High Risk Medications in the Elderly (Age≥65) and Suggested Alternatives

The medications listed below reflect the most recent High Risk Medication (HRM) list, developed and endorsed by the Pharmacy Quality Alliance (PQA) in June 2012. The safer treatment options provided represent potential alternatives to HRMs. Providers should evaluate whether these alternatives can be used in place of HRMs for their patients. Therapeutic Class High Risk Medications Potential Risks Safer Treatment Options† First Generation - Brompheniramine Elderly patients are more For Allergic Rhinitis: Levocetirizine, Desloratadine, Antihistamines1,2,3 - Carbinoxamine (Arbinoxa, Palgic) susceptible to anticholinergic Azelastine (nasal), Fluticasone (nasal), Flunisolide (nasal), and - Chlorpheniramine adverse events including urine Nasonex - Clemastine retention, confusion, and sedation. For N/V: Ondansetron (QL = 90/30) - Cyproheptadine For Pruritus: Ammonium lactate, Levocetirizine, Desloratadine, - Dexbrompheniramine Topical steroids - Dexchlorpheniramine For Anxiety: SSRIs, buspirone, venlafaxine - Diphenhydramine (Benadryl) In addition, there are OTC Options for which coverage may vary - Doxylamine (Doxytex) depending on benefit plan design: - Hydroxyzine (Vistaril) - Cetirizine (Zyrtec), Loratadine (Claritin), Fexofenadine (Allegra) - Promethazine (Phenergan) - Triprolidine - All combination products containing one of these medications Skeletal Muscle - Carisoprodol (Soma) Most muscle relaxants are poorly For Spasticity: Baclofen, Tizanidine, and Dantrolene 1,2,4 Relaxants - Cyclobenzaprine (Flexeril) tolerated in the elderly due to anti- : oral NSAIDs*, Voltaren gel, Cymbalta; - Methocarbamol (Robaxin) cholinergic effects, sedation and For Muscluloskeletal Pain May consider non-pharmacologic treatments, such as cryotherapy, - Orphenadrine (Norflex) cognitive impairment. In addition, heat, massage, stretching/exercise, and transcutaneous electrical - Metaxalone (Skelaxin) these agents have abuse potential. nerve stimulation (TENS) - Chlorzoxazone (Parafon Forte) - All combination products containing * Gastroprotective therapy with a PPI recommended in chronic NSAID use one of these medications Non-Narcotic - Indomethacin Among available NSAIDs, For Moderate to Severe Pain: Other NSAIDs*, Tramadol, 1,2 Analgesics - Ketorolac (Toradol) indomethacin produces the highest Hydrocodone/ acetaminophen, Oxycodone/acetaminophen - Ketorolac nasal (Sprix) rates of CNS adverse events, including confusion and (rarely) * Gastroprotective therapy with a PPI recommended in chronic NSAID use psychosis. Ketorolac is associated with a high risk of GI bleeds in the elderly. Narcotic - Meperidine (Demerol) These specific medications are less For Moderate Pain: NSAIDs*, Tramadol, Hydrocodone/APAP, 1,2 Analgesics - Pentazocine / APAP (Talacen) effective than other narcotics and APAP with codeine - Pentazocine / naloxone (Talwin NX) have more CNS adverse effects For Severe Pain: Oxycodone, Oxycodone/APAP, Hydromorphone, such as confusion and hallucina- Morphine tions. Also, their use increases the risk of falls and seizures. * Gastroprotective therapy with a PPI recommended in chronic NSAID use Progestins1,2,5 - Megestrol (Megace, Megace ES) Megestrol is substantially excreted - Medroxyprogesterone by the kidney. Because elderly - Dronabinol patients are more likely to have decreased renal function, there is an increased risk of toxicity, including adrenal suppression and thrombosis.

† Treatment alternatives may require prior authorization or step therapy. For the most current formulary listings, please consult: http://www.myhealthspring.com/formularies, or http://www.mybravohealth.com/formulary. 1

High Risk Medications in the Elderly (Age≥65) and Suggested Alternatives Therapeutic Class High Risk Medications Potential Risks Safer Treatment Options†

