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Home , Dexchlorpheniramine, Hyoscyamine

to Avoid in the Elderly Adapted from NCQA’s HEDIS® measure, Use of High-Risk Medications in the Elderly

Description Prescription Adverse Side Formulary Alternatives1 Effects/Concerns Anti-anxiety • aspirin-meprobamate • meprobamate Addictive and sedating Low-dose short-acting (includes anxiolytic benzodiazepines, combination drugs) , buspirone Anti-emetics • • Extra pyramidal adverse , effects (Anzemet) Analgesics • ketorolac Potential for GI bleeding, Acetaminophen, Trisalicylate (includes renal failure, high blood (Trilisate), Topicals combination drugs) pressure and heart failure (capsaicin) • • -amitriptyline Anti- and Condition dependent: SSRIs, • Chlordiazepoxide • sedative effects; increased bupropion, , amitriptyline risk of falls and fractures , Weight management: diet and lifestyle modifications • APAP// • / Anti-cholinergic effects and , (includes methscopolamine/PSE sedation, weakness, blood (Astelin) combination drugs) • APAP/diphenhydramine/ • dexchlorpheniramine- pressure changes, dry phenylephrine pseudoephedrine mouth, urinary retention • APAP/diphenhydramine/ • dextromethorphan- pseudoephedrine • acetaminophen- • diphenhydramine diphenhydramine • diphenhydramine/ • carbetapentane/diphen- hydrocodone/phenylephrine hydramine/phenylephrine • diphenhydramine- • codeine/phenylephrine/ magnesium salicylate promethazine • diphenhydramine- • codeine-promethazine phenylephrine • • diphenhydramine- • dexchlorpheniramine pseudoephedrine • dexchlorpheniramine/ • hydrochloride dextromethorphan/PSE • hydroxyzine pamoate • dexchlorpheniramine/ • phenylephrine-promethazine guaifenesin/PSE • promethazine • dexchlorpheniramine/ hydrocodone/phenylephrine Antipsychotic, • Central nervous system (Zyprexa), typical (CNS) and extra pyramidal (Seroquel), effects (Risperdal), pimozide (Orap), Printed with permission from National Committee for Quality Assurance (NCQA) – HEDIS measure 651ALL0111-E Medications to Avoid in the Elderly Adapted from NCQA’s HEDIS® measure, Use of High-Risk Medications in the Elderly

Description Prescription Adverse Side Formulary Alternatives1 Effects/Concerns • - • Addictive properties, angina, Condition dependent: dextroamphetamine • hypertension and myocardial Depression: SSRIs, • benzphetamine • phendimetrazine infarction bupropion, mirtazapine, • dexmethylphenidate • phentermine nortriptyline, desipramine • dextroamphetamine • diethylpropion Barbiturates • butabarbital • phenobarbital Condition-dependent • mephobarbital • secobarbital Insomnia: • pentobarbital Long-acting • amitriptyline- • chlordiazepoxide-clidinium Causes prolonged sedation, Low-dose short–acting benzodiazepines chlordiazepoxide • diazepam increased risk of falls and benzodiazepines, if they (includes • chlordiazepoxide • flurazepam fractures must be used combination drugs) Calcium channel • nifedipine − short-acting only Potential for hypotension. Use Felodipine, nifedipine-long- blockers long-acting formulation to acting (nifedipine ER) avoid adverse effects. Cardiovascular • amiodarone Anti-arrhythmia (amiodarone) Metoprolol, Atenolol; Sotalol associated with prolonged QT intervals; possible torsades de pointes, bradycardia and thyroiditis Gastrointestinal • dicyclomine • propantheline Anti-cholinergic effects Duodenal ulcer: omeprazole anti-spasmodics Constipation: psyllium, PEG, stool softener, lubiprostone (Amitiza) Diarrhea: loperamide, aluminum hydroxide Belladonna • • atropine-edrophonium Anti-cholinergic effects Constipation: psyllium, (includes • atropine/CPM// • belladonna PEG, stool softener, combination drugs) PE/scopolamine • belladonna/ergotamine/ lubiprostone (Amitiza) • atropine/hyoscyamine/PB/ phenobarbital Diarrhea: loperamide, aluminum hydroxide scopolamine • butabarbital/hyoscyamine/ • atropine- phenazopyridine • atropine-diphenoxylate • digestive enzymes/hyos- cyamine/

• hyoscyamine

• hyoscyamine/methenam/ m-blue/phenyl salicylate

Printed with permission from National Committee for Quality Assurance (NCQA) – HEDIS measure 651ALL0111-E Medications to Avoid in the Elderly Adapted from NCQA’s HEDIS® measure, Use of High-Risk Medications in the Elderly

Description Prescription Adverse Side Formulary Alternatives1 Effects/Concerns Skeletal muscle • ASA/caffeine/ • chlorzoxazone Anti-cholinergic effects, Baclofen, tizanidine relaxants (includes • ASA/carisoprodol/codeine • sedation and weakness. combination drugs) • aspirin-carisoprodol • metaxalone Poorly tolerated • aspirin-methocarbamol • methocarbamol • carisoprodol • orphenadrine Oral estrogens • conjugated estrogen • esterified estrogen Cardio-protective properties Hot flashes: nondrug (includes • conjugated estrogen- • esterified estrogen- are absent; high carcinogenic comfort therapy, SSRIs, combination drugs) medroxyprogesterone methyl-testosterone effects (breast cancer and venlafaxine • estropipate endometrial cancer) Bone density: calcium, vitamin D, alendronate Oral hypoglycemics • Chlorpropamide Prolonged half-life causing Glipizide prolonged hypoglycemia. Causes syndrome of inappropriate anti-diuretic hormone secretion (SIADH) Narcotics (includes • ASA/caffeine/propoxyphene • meperidine-promethazine • produces high Hydrocodone, combination drugs) • acetaminophen-pentazocine • naloxone-pentazocine CNS adverse effects oxycodone, fentanyl • acetaminophen- • pentazocine • Propoxyphene produces transdermal patch, propoxyphene • propoxyphene similar effects as other acetaminophen (not in • belladonna- hydrochloride narcotic medications combination product) • meperidine • propoxyphene napsylate Respiratory • theophylline Delirium, seizures and status Inhaled corticosteroid (e.g., epilepticus Flovent HFA or QVAR) with or without Serevent. Note: Long-acting beta agonists (LABAs) should be used in combination with ICS, for asthma maintenance therapy. LABAs are NOT indicated as monotherapy for asthma. Vasodilators • Dipyridamole − short-acting • isoxsuprine Orthostatic hypotension Aspirin/Dipyridamole only extended-release capsules, • ergot mesyloid low-dose aspirin

Printed with permission from National Committee for Quality Assurance (NCQA) – HEDIS measure 651ALL0111-E Medications to Avoid in the Elderly Adapted from NCQA’s HEDIS® measure, Use of High-Risk Medications in the Elderly

Description Prescription Adverse Side Formulary Alternatives1 Effects/Concerns Others (including • methyltestosterone • nitrofurantoin Prostatic hypertrophy and Danazol androgens and • nitrofurantoin macrocrystals- cardiac concerns; anabolic steroids, • nitrofurantoin macrocrystals monohydrate nitrofurantoin causes renal thyroid drugs, • thyroid desiccated impairment urinary anti- infectives)

1Source: Potentially Harmful Drugs in the Elderly: Beers List and More. Pharmacist's Letter/Prescriber's Letter 23.9. (2007):230907.

Printed with permission from National Committee for Quality Assurance (NCQA) – HEDIS measure 651ALL0111-E