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Medications to avoid in the elderly

1 2, 3 Description Medications to avoid (nonformulary in 2016) Adverse side effects/concerns Formulary alternatives High risk of central nervous system • guanabenz • (CNS) effects; may cause bradycardia lisinopril*, enalapril*, losartan**, Alpha agonists, • guanfacine • and orthostatic hypotension; not felodipine***, nifedipine long‐acting central (doses greater than 0.1 recommended for routine treatment (nifedipine ER)***, amlodipine*, atenolol* mg/day) of hypertension Potential for gastrointestinal acetaminophen (not in combination • indomethacin Analgesics bleeding, renal failure, high blood product)∆, trisalicylate (Trilisate), topicals • ketorolac pressure and heart failure (capsaicin)∆ Prostatic hypertrophy and cardiac danazol*** Androgen • methyltestosterone concerns Anxiety: buspirone**, ***, **, **, *, • aspirin‐meprobamate Anti‐anxiety Addictive and sedating anxiolytic * • meprobamate Insomnia: See the nonbenzodiazepine hypnotic section for insomnia alternatives.

* = Tier 1; ** = Tier 2; *** = Tier 3; + = Tier 4; ∆ = OTC medication, £ = generic is tier 1 for 16342. Note: Tier information is based on formularies: [16342 (Puerto Rico) – 16364 (6‐Tier closed [Medicare Advantage program]. $ = Selective serotonin reuptake inhibitors can be considered a clinical alternative for patients older than 65 years old on a high‐risk medication (HRM), but should NOT be considered an alternative or used in patients with a history of falls or dementia.

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1 2, 3 Description Medications to avoid Adverse side effects/concerns Formulary alternatives Depression: Selective serotonin reuptake inhibitors (SSRIs)$ – escitalopram**, • fluvoxamine**, sertraline*; serotonin and • , Highly effects; may norepinephrine reuptake inhibitors (SNRIs) – • (doses greater than 6 mg/day) tricyclic cause orthostatic hypotension duloxetine***, venlafaxine* • Insomnia: See the nonbenzodiazepine • hypnotic section for insomnia alternatives. Neuropathic pain: gabapentin*

Anti‐emetics • trimethobenzamide Extrapyramidal adverse effects ondansetron***, * Pruritus/urticaria: ∆, **£, ∆, • • syrup** • (oral) Highly anticholinergic effects, Nausea/vomiting: ondansetron*** • chlorpheniramine • sedation, weakness, blood pressure Allergic rhinitis: fexofenadine∆, (includes single • • changes, dry mouth, urinary levocetirizine**£, loratadine∆, cetirizine entity or as part • •hydrochloride retention; clearance reduced in syrup**, ***, fluticasone** of a combination • •hydroxyzine pamoate advanced age (Tolerance develops Insomnia: See the nonbenzodiazepine product) • • when used as hypnotic.) hypnotic section for insomnia alternatives. • Over‐the‐counter option: melatonin, if appropriate; regarded as safe in recommended doses (up to 15 mg daily) for up to two years

* = Tier 1; ** = Tier 2; *** = Tier 3; + = Tier 4; ∆ = OTC medication, £ = generic is tier 1 for 16342. Note: Tier information is based on formularies: [16342 (Puerto Rico) – 16364 (6‐Tier closed [Medicare Advantage Prescription Drug program]. $ = Selective serotonin reuptake inhibitors can be considered a clinical alternative for patients older than 65 years old on a high‐risk medication (HRM), but should NOT be considered an alternative or used in patients with a history of falls or dementia.

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1 2, 3 Description Medications to avoid Adverse side effects/concerns Formulary alternatives

Potential for pulmonary toxicity, Anti‐infectives hepatotoxicity and peripheral (when cumulative neuropathy; nitrofurantoin causes Dependent on the infection: • nitrofurantoin days’ supply renal impairment; avoid in persons sulfamethoxazole/trimethoprim*, • nitrofurantoin macrocrystals greater than with a CrCl less than 60 mL/min due ciprofloxacin*, cephalexin* 90 days) to inadequate drug concentration in the urine

Not recommended for prevention Anti‐Parkinson • benzatropine (oral) (Requip)**, +, of with agents • (Mirapex)** Highly anticholinergic; Central (Zyprexa)***, nervous system and extrapyramidal (Seroquel)**£, (Risperdal)**£ effects; greater risk of QT interval Antipsychotics • prolongation; associated with Note: All antipsychotics have been associated , slurred speech, with increased mortality when used to treat bradykinesia, , muscle psychosis related to dementia. rigidity and Dipyridamole may cause orthostatic • dipyridamole, oral short‐acting only low‐dose aspirin∆, clopidogrel**, Anti‐thrombotics hypotension; more effective • ticlopidine cilostazol** alternatives are available

* = Tier 1; ** = Tier 2; *** = Tier 3; + = Tier 4; ∆ = OTC medication, £ = generic is tier 1 for 16342. Note: Tier information is based on formularies: [16342 (Puerto Rico) – 16364 (6‐Tier closed [Medicare Advantage Prescription Drug program]. $ = Selective serotonin reuptake inhibitors can be considered a clinical alternative for patients older than 65 years old on a high‐risk medication (HRM), but should NOT be considered an alternative or used in patients with a history of falls or dementia.

