimethoprim-sulfamethoxazole (BACTRIM DS), megestrol (MEGACE, MEGACE ES) culture specific antibiotic For Depressed Patients: Low dose mirtazapine (REMERON) For Loss of : (MARINOL)