CMS: High-Risk Medications (Relevant for older people defined as greater than 65 years of age)
Drug High-risk agents to Avoid Non-high risk alternatives Reason for Risk classification (H) = considered Highest-risk¹ Drug Amphetamines amphetamine & dextroamphetamine (H) CNS stimulation: agitation, insomnia; Consider discontinuing (ADDERALL/XR ) hypertension, myocardial ischemia; benzphetamine (H) (DIDREX ) dependence; appetite suppression dexmethylphenidate (H) (FOCALIN/XR ) dextroamphetamine (H) (DEXADRINE, DEXTROSTAT ) diethylpropion (H) (DURAD, TENUATE, TEPANIL ) INTUNIV (H) methamphetamine (H) (DESOXYN ) methylphenidate (H) (RITALIN/LA, CONCERTA, DAYTRANA, METADATE CD ) phendimetrazine (H) (BONTRIL ) phentermine (H) (ADIPEX-P ) Drug High-risk agents to Avoid Non-high risk alternatives Reason for Risk classification (H) = considered Highest-risk¹ Drug Analgesics indomethacin (INDOCIN) Ketorolac: Gastrointestinal bleeding risk mild pain: ketorolac (H) (TORADOL ) increased in elderly. APAP ibuprofen Indomethacin: GI bleeding/peptic ulcer in high- naproxen risk patients.a Has more adverse effects than meloxicam other NSAIDs. Edema may worsen heart failure. moderate/severe pain: tramadol morphine sulfate (MS CONTIN) hydrocodone/APAP(V ICODIN , etc) oxycodone (OXYIR) oxycodone/APAP (PERCOCET) fentanyl patch (DURAGESIC) OXYCONTIN AVINZA
use lowest dose possible to avoid side effects and reduce pain
Anti-adrenergics guanabenz Orthostatic hypotension, bradycardia, CNS HCTZ guanfacine (TENEX) adverse effects lisinopril methyldopa (ALDOMET) enalapril methyldopa/HCTZ (ALCOLOR, ALDORIL) losartan metoprolol
Anti-anxiety meprobamate (H) (EQUINIL ) Dependence; sedation; depression; confusion; anxiety: aspirin/meprobamate (H) (EQUAGESIC ) falls; fractures; respiratory depression buspirone (BUSPAR) (especially in COPD) sleep: ROZEREM Drug High-risk agents to Avoid Non-high risk alternatives Reason for Risk classification (H) = considered Highest-risk¹ Drug Anti-emetics trimethobenzamide (H) (TIGAN ) Anticholinergic side effects: worsened TRANSDERM-SCOP promethazine (H) (PHENERGAN) cognition & behavioral problems (especially in ondansetron (ZOFRAN) dementia); urinary retention OR incontinence; granisetron (KYTRIL) questionable efficacy prochlorperazine (COMPAZINE) metoclopramide (REGLAN)*
*avoid using long-term and/or in Parkinson’s disease
Antihistamines APAP/dextromethorphan/diphenhydramine (H) Anticholinergic side effects: worsened Levocetirizine (XYZAL) APAP/diphenhydramine/phenylephrine (H) cognition & behavioral problems (especially in CLARINEX APAP= APAP/diphenhydramine/PSE (H) dementia); urinary retention OR incontinence; acetaminophen APAP & diphenhydramine (H) confusion; enhanced sedation; PSE= Brompheniramine / combination products (H) pseudoephedrine carbetapentane/diphenhydramine/ phenylephrine (H) carbinoxamine / combination products (H) chlorpheniramine / combination products (H) clemastine (H) codeine/promethazine/phenylephrine (H) codeine & promethazine (H) cyproheptadine (H) dexbrompheniramine-Pyrilamine (H) dexchlorpheniramine dexchlorpheniramine/dextromethorphan/PSE (H) dexchlorpheniramine/guaifenesin/PSE (H) dexchlorpheniramine/hydrocodone/ phenylephrine (H) dexchlorpheniramine/methscopolamine/PSE (H) dexchlorpheniramine & PSE (H) dextromethorphan & promethazine (H) diphenhydramine (H) diphenhydramine/hydrocodone/ phenylephrine (H) diphenhydramine & phenylephrine (H) diphenhydramine & PSE (H) diphenhydramine & magnesium salicylate (H) doxylamine hydroxyzine hydrochloride (H) hydroxyzine pamoate (H) phenylephrine & promethazine (H) promethazine (H) triprolidine