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1 2, 3 Description Medications to avoid Adverse side effects/concerns Formulary alternatives

High rate of physical dependence; $ Anxiety: SSRIs (escitalopram**, • amobarbital •pentobarbital patients develop tolerance, which fluvoxamine**, sertraline*); SNRIs • butabarbital •phenobarbital reduces sleep benefits; risk of Barbiturates (duloxetine***, venlafaxine*); buspirone** • butalbital •secobarbital overdose at low dosage due to Insomnia: See nonbenzodiazepine hypnotic • mephobarbital tolerance and patient choice to over‐ medicate to achieve therapeutic effect section for insomnia alternatives.

Belladonna alkaloids (includes • //phenobarbital/ : psyllium∆, polyethyleneglycal∆, single entity or as Anticholinergic effects stool softener∆, lubiprostone (Amitiza)*** part of a • belladonna/phenobarbital Diarrhea: loperamide**, aluminum hydroxide∆ combination • butabarbital/hyoscyamine/phenazopyridine product) Use long‐acting formulation to avoid adverse Calcium channel Potential for hypotension; risk of • nifedipine − short‐acting only effects: felodipine***, nifedipine long‐acting blockers causing myocardial ischemia (nifedipine ER)***

* = Tier 1; ** = Tier 2; *** = Tier 3; + = Tier 4; ∆ = OTC medication, £ = generic is tier 1 for 16342. Note: Tier information is based on formularies: [16342 (Puerto Rico) – 16364 (6‐Tier closed [Medicare Advantage Prescription Drug program]. $ = Selective serotonin reuptake inhibitors can be considered a clinical alternative for patients older than 65 years old on a high‐risk medication (HRM), but should NOT be considered an alternative or used in patients with a history of falls or dementia.

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1 2, 3 Description Medications to avoid Adverse side effects/concerns Formulary alternatives Heart failure: Angiotensin‐converting enzyme inhibitors (ACEI) (lisinopril, quinapril, enalapril)* Digoxin: in heart failure, higher doses or angiotensin receptor blockers (ARB) have increased risk of toxicity; (losartan)* and/or a beta blocker (metoprolol decreased renal clearance • digoxin (doses greater than 0.125 mg/day) succinate XL**, bisoprolol**, carvedilol*) Cardiovascular Disopyramide: potent negative inotrope • disopyramide instead of digoxin, aldosterone antagonist that may induce heart failure in older (spironolactone**) and digoxin 0.125 mg. adults; anticholinergic effects Optimize ACEI/ARB, beta blocker and/or aldosterone antagonist prior to digoxin use. Digoxin doesn’t decrease morbidity/mortality.

Digoxin doesn’t decrease morbidity/mortality. Consider nutritional support and treatment of potential cause (e.g., depression, certain medications); consider dronabinol*** for Increases risk of thrombotic event and Endocrine • megestrol associated with weight loss in patients possibly death in older adults with AIDS or for nausea and vomiting in chemotherapy patients who failed to respond adequately to conventional treatments.

* = Tier 1; ** = Tier 2; *** = Tier 3; + = Tier 4; ∆ = OTC medication, £ = generic is tier 1 for 16342. Note: Tier information is based on formularies: [16342 (Puerto Rico) – 16364 (6‐Tier closed [Medicare Advantage Prescription Drug program]. $ = Selective serotonin reuptake inhibitors can be considered a clinical alternative for patients older than 65 years old on a high‐risk medication (HRM), but should NOT be considered an alternative or used in patients with a history of falls or dementia.

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1 2, 3 Description Medications to avoid Adverse side effects/concerns Formulary alternatives Meperidine: May not be effective at commonly prescribed doses; side effects • acetaminophen‐ include confusion, falls, fractures, • belladonna‐opium dependency and withdrawal hydrocodone*, morphine***, oxycodone***, • meperidine Pentazocine: Produces central nervous fentanyl transdermal patch+, acetaminophen Narcotics • meperidine‐promethazine system adverse effects, including (not in combination product)∆, ** • naloxone‐pentazocine confusion and and is a • pentazocine mixed agonist and antagonist; safer alternatives are available

* = Tier 1; ** = Tier 2; *** = Tier 3; + = Tier 4; ∆ = OTC medication, £ = generic is tier 1 for 16342. Note: Tier information is based on formularies: [16342 (Puerto Rico) – 16364 (6‐Tier closed [Medicare Advantage Prescription Drug program]. $ = Selective serotonin reuptake inhibitors can be considered a clinical alternative for patients older than 65 years old on a high‐risk medication (HRM), but should NOT be considered an alternative or used in patients with a history of falls or dementia.

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Consider only short‐term or intermittent use (less than 90 days per year).

