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Prescribing Focus Polypharmacy Program - Drug-Disease Interactions Medication Appropriateness Evaluation (MAE) tool Drug-disease interactions (regardless of patient age) Condition Interacting Drug(s) Potential Complication(s) Recommendation(s) CHF Most calcium CCBs with negative inotropic • Most CCBs should be avoided channel blockers effects can worsen CHF in patients whenever possible in patients (CCBs) (except with reduced ejection fraction.1 with heart failure, even when amlodipine) used for the treatment of angina or hypertension.1 • Amlodipine is the only CCB to not adversely affect survival in CHF patients.1 CHF Class I/III • These drugs are known to • These antiarrhythmics are not antiarrhythmics adversely affect the clinical status recommended in CHF patients of patients with current or prior for the prevention of ventricular symptoms of heart failure and arrhythmias.1 reduced LVEF.1 • May consider amiodarone or • Nearly all antiarrhythmics have dofetilide for patients with negative inotropic effects. The symptomatic arrhythmias.1 risk of serious arrhythmia is increased in CHF patients.1 Abbreviations: CHF — congestive heart failure. CCB — calcium channel blocker. LVEF — left ventricular ejection fraction. NSAID — non-steroidal anti-inflammatory drug. NYHA — New York Heart Association. TCA — tricyclic antidepressant. SSRI — selective serotonin reuptake inhibitor. SNRI — selective norepinephrine reuptake inhibitor. COPD — chronic obstructive pulmonary disease. BPH — benign prostatic hyperplasia. COX-2 — cyclooxygenase-2. CNS — central nervous system. MI – myocardial infarction. OptumRx | optumrx.com Polypharmacy Program – Drug-Disease Interactions Medication Appropriateness Evaluation (MAE) tool CHF Non-steroidal • NSAIDs are known to adversely NSAIDs should be used with anti-inflammatory affect the clinical status of patients caution or avoided in the CHF drugs (NSAIDs) with current or prior symptoms of population when possible.1 heart failure and reduced LVEF.1 • NSAIDs cause a blunted response to exogenous diuretics and may increase systemic vascular resistance.1 CHF Thiazolidinediones Fluid retention may occur with • Boxed warning: (e.g., pioglitazone, thiazolidinediones. This may lead to Thiazolidinediones are rosiglitazone) or exacerbate heart failure. The risk contraindicated in patients with is increased in patients concurrently NYHA functional class III-IV CHF. taking insulin.1 They should be used cautiously in any CHF class.1 • Patient should be monitored for new or increased CHF symptoms.1 CHF metformin Patients with unstable or • Due to the risk of developing acute CHF who are at risk of lactic acidosis, metformin should hypoperfusion and hypoxia are at be avoided in hospitalized patients increased risk of lactic acidosis.2 or those with unstable CHF.3 • Metformin may be used in patients with stable CHF if renal function is normal.3 CHF cilostazol • Cilostazol and several of its Contraindication: Cilostazol is metabolites are inhibitors of contraindicated in patients with phosphodiesterase III, resulting CHF of any severity.4 Avoid use in in ventricular tachycardia and this population. premature ventricular complexes.5 • Other drugs that inhibit phosphodiesterase III have caused death in patients with class III-IV CHF.5 History of NSAIDs • NSAIDs may increase the risk of Consider alternative therapies if MI cardiovascular thrombotic events, clinically appropriate or prescribing such as MI and stroke. Patients the lowest effective NSAID dose for who have had a prior MI may be the shortest duration possible to at an increased risk.18 minimize the risk.18 Abbreviations: CHF — congestive heart failure. CCB — calcium channel blocker. LVEF — left ventricular ejection fraction. NSAID — non-steroidal anti-inflammatory drug. NYHA — New York Heart Association. TCA — tricyclic antidepressant.. SSRI — selective serotonin reuptake inhibitor. SNRI — selective norepinephrine reuptake inhibitor. COPD — chronic obstructive pulmonary disease. BPH — benign prostatic hyperplasia. COX-2 — cyclooxygenase-2. CNS — central nervous system. MI – myocardial infarction. 