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Home , Carbinoxamine, Dexbrompheniramine, Dexchlorpheniramine, Ergoloid, Isoxsuprine, Meclizine

Prescribing Focus

Geriatric RxMonitor Appropriateness Evaluation (MAE) tool

High risk in patients ≥ 65 years

Drug Class 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 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 reuptake inhibitor. TAB — tablet. TCA — .

OptumRx | optumrx.com Geriatric RxMonitor Medication Appropriateness Evaluation (MAE) tool

Drug Class Generic Drug Name Clinical Rationale/Reasons

Analgesic, Pentazocine is a mixed opioid - 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 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 are not agents Trihexyphenidyl recommended in the elderly due to the availability of other safer alternatives with less properties. Elderly patients are more susceptible to memory impairment, confusion, and hallucinations. Consider other safer alternatives.1,6

Antidepressants, SSRI 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 — .

2 OptumRx | optumrx.com Drug Class Generic Drug Name Clinical Rationale/Reasons

Antidepressants, Tricyclic antidepressants (TCAs) have tertiary TCAs severe anticholinergic adverse events (e.g., sedation, confusion, constipation) and can cause . TCAs are contraindicated in the acute recovery period of a myocardial infarction. Consider other safer alternatives.1,6

Antidepressants, 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 have anticholinergic adverse events (e.g., sedation, dizziness, blurred vision) that are more susceptible in Chlorpheniramine patients ≥ 65 years. Consider other safer alternatives.1,6,8 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 (excludes ophthalmic) Antispasmodics have strong anticholinergic Belladonna properties (e.g., sedation, dizziness, and blurred vision) and uncertain effectiveness. Clidinium- Elderly patients may be at risk for toxicity Dicyclomine due to reduced renal function. Consider other safer alternatives with better Propantheline efficacy.1,6

Antithrombotic Ticlopidine Ticlopidine has been demonstrated to cause life-threatening neutropenia or agranulocytosis. Consider other safer alternatives with better efficacy.1,3

Barbiturates are highly addictive, and can cause more side effects than other / (especially in patients ≥ 65 years). With low dosages, tolerance to sleep effects Mephobarbital and increased risk of physical dependence can occur. Use should be avoided due to risk of overdose unless if being used for seizures.1,3,5,9

Benzodiazepines, are not recommended short- and immediate- for use in the elderly due to an increased acting risk of cognitive impairment, , falls, fractures, and motor vehicle crashes. Consider other safer alternatives.1

Benzodiazepines, Elderly patients have decreased metabolism long-acting Chlordiazepoxide of long-acting benzodiazepines. Use of long-acting agents may increase the risk of falls and cognitive impairment.1

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, Central are not recommended central alpha-1 for routine treatment of hypertension. blockers There is a high risk of CNS adverse effects, bradycardia, and orthostatic hypotension when used in the elderly. Avoid clonidine as a first-line antihypertensive. Consider other safer alternatives.1,3

Cardiovascular, immediate release Immediate-release nifedipine is not 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, 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, 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 ). 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 fractures. 1 Pantoprazole

Hypnotics, hypnotics have adverse nonbenzodiazepine, events such as delirium and falls potentiating nonbarbiturate the risk for fractures in the elderly. Avoid use in this population.1

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.

6 OptumRx | optumrx.com Drug Class Generic Drug Name Clinical Rationale/Reasons

Oral Hypoglycemics, Chlorpropamide and glyburide can cause sulfonylureas Glyburide prolonged hypoglycemia and increase the risk of Syndrome of Inappropriate Antidiuretic Hormone (SIADH), especially in older patients. Sulfonylureas with a shorter half-life, such as , should be considered instead.1,3

Skeletal Muscle Chlorzoxazone Muscle relaxants are poorly tolerated and Relaxants have questionable efficacy in patients≥ 65 years. Side effects include anticholinergic effects, prolonged sedation, and Metaxalone increased risk of falls. Consider other safer Methocarbamol alternatives.1,13,14

Vasodilator Mesylates Ergoloid mesylates have not been shown to be effective, in the doses studied, for the treatment of . Side effects are unfavorable and should be avoided, if possible.1,15

Vasodilator Dipyridamole, oral short acting Oral short acting dipyridamole is ineffective as an antithrombotic in patients with myocardial infarction when used alone. Patients ≥ 65 years are at increased risk of orthostatic hypotension. Consider other safer alternatives with better efficacy.1,6,16

Vasodilator Isoxsuprine is listed as only possibly effective for its labeled indication. Consider alternatives with better efficacy.1,6,17

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.

7 Geriatric RxMonitor Medication Appropriateness Evaluation (MAE) tool

References:

1. American Society 2015 Beers Criteria Update Expert Panel (2015). American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. Doi: 2015 Nov;63(11):2227-46. 2. Aparasu RR and Fliginger SE. Inappropriate medication prescribing for the elderly by office-based physicians. Ann Pharmacother. 1997 Jul-Aug;31(7-8):823-829. 3. Micromedex Healthcare Series website. http://www.micromedex.com. Accessed December 17, 2015. 4. Ketorolac tablets package insert. Gainesville, GA: Stat Rx USA; 2011 August. 5. McLeod PJ, Huang AR, Tamblyn RM, Gayton DC. Defining inappropriate practices in prescribing for elderly people. Can Med Assoc J. 1997;156(3):385-391. 6. Facts & Comparisons®. Medication Interaction Facts website. http://online.factsandcomparisons.com/ Accessed December 17, 2015. 7. Wiese BS. Geriatric depression: The use of antidepressants in the elderly. BC Med J. 2011;53(7):341-347. 8. UpToDate®. Pharmacotherapy of . http://www.uptodate.com. Accessed December 17, 2015. 9. UpToDate®. Butalbital Drug Information. http://www.uptodate.com. Accessed December 17, 2015. 10. Procardia® Prescribing Information. New York, NY: Pfizer Labs; 2010. 11. Cheng JW and Rybak I, “Use of Digoxin for Heart Failure and Atrial Fibrillation in Elderly Patients,” Am J Geriatr Pharmacother, 2010, 8(5):419-27. 12. North American Menopause Society. The 2012 hormone therapy position statement of: The North American Menopause Society. Menopause. 2012 Mar;19(3):257-71 13. Cyclobenzaprine tablets package insert. Morgantown, WV: Mylan Pharmaceutical; 2013 April. 14. Fick DM, Copper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in the older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163(22):2716-2724. 15. Hanlon JT, Shimp LA, Semla TP. Recent advances in geriatrics: drug-related problems in the elderly. Ann Pharmacother. 2000 Mar;34(3):360-5. 16. UpToDate®. Antiplatelet therapy for secondary prevention of . http://www.uptodate.com. Accessed December 17, 2015. 17. Isoxsuprine tablets package insert. Red Bank, NJ: Bi-Coastal Pharmaceutical Corp.; 2012 December.

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