Chloral hydrate: Tolerance develops Discuss sleep hygiene and avoidance of within 10 days; risks outweigh benefits: , , nicotine and medications Nonbarbiturate , overdose (narrow therapeutic that cause insomnia. or nonbenzodiaze‐ • chloral hydrate window) pine hypnotic • Lunesta (eszopiclone) All others: Benzodiazepine‐receptor Evaluate for depression, a common cause (when cumulative • Sonata (zaleplon) agonists have adverse events similar to of insomnia in the elderly. Secondary days’ supply is • Ambien (zolpidem) those of benzodiazepines in older adults insomnia can be treated with * greater than 90 (e.g., delirium, falls, fractures); they 50 mg (may cause orthostatic hypotension), 90 days) produce minimal improvement in sleep or doxepin** (less than 6 mg per day).+ 1 latency and duration Over‐the‐counter option: melatonin, if appropriate; regarded as safe in recommended doses (up to 15 mg daily) for up to two years. 1 2, 3 Description Medications to avoid Adverse side effects/concerns Formulary alternatives Hot flashes: nondrug comfort therapy • conjugated estrogen • esterified estrogen‐ SSRIs$: *, escitalopram**, • conjugated estrogen‐ methyltestosterone Cardio‐protective properties are fluvoxamine**, sertraline*; SNRIs: Oral estrogens medroxyprogesterone • estropipate absent; high carcinogenic effects venlafaxine* and estradiol • drospirenone‐estradiol • estradiol (breast cancer and endometrial Vaginal dryness: Premarin vaginal transdermal patch • esterified estrogen • estradiol‐ cancer) cream*** norethindrone levonorgestrel Bone density: calcium∆, vitamin D∆, alendronate**, raloxifene***

* = Tier 1; ** = Tier 2; *** = Tier 3; + = Tier 4; ∆ = OTC medication, £ = generic is tier 1 for 16342. Note: Tier information is based on formularies: [16342 (Puerto Rico) – 16364 (6‐Tier closed [Medicare Advantage Prescription Drug program]. $ = Selective serotonin reuptake inhibitors can be considered a clinical alternative for patients older than 65 years old on a high‐risk medication (HRM), but should NOT be considered an alternative or used in patients with a history of falls or dementia.

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Prolonged half‐life causing prolonged Oral • chlorpropamide hypoglycemia; also causes syndrome glimepiride*, glipizide* hypoglycemics • glyburide of inappropriate anti‐diuretic hormone secretion (SIADH)

Anticholinergic effects, sedation, • ASA/caffeine/ • weakness and increased risk of • metaxalone baclofen**, tizanidine** fractures Skeletal muscle • ASA/carisoprodol/ • methocarbamol codeine

relaxants orphenadrine Nonpharmacologic treatment for muscle Poorly tolerated; effectiveness at • aspirin‐carisoprodol spasms: heat, massage, stretching/exercise doses tolerated by older adults is • carisoprodol chlorzoxazone questionable

Thyroid • thyroid desiccated Cardiac concerns levothyroxine*

1 2, 3 Description Medications to avoid Adverse side effects/concerns Formulary alternatives Stroke prevention: low‐dose aspirin∆, • dipyridamole − short‐acting only clopidogrel** Vasodilators • ergot mesyloid Orthostatic hypotension Alzheimer’s disease/dementia: galantamine+, • isoxsuprine rivastigmine+, donepezil**

. References: 1. The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in

* = Tier 1; ** = Tier 2; *** = Tier 3; + = Tier 4; ∆ = OTC medication, £ = generic is tier 1 for 16342. Note: Tier information is based on formularies: [16342 (Puerto Rico) – 16364 (6‐Tier closed [Medicare Advantage Prescription Drug program]. $ = Selective serotonin reuptake inhibitors can be considered a clinical alternative for patients older than 65 years old on a high‐risk medication (HRM), but should NOT be considered an alternative or used in patients with a history of falls or dementia.

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Older Adult. http://www.americangeriatrics.org/files/documents/beers/2012AGSBeersCriteriaCitations.pdf. Accessed Sept. 30, 2015, to Oct. 7, 2015. 2. Source: PL Detail‐Document, Potentially Harmful Drugs in the Elderly: Beers List. Pharmacist’s Letter/Prescriber’s Letter. June 2012. 3. STARTing and STOPPing Medications in the Elderly. Pharmacist’s Letter/Prescriber’s Letter. (2011): 270906. 4. The American Geriatrics Society 2015 Beers Criteria Update Expert Panel (2015). American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society. DOI: 10.1111/jgs.13702. http://onlinelibrary.wiley.com/doi/10.1111/jgs.13702/full. Accessed Oct. 23, 2015.

* = Tier 1; ** = Tier 2; *** = Tier 3; + = Tier 4; ∆ = OTC medication, £ = generic is tier 1 for 16342. Note: Tier information is based on formularies: [16342 (Puerto Rico) – 16364 (6‐Tier closed [Medicare Advantage Prescription Drug program]. $ = Selective serotonin reuptake inhibitors can be considered a clinical alternative for patients older than 65 years old on a high‐risk medication (HRM), but should NOT be considered an alternative or used in patients with a history of falls or dementia.

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