Prescribing Focus Geriatric RxMonitor Medication Appropriateness Evaluation (MAE) tool High risk medications in patients ≥ 65 years Drug Class Generic Drug Name Clinical Rationale/Reasons Analgesic, Indomethacin Indomethacin carries a black box NSAID warning for increased risk of GI bleeds/ perforation (higher risk in patients ≥ 65) and cardiovascular events. Indomethacin has the most adverse effects of all NSAIDS. Consider other safer alternatives.1,2,3 Analgesic, Ketorolac Ketorolac carries a black box warning for NSAID increased risk of GI bleeds/perforation (higher risk in patients ≥ 65) and cardiovascular events. Consider other safer alternatives.1,2,3,4 Analgesic, Meperidine Meperidine is not recommended for use in opioid narcotic the elderly. Accumulation of its metabolite (normeperidine) is associated with neurotoxicity. Commonly used dosages are not effective as an oral analgesic. Consider other safer alternatives.1,3,5 Abbreviations: CAPS — capsules. CNS — central nervous system. CrCl — creatinine clearance. GI — gastrointestinal. HTN — hypertension. NSAID — non-steroidal anti-inflammatory drug. SIADH — syndrome of inappropriate anti-diuretic hormone. SSRI — selective serotonin reuptake inhibitor. TAB — tablet. TCA — tricyclic antidepressant. OptumRx | optumrx.com Geriatric RxMonitor Medication Appropriateness Evaluation (MAE) tool Drug Class Generic Drug Name Clinical Rationale/Reasons Analgesic, Pentazocine Pentazocine is a mixed opioid agonist- opioid narcotic antagonist with more CNS side effects (e.g., confusion, hallucinations) than other narcotics. Use in the elderly may cause falls/ fractures, dependency, and withdrawal. Consider other safer alternatives.1,2 Anti-anxiety Meprobamate Meprobamate is a highly addictive and sedating anxiolytic and is not recommended in patients ≥ 65 years. Consider other safer alternatives.1,6 Antibiotic Nitrofurantoin Nitrofurantoin is not recommended in elderly patients, who are more likely to have CrCl < 30mL/min, due to risk of pulmonary and hepatic toxicity and ineffective drug concentration in the urine. Consider other safer alternatives.1,3 Anti-parkinsonian Benztropine (oral) Benztropine and trihexyphenidyl are not agents Trihexyphenidyl recommended in the elderly due to the availability of other safer alternatives with less anticholinergic properties. Elderly patients are more susceptible to memory impairment, confusion, and hallucinations. Consider other safer alternatives.1,6 Antidepressants, SSRI Paroxetine Paroxetine has the greatest anticholinergic properties (e.g., dizziness, blurred vision) of all SSRIs. Consider other safer alternatives.1,7 Abbreviations: CAPS — capsules. CNS — central nervous system. CrCl — creatinine clearance. GI — gastrointestinal. HTN — hypertension. NSAID — non-steroidal anti-inflammatory drug. SIADH — syndrome of inappropriate anti-diuretic hormone. SSRI — selective serotonin reuptake inhibitor. TAB — tablet. TCA — tricyclic antidepressant. 2 OptumRx | optumrx.com Drug Class Generic Drug Name Clinical Rationale/Reasons Antidepressants, Amitriptyline Tricyclic antidepressants (TCAs) have tertiary TCAs Amoxapine severe anticholinergic adverse events (e.g., sedation, confusion, constipation) and Clomipramine can cause orthostatic hypotension. TCAs Desipramine are contraindicated in the acute recovery Imipramine period of a myocardial infarction. Consider Nortriptyline other safer alternatives.1,6 Protriptyline Trimipramine Antidepressants, Doxepin cap > 6 mg/day Doxepin has strong anticholinergic properties tertiary TCAs (e.g., sedation, confusion, constipation) and can cause orthostatic hypotension. If used, monitor sodium concentrations closely with dosage adjustments. Consider other safer alternatives.1,5 Antihistamines Bropheniramine Antihistamines have anticholinergic Carbinoxamine adverse events (e.g., sedation, dizziness, blurred vision) that are more susceptible in Chlorpheniramine patients ≥ 65 years. Consider other safer Clemastine alternatives.1,6,8 Cyproheptadine Dexbrompheniramine Dexchlorpheniramine Diphenhydramine Dimenhydrinate Doxylamine Hydroxyzine Meclizine Promethazine Tiprolidine Abbreviations: CAPS — capsules. CNS — central nervous system. CrCl — creatinine clearance. GI — gastrointestinal. HTN — hypertension. NSAID — non-steroidal anti-inflammatory drug. SIADH — syndrome of inappropriate anti-diuretic hormone. SSRI — selective serotonin reuptake inhibitor. TAB — tablet. TCA — tricyclic antidepressant. 