2 OptumRx | optumrx.com Asthma or Non-selective Non-selective beta-blockers may • Contraindication: Most COPD beta-blockers cause bronchoconstriction by non-selective beta-blockers are (e.g., propranolol) counteracting the bronchodilation contraindicated or should be produced by catecholamine avoided in patients with bronchial stimulation of beta-2 receptors.4,7 asthma, bronchospasm, or COPD.2,7 • Cardioselective beta-blockers (e.g., atenolol, metoprolol) or another class of antihypertensives (e.g., diuretics, angiotensin- converting enzyme inhibitors, angiotensin II receptor blockers) may be used cautiously.7,8 Parkinson’s metoclopramide Metoclopramide has Metoclopramide should be used disease antidopaminergic effects and with caution in patients with may exacerbate Parkinsonian- Parkinson’s disease.2 like symptoms, such as akinesia, tremors and cogwheel rigidity.5,6,9 Seizure or bupropion Bupropion may lower the seizure • Contraindication: Bupropion is epilepsy threshold. The incidence of seizures contraindicated in patients with increases at higher dosages.5,6 a seizure disorder and should be used with extreme caution in patients with a history of seizures or those with other predisposing factors for seizures.4 • Consider antidepressants with lower risk for seizure, such as mirtazapine, trazodone, nefazodone and SSRIs (e.g., fluoxetine), as well as other alternatives for smoking cessation and/or weight loss if clinically appropriate.4,5 BPH atropine- Select antimuscarinics with highly • Highly anticholinergic medications containing drugs anticholinergic properties may are not recommended for use in benztropine aggravate BPH symptoms and/or patients with BPH. mesylate lead to urinary retention.5,6,10 • Topical oxybutynin (transdermal dicyclomine patch, topical gel) have less anticholinergic effects than oral hyoscyamine formulations although caution oxybutynin is still advised when used in BPH patients.4,5 Abbreviations: CHF — congestive heart failure. CCB — calcium channel blocker. LVEF — left ventricular ejection fraction. NSAID — non-steroidal anti-inflammatory drug. NYHA — New York Heart Association. TCA — tricyclic antidepressant.. SSRI — selective serotonin reuptake inhibitor. SNRI — selective norepinephrine reuptake inhibitor. COPD — chronic obstructive pulmonary disease. BPH — benign prostatic hyperplasia. COX-2 — cyclooxygenase-2. CNS — central nervous system. MI – myocardial infarction. 3 Polypharmacy Program – Drug-Disease Interactions Medication Appropriateness Evaluation (MAE) tool BPH amitriptyline Select TCAs have highly • Highly anticholinergic medications clomipramine anticholinergic properties.11 are not recommended for use in Their use in patients with BPH may patients with BPH. doxepin aggravate BPH symptoms and/or • Alternative antidepressant imipramine lead to urinary retention.5,9 drugs with less anticholinergic trimipramine activity include trazodone, nefazodone and the SSRIs (e.g., fluoxetine).4,5 Secondary amine TCAs (nortriptyline, protriptyline, desipramine) have the least amount of anticholinergic activity among the TCAs.11,12 BPH chlorpromazine Phenothiazines with highly Highly anticholinergic medications perphenazine anticholinergic properties may are not recommended for use in aggravate BPH symptoms and/or patients with BPH. thioridazine lead to urinary retention.5,6,10 trifluoperazine BPH hydroxyzine Antihistamines with highly • Highly anticholinergic medications meclizine anticholinergic properties may are not recommended for use in aggravate BPH symptoms and/or patients with BPH. lead to urinary retention.5,6,10 • Consider antihistamines with less anticholinergic activity, such as loratadine and fexofenadine.4,5 BPH loxapine Antipsychotics with highly Highly anticholinergic medications anticholinergic properties may are not recommended for use in aggravate BPH symptoms and/or patients with BPH. lead to urinary retention.5,6,10 Gallbladder Fibric acid derivatives Fibric acid derivatives may increase • Contraindication: Fibric acid disease cholesterol excretion into the derivatives are contraindicated bile, thereby increasing the risk of in patients with gallbladder developing gallstones.4 disease.4 • In patients with pre-existing gallstones, consider the use of other agents for the treatment of hypertriglyceridemia.2 Gout Thiazides and Thiazide diuretics decrease uric For patients with frequent gout thiazide-like diuretics acid excretion, thus increasing the attacks, consider another class of risk of precipitating gout attacks or antihypertensives (e.g., angiotensin- developing hyperuricemia in certain converting enzyme inhibitors, patients.2,5 angiotensin II receptor blockers).2 Abbreviations: CHF — congestive heart failure. CCB — calcium channel blocker. LVEF — left ventricular ejection fraction. NSAID — non-steroidal anti-inflammatory drug. NYHA — New York Heart Association. TCA — tricyclic antidepressant.. SSRI — selective serotonin reuptake inhibitor. SNRI — selective norepinephrine reuptake inhibitor. COPD — chronic obstructive pulmonary disease. BPH — benign prostatic hyperplasia. COX-2 — cyclooxygenase-2. CNS — central nervous system. MI – myocardial infarction. 4 OptumRx | optumrx.com Glaucoma atropine- Select antimuscarinics with highly Highly anticholinergic medications (closed- containing drugs anticholinergic properties may are not recommended for use angle) benztropine lead to ocular hypertensive crisis in patients
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