Note: Various brand name drugs apply. Antihistamines APAP/dextromethorphan/diphenhydramine (H) Anticholinergic side effects: worsened Levocetirizine (XYZAL) APAP/diphenhydramine/phenylephrine (H) cognition & behavioral problems (especially in CLARINEX APAP= APAP/diphenhydramine/PSE (H) dementia); urinary retention OR incontinence; acetaminophen APAP & diphenhydramine (H) confusion; enhanced sedation; PSE= Brompheniramine / combination products (H) pseudoephedrine carbetapentane/diphenhydramine/ phenylephrine (H) carbinoxamine / combination products (H) chlorpheniramine / combination products (H) clemastine (H) codeine/promethazine/phenylephrine (H) codeine & promethazine (H) cyproheptadine (H) dexbrompheniramine-Pyrilamine (H) dexchlorpheniramine dexchlorpheniramine/dextromethorphan/PSE (H) dexchlorpheniramine/guaifenesin/PSE (H) dexchlorpheniramine/hydrocodone/ phenylephrine (H) dexchlorpheniramine/methscopolamine/PSE (H) dexchlorpheniramine & PSE (H) dextromethorphan & promethazine (H) diphenhydramine (H) diphenhydramine/hydrocodone/ phenylephrine (H) diphenhydramine & phenylephrine (H) diphenhydramine & PSE (H) diphenhydramine & magnesium salicylate (H) doxylamine Drug High-risk agents to Avoid Non-high risk alternatives hydroxyzine hydrochloride (H) Reason for Risk classification hydroxyzine(H) =pamoate considered (H) Highest-risk¹ Drug phenylephrine & promethazine (H) promethazine (H) triprolidine
Note: Various brand name drugs apply.
Antiparkinson/ benztropine (COGENTIN) Delirium, worsen cognitive impairment, worsen Consider discontinuing or using atypical antipsychotics trihexyphenidyl constipation, worsen urinary retention; not antipsychotic recommended to prevent antipsychoticassociated extrapyramidal effects; not very effective for Parkinson’s disease
Antipsychotics thioridazine (H) (MELLARIL ) CNS side effects; seizure risk; extrapyramidal haloperidol (HALDOL) effects: tremor, slurred speech, muscular risperidone (RISPERDAL)* rigidity, dystonia (involuntary muscle ABILIFY* contractions), bradykinesia (slowing of FANAPT* movement), akathisia (inability to sit/stand still) GEODON* INVEGA* SEROQUEL* ZYPREXA*
*atypical antipsychotics associated w/ increased mortality when used to treat behavioral issues in elderly w/ dementia Drug High-risk agents to Avoid Non-high risk alternatives Reason for Risk classification (H) = considered Highest-risk¹ Drug Barbiturates butabarbital (H) (BUTISOL ) Higher risk of side effects: falls; fractures; sleep: butalbital / combinations (H) (FIORICET, confusion; cognitive impairment; dependence ROZEREM FIORINAL, DOLGIC, ESGIC) mephobarbital (H) (MEBARAL ) mild pain: pentobarbital (H) (NEMBUTAL ) APAP phenobarbital (H) (LUMINAL) ibuprofen naproxen secobarbital (H) (SECONAl) meloxicam
moderate/severe pain: tramadol morphine sulfate (MS CONTIN) hydrocodone/APAP (VICODIN, etc) oxycodone (OXYIR) oxycodone/APAP (PERCOCET) fentanyl patch (DURAGESIC) OXYCONTIN AVINZA
