HealthPartners List of Potentially Inappropriate Medications for the Elderly

MEDICATION (includes combinations)1‐3 PRESCRIBING CONCERN1‐2 ALTERNATIVES4‐5 Antianxiety Possible dependence and sedation for Anxiety: citalopram, sertraline, buspirone meprobamate meprobamate. Sleep: trazodone Long‐acting benzodiazepines Long half life (up to several days) in elderly Restless legs syndrome: pramipexole, ropinirole, (chlordiazepoxide, diazepam, flurazepam) patients; prolonged sedation and risk of levodopa, gabapentin falls/fractures If benzodiazepines are required, use shorter acting agents at low doses. Antiemetics Questionable safety, cause extrapyramidal Monitor closely and use low doses: scopolamine, trimethobenzamide adverse effects. metoclopramide, prochlorperazine Analgesics Increased risk of upper gastrointestinal APAP, topical creams (capsaicin), short acting ketorolac bleeding in the elderly NSAIDs (ibuprofen) Antihistamines (1st generation) Anticholinergic properties, including CNS Allergies: loratadine, cetirizine, fexofenadine cyproheptadine, diphenhydramine, depression, orthostasis, confusion, urinary Sleep: trazodone dexchlorpheniramine, hydroxyzine, retention, blurred vision, and constipation. promethazine, tripelennamine Antipsychotics (typical) Sedation, seizures, extrapyramidal effects, Atypicals (increased mortality when used to treat mesoridazine, thioridazine hypotension, constipation, prolongs QT behavioral problems in elderly patients with dementia) Amphetamines Dependence, hypertension, myocardial Depression: citalopram, sertraline, mirtazapine dextro/amphetamine salts, infarction, CNS stimulation (agitation, Weight control: diet and lifestyle modifications phendimetrazine, diethylpropion, insomnia), seizures benzphetamine, methamphetamine, dex/methylphenidate, phentermine Barbiturates (except phenobarbital when Highly addictive (risk for withdrawal reactions), Sleep: trazodone used for seizures) long half lives cause more sedation, CNS Anxiety: citalopram, sertraline, buspirone butabarbital, secobarbital, pentobarbital, depression, risk of falls/fractures, confusion, mephobarbital, amobarbital ataxia. Calcium Channel Blockers Hypotension, constipation, reflex tachycardia Long acting nifedipine or another calcium channel nifedipine, short‐acting blocker Gastrointestinal / antispasmodics Highly anticholinergic (urinary retention, Lifestyle modifications: fluids, fiber, exercise dicyclomine, propantheline worsened cognition) with uncertain Constipation: psyllium, polyethylene glycol, Belladonna alkaloids (atropine, effectiveness. docusate hyoscyamine, belladonna) Diarrhea: probiotics, occasional loperimide Skeletal Muscle Relaxants Most are poorly tolerated due to Monitor side effects, use low doses, consider metaxalone, methocarbamol, anticholinergic effects, sedation, and lifestyle modifications (rest, stretching, heat, cyclobenzaprine, carisoprodol, weakness. physical therapy) chlorzoxazone, orphenadrine Muscle spasms: baclofen, tizanidine Oral Estrogens Increased risk of breast cancer and Vasomotor symptoms: nondrug therapies, conjugated estrogens, esterified estrogens, endometrial cancer, not cardioprotective citalopram, sertaline, gabapentin estropipate Bone Density: calcium/Vit D, alendronate Oral Hypoglycemics Prolonged half life could cause prolonged glipizide, glimepiride, metformin chlorpropamide hypoglycemia, possibly causes SIADH Narcotics Limited efficacy with narcotic side effects APAP, short‐acting NSAID (ibuprofen), topical propoxyphene, pentazocine, belladonna‐ (confusion, constipation) creams (capsaicin), other narcotics (APAP w/ opium, meperidine Meperidine can cause seizures in patients with hydrocodone, oxycodone or codeine, morphine) renal impairment Vasodilators Limited efficacy, orthostatic hypotension, Stroke prevention: low‐dose aspirin short‐acting dipyridamole, ergot mesyloid, dementia isoxsuprine Urinary Antibiotics Should not be used for UTI prophylaxis (risk of UTI prophylaxis: TMP‐sulfa, trimethoprim, nitrofurantoin (macrocrystal and pulmonary and neurological toxicity, ciprofloxacin macrocrystal/monohydrate) nephrotoxicity) Short term use for acute UTI is acceptable. Androgens Prostatic hyperplasia, cardiac adverse effects None, use cautiously and sparingly based on careful methyltestosterone assessment of risks and benefits Thyroid, desiccated Cardiac adverse effects (tachyarrhythmia, levothyroxine palpitations) References: 1. Fick DM, Cooper JW, Wade WE et al. Updating the beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163(22):2716‐2724. 2. Guay DR. Beers 2003 update: An advance of the same? Consultant Pharmacist. 2004;19(4):364‐370. 3. HEDIS 2011 Final NDC Lists. Use of High‐Risk Medications in the Elderly (DAE). http://www.ncqa.org/tabid/1274/Default.aspx. Updated 15 November 2010. Accessed 17 January 2011. 4. Potentially harmful drugs in the elderly: Beers list and more. Pharmacist’s/Prescriber’s Letter. 2007;23(9):230907. Updated Oct 2009. 5. Christian JB, Vanhaaran A, Cameron, KA, Lapane KL. Alternatives for potentially inappropriate medications in the elderly population: treatment algorithms for use in the Fleetwood Phase III Study. Consul Pharm. 2004;19(11):1011‐1028.