3 Geriatric RxMonitor Medication Appropriateness Evaluation (MAE) tool Drug Class Generic Drug Name Clinical Rationale/Reasons Antispasmodics Atropine (excludes ophthalmic) Antispasmodics have strong anticholinergic Belladonna Alkaloids properties (e.g., sedation, dizziness, and blurred vision) and uncertain effectiveness. Clidinium-Chlordiazepoxide Elderly patients may be at risk for toxicity Dicyclomine due to reduced renal function. Consider Hyoscyamine other safer alternatives with better Propantheline efficacy.1,6 Scopolamine Antithrombotic Ticlopidine Ticlopidine has been demonstrated to cause life-threatening neutropenia or agranulocytosis. Consider other safer alternatives with better efficacy.1,3 Barbiturates Amobarbital Barbiturates are highly addictive, and can Butabarbital cause more side effects than other sedative/ hypnotics (especially in patients ≥ 65 years). Butalbital With low dosages, tolerance to sleep effects Mephobarbital and increased risk of physical dependence can Pentobarbital occur. Use should be avoided due to risk of Phenobarbital overdose unless if being used for seizures.1,3,5,9 Secobarbital Benzodiazepines, Alprazolam Benzodiazepines are not recommended short- and immediate- Estazolam for use in the elderly due to an increased acting risk of cognitive impairment, delirium, Lorazepam falls, fractures, and motor vehicle crashes. Oxazepam Consider other safer alternatives.1 Temazepam Triazolam Benzodiazepines, Clorazepate Elderly patients have decreased metabolism long-acting Chlordiazepoxide of long-acting benzodiazepines. Use of long-acting agents may increase the risk of Clonazepam falls and cognitive impairment.1 Diazepam Flurazepam Quazepam Abbreviations: CAPS — capsules. CNS — central nervous system. CrCl — creatinine clearance. GI — gastrointestinal. HTN — hypertension. NSAID — non-steroidal anti-inflammatory drug. SIADH — syndrome of inappropriate anti-diuretic hormone. SSRI — selective serotonin reuptake inhibitor. TAB — tablet. TCA — tricyclic antidepressant. 4 OptumRx | optumrx.com Drug Class Generic Drug Name Clinical Rationale/Reasons Cardiovascular, Clonidine Central alpha agonists are not recommended central alpha-1 Guanabenz for routine treatment of hypertension. blockers There is a high risk of CNS adverse effects, Guanfacine bradycardia, and orthostatic hypotension Methyldopa when used in the elderly. Avoid clonidine as a first-line antihypertensive. Consider other safer alternatives.1,3 Cardiovascular, Nifedipine immediate release Immediate-release nifedipine is not calcium channel recommended for the treatment of chronic blocker HTN. Side effects include hypotension and the risk of precipitating heart attack. Consider other safer alternatives.1,10 Cardiovascular, Digoxin tab > 0.125 mg Since digoxin is renally eliminated, older other patients have a higher risk for toxicity (GI side effects, confusion, agitation, delirium) due to declining renal function. Avoid as first-line therapy for heart failure or atrial fibrillation and doses exceeding 0.125 mg/ day if possible.1,6,11 Cardiovascular, Disopyramide As a potent negative ionotrope, other disopyramide may induce heart failure in older patients. Disopyramide also has strong anticholinergic properties and should be avoided as an antiarrhythmic, if possible.1,3,6 Cardiovascular, Reserpine tab > 0.1 mg/day Reserpine side effects include bradycardia, other orthostatic hypotension and a high risk of CNS adverse effects. Avoid use in the elderly for the routine treatment of hypertension and in doses higher than 0.1 mg/day.1,6 Abbreviations: CAPS — capsules. CNS — central nervous system. CrCl — creatinine clearance. GI — gastrointestinal. HTN — hypertension. NSAID — non-steroidal anti-inflammatory drug. SIADH — syndrome of inappropriate anti-diuretic hormone. SSRI — selective serotonin reuptake inhibitor. TAB — tablet. TCA — tricyclic antidepressant. 5 Geriatric RxMonitor Medication Appropriateness Evaluation (MAE) tool Drug Class Generic Drug Name Clinical Rationale/Reasons Endocrine system, Megestrol Megestrol increases the risk of thrombotic progestin events (e.g., thrombophlebitis, pulmonary embolism) and death in patients ≥ 65 years with reduced kidney excretion. Consider other safer alternatives.1,6 Endocrine system, Estrogens oral or transdermal In older women (65 years and older), estrogens (conjugated, esterified) estrogen therapy shows evidence of carcinogenic potential and lack of cardio protective effect and cognitive protection (with or without progesterone). Weigh the risks and benefits of use.1,12 Endocrine system, Dessicated thyroid Elderly patients may have underlying other cardiovascular instability; therefore, thyroid doses in this population should be titrated carefully. Consider other safer alternatives.1,3 Gastrointestinal, Dexlansoprazole Avoid scheduled use of proton-pump proton-pump Esomeprazole inhibitors for > 8 weeks without a inhibitors strong indication due to increased risk of Lansoprazole Clostridium difficile infection, bone loss and Omeprazole fractures. 1 Pantoprazole Hypnotics, Eszopiclone