Belladona alkaloids atropine/hyoscyamine/phenobarbital/ Anticholinergic AEs: worsened cognition & constipation: scopolamine (H) (BELLADONNA ALKALOIDS, behavioral problems (especially in dementia); psyllium fiber (METAMUCIL) CPM= DONNATAL, ANTISPASMODIC ELIXIR) urine retention; agitation & delirium polyethylene glycol (MIRALAX) chlorpheniramine atropine & edrophonium (ENLON) docusate belladonna (H) PE=phenylephrine belladonna/ergotamine/phenobarbital (H) diarrhea: (BELLAMINE ) loperamide (IMODIUM) butabarbital/hyoscyamine/phenazopyridine (H) aluminum hydroxide (PHENAZOPYRIDEINE PLUS, atropine & difenoxin (MOTOFEN ) PHENAZOFORTE PLUS) atropine & diphenoxylate digestive- enzymes/ hyoscyamine/ (LOMOTIL, LONOX, LOGEN, phenyltoloxamine (H) (DIGEX NF) LOMANATE )
Benzodiazepines amitriptyline & chlordiazepoxide (H) (LIMBITROL Dependence; depression; prolonged sedation; buspirone (BUSPAR) (long-acting) DS ) confusion; falls; fractures; respiratory chlordiazepoxide (H) (LIBRIUM ) depression (especially in COPD); accumulation diazepam (VALIUM ) of drug flurazepam (DALMANE ) Drug High-risk agents to Avoid Non-high risk alternatives Reason for Risk classification (H) = considered Highest-risk¹ Drug Calcium channel nifedipine (short-acting immediate release only) Hypotension; constipation nifedipine ER (PROCARDIAXL) blockers (H) (ADALAT CC, PROCARDIA )
Cardiac glycosides digoxin (LANOXIN, DIGITEK, LANOXICAPS) No additional efficacy vs lower doses; toxicity Consider discontinuing or dose reduction due to reduced renal clearance (e.g. 0.125mg) with monitoring Drug High-risk agents to Avoid Non-high risk alternatives Reason for Risk classification (H) = considered Highest-risk¹ Drug Estrogens and Oral Increased risk of breast &/or endometrial Hot flashes*: progestins ANGELIQ cancer; NOT cardioprotective venlafaxine (EFFEXOR) conjugated estrogen (PREMARIN, ESTINYL) paroxetine (PAXIL) conjugated estrogen & medroxyprogesterone fluoxetine (PROZAC) (PREMPRO, PREMPHASE) sertraline (ZOLOFT) esterified estrogen (MENEST ) gabapentin esterified estrogen & methyltestosterone (H) * nondrug therapy should be emphasized (COVARYX, ESTRATEST) Bone density: estropipate (OGEN, ORTHO-EST) Calcium vitamin D estradiol (H) (ESTRACE, GYNODIOL) (H) alendronate (FOSAMAX) estradiol/norethindrone (H) (ACTIVELLA, ACTONEL MIMVEY) Ibandronate (BONIVA) FEMHRT (H) EVISTA JEVANTIQUE (H) JINTELI (H) Genitourinary symptoms: Megestrol (MEGACE/ES) (H) Femring ORTHOPREFEST (H) Premarin vaginal cream PREFEST (H) Vagifem
Transdermal estradiol patch (H) ALORA patch (H) ESTRASORB (H) ESCLIM patch (H) CLIMARA PRO patch (H) COMBIPATCH (H) VIVELLE-DOT patch (H) MENOSTAR patch (H) DIVIGEL topical gel (H) ELESTRIN topical gel (H) EVAMIST topical spray (H) Drug High-risk agents to Avoid Non-high risk alternatives Reason for Risk classification (H) = considered Highest-risk¹ Drug Narcotics ASA/caffeine/propoxyphene (DARVON Enhanced CNS effects: confusion, mild pain: COMPOUND ) hallucinations; falls; fractures; seizure risk APAP ASA=aspirin APAP & pentazocine (H) (TALACEN ) ibuprofen APAP & propoxyphene (DARVOCET ) naproxen APAP= meperidine (H) (DEMEROL ) meloxicam acetaminophen meperidine & promethazine (H) (MEPROZINE ) moderate/severe pain: naloxone & pentazocine (H) (TALWIN NX ) tramadol pentazocine (H) (TALWIN ) morphine sulfate (MS CONTIN) propoxyphene hydrochloride (DARVON) hydrocodone/APAP (VICODIN, etc) propoxyphene napsylate (DARVON) oxycodone (OXYIR) oxycodone/APAP (PERCOCET) fentanyl patch (DURAGESIC) OXYCONTIN AVINZA
Oral hypoglycemics chlorpropamide (H) (DIABINESE, INSULASE ) Prolonged hypoglycemia; risk of SIADH glimepiride (AMARYL) glyburide (DIABETA, MICRONASE, GLYCRON, glipizide (GLUCOTROL) GLYNASE) (H) glyburide/metformin (GLUCOVANCE) (H)
Sedative hypnotics chloral hydrate (SOMNOTE) (H) Cognitive impairment, delirium, unsteady gait, Temazepam LUNESTA (H) syncope, falls, accidents, Trazodone zaleplon (SONATA) (H) fractures, tolerance, delirium, risk of overdose ROZEREM zolpidem (AMBIEN/CR, INTERMEZZO, (narrow therapeutic window – chloral hydrate) Limit use of sedative hypnotic to short-term EDLUAR, ZOLPIMIST) (H) use Drug High-risk agents to Avoid Non-high risk alternatives Reason for Risk classification (H) = considered Highest-risk¹ Drug Skeletal muscle ASA/caffeine/orphenadrine (H) Anticholinergic side effects: worsened baclofen (LIORESAL) relaxants ASA/carisoprodol/codeine (H) cognition & behavioral problems (especially in tizanidine (ZANAFLEX) ASA & carisoprodol (H) dementia); urinary retention OR incontinence; ASA=aspirin ASA & methocarbamol (H) confusion sedation; weakness; questionable carisoprodol (H) (SOMA ) efficacy (at lower doses) chlorzoxazone (H) (PARAFON FORTE ) cyclobenzaprine (H) (FLEXERIL, AMRIX, FEXMID ) metaxalone (H) (SKELAXIN ) methocarbamol (H) (ROBAXIN ) orphenadrine (H) (NORFLEX )
Tricyclic amitriptyline/combinations (ELAVIL, Anticholinergic effects (e.g., confusion, dry nortriptyline antidepressants VANATRIP) (H) mouth, constipation), cognitive impairment, desipramine clomipramine (ANAFRANIL) (H) delirium, sedation, orthostatic hypotension trazodone (low dose) doxepin (SINEQUAN, SILENOR) (H) imipramine (TOFRANIL) (H) Trimipramine (SURMONTIL) (H)
Vasodilators dipyridamole (short-acting only) (PERSANTINE ) Orthostatic hypotension; ineffective for stroke stroke prevention: ergot mesyloid (ERGOMAR ) prevention; unproven &/or questionable aspirin isoxsuprine (VASODILAN ) efficacy PLAVIX AGGRENOX
Alzheimer’s/dementia: galantamine rivastigmine ARICEPT EXELON Drug High-risk agents to Avoid Non-high risk alternatives Reason for Risk classification (H) = considered Highest-risk¹ Drug Other methyltestosterone (H) (ANDROID, TESTRED ) Methyltestosterone = cardiac side effects & NA nitrofurantoin (H) (FURADANTIN ) prostatic enlargement in men (androgen, anabolic nitrofurantoin macrocrystals (H) Nitrofurantoin = nephrotoxicity (kidney) Thyroid urinary tract infections steroid; thyroid drug; (MACRODANTIN ) desiccated = cardiac AEs ciprofloxacin urinary anti- infectives, nitrofurantoin macrocrystals-monohydrate (H) trimethoprim-sulfamethoxazole psych, cardiac) (MACROBID ) (BACTRIM DS) thyroid desiccated (H) (ARMOUR THYROID ) SERENTIL (H) thyroid: levothyroxine (SYNTHROID) ergoloid (HYDERDINE) (H) levoxyl reserpine/combinations (H) ticlopidine (TICLID) (H) anti-platelet clopidogrel
References 1. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the beers criteria for potentially inappropriate medication use in older adults. Arch Intern Med. 2003; 163(22): 2716-24.
2. Simon SR, Chan A, Soumerai SB, Wagner AK, Andrade SE, Feldstein AC, et al. Potentially inappropriate medication use by elderly persons in U.S. health maintenance organizations, 2000-2001. J Am Geriatr Soc. 2005; 53(2): 227-32.
3. Chang CM, Liu PY, Yang YK, Yang YC, Wu C, Lu F. Use of the beers criteria to predict adverse drug reactions among first-visit elderly outpatients. Pharmacotherapy. 2005; 25 (6): 831-38.
4. PL Detail-Document, Potentially Harmful Drugs in the Elderly: Beers List. Pharmacist’s Letter/Prescriber’s Letter. June 2012.