Estrogens and - Conjugated estrogen (Premarin) Elderly patients on long-term oral For Hot Flashes: Estrogen / - Conjugated estrogen / medroxy- estrogens are at increased risk for Continuously re-evaluate the need for long-term estrogen therapy; Progesterone progesterone (Prempro, Premphase) breast and endometrial cancer. In evaluate non-drug therapy. Postmenopausal women should avoid Products (Oral and - Estradiol, oral (Estrace, Femtrace) addition, results from the Women’s using oral estrogens for more than 3 years. After 3 years patients 1,2,6 Transdermal) - Estradiol patch (Alora, Climara, Health Initiative (WHI) hormone should be titrated off therapy due to the risks outweighing the Estraderm, Estradiol, Menostar, trial suggest these medications benefits. Vivelle-Dot) may increase the risk of heart SSRIs, Gabapentin, and Venlafaxine have non-FDA labeled - Estradiol / drospirenone (Angeliq) attack, stroke, blood clots, and indications (medically accepted use) for hot flashes. - Estradiol / levonorgestrel dementia. For Vaginal Symptoms: Premarin Cream, Estring, Femring, (ClimaraPro) Vagifem - Estradiol / norethindrone (CombiPatch) For Bone Density: Alendronate, Actonel, Atelvia, Evista, Prolia - Estradiol / norgestimate (Prefest) - Estropipate (Ogen, Ortho-Est) - Esterified estrogen (Menest) - Esterified estrogen / methyltestosterone (Covaryx, Estratest) - Ethinyl estradiol / norethindrone (Activella, FemHRT) Urinary Anti- Greater than 90 days cumulative Nitrofurantoin is substantially For treatment of acute UTI: Ciprofloxacin, Trimethoprim / 1,2,7 Infectives supply during the plan year: excreted by the kidney. Since sulfamethoxazole (TMP/SMX), Amoxicillin/clavulanate, Cefdinir, - Nitrofurantoin (Furadantin) elderly patients are more likely to Cefaclor, Cefpodoxime, Suprax - Nitrofurantoin monohydrate/ have decreased renal function, macrocrystals (Macrobid) nitrofurantoin use is associated For prevention of recurrent UTIs: - Nitrofurantoin macrocrystals with an increased risk of pulmonary Prescription options include: TMP/SMX, Methenamine hippurate (Macrodantin) toxicity, neuropathy, and hepato- toxicity. In addition, there is a lack Non-prescription options include practicing good personal hygiene, of efficacy in patients with a CrCl avoiding baths, and wearing cotton underwear. <60 mL/min due to inadequate drug concentration in the urine. Anti-emetics1,2 - Promethazine Elderly patients are more For N/V: Ondansetron (QL = 90/30) - Trimethobenzamide (Tigan) susceptible to anticholinergic adverse events including urine retention, confusion, and sedation. Anti-Anxiety - Meprobamate Meprobamate has a high risk of - Buspirone Agents1,2 abuse, and is highly sedating. Use in the elderly may result in - SSRIs (Fluoxetine, Citalopram, Paroxetine) confusion, falls/fractures,and - SNRIs (Venlafaxine, Cymbalta) respiratory depression. Alpha-Blockers, - Guanabenz May cause bradycardia, sedation, - ACE inhibitors / ARBs 1,2 Central - Guanfacine orthostatic hypotension, and - Beta-blockers - Methyldopa exacerbate depression. - Calcium channel blockers - Reserpine (>0.1 mg/day) - Thiazide diuretics

High Risk Medications in the Elderly (Age≥65) and Suggested Alternatives Therapeutic Class High Risk Medications Potential Risks Safer Treatment Options†

Calcium Channel - Nifedipine immediate-release Immediate release nifedipine may - Amlodipine, Felodipine, Isradipine, Nicardipine, Nisoldipine 1,2 Blockers (Adalat, Procardia) cause excessive hypotension and - Extended-release Nifedipine constipation in the elderly. Cardiovascular, - Disopyramide Disopyramide may induce heart - For disopyramide: Beta-blockers, Calcium channel blockers, 1,2 Other - Digoxin (>0.125 mg/day) failure in elderly patients. It is also Flecainide strongly anticholinergic, and may cause urine retention, confusion, - For digoxin > 0.125 mg/day: In heart failure, digoxin dosages and sedation. >0.125 mg/day have been associated with no additional benefit and may have increased toxic effects. Digoxin is substantially excreted by the kidney. Because elderly patients are more likely to have decreased renal function, there is an increased risk of toxicity at doses exceeding 0.125 mg/day. Sedative - Chloral hydrate Impaired motor and/or cognitive Consider non-pharmacologic interventions, focusing on proper sleep Hypnotics1,2 performance after repeated hygiene. When sedative hypnotic medications are deemed clinically Greater than 90 days cumulative exposure. necessary, use should be at the lowest possible dose for the supply during plan year: shortest possible time. - Eszopiclone (Lunesta) Rozerem may be considered as a safer option - Zolpidem (Ambien, Ambien CR) - Zaleplon (Sonata) with less abuse potential.

1,2 Barbiturates - Phenobarbital (Luminal) These medications are highly PLEASE NOTE: Patients being switched off barbiturates should (Currently covered if - Mephobarbital (Mebaral) addictive and cause more adverse be tapered slowly over a prolonged period of time. used in the treatment - Secobarbital (Seconal) effects than most other sedatives in For seizures: Divalproex, Levetiracetam, Lamotrigine, of epilepsy, cancer, or - Butabarbital (Butisol) the elderly, greatly increasing Carbamazepine a chronic mental health - Pentobarbital (Nembutal) cognitive impairment, confusion, 8 For sleep: Consider non-pharmacologic interventions, focusing on disorder.) - Butalbital and Butalbital and risk of falls. proper sleep hygiene. When sedative hypnotic medications are combinations (Fioricet/Codeine) deemed clinically necessary, use should be at the lowest possible dose for the shortest possible time. Rozerem may be considered as a safer option with less abuse potential. For headache: Naratriptan, Sumatriptan Tertiary Amine - Amitriptyline Elderly patients are more For Depression / Anxiety / OCD: Tricyclic - Clomipramine susceptible to anticholinergic - Secondary Amine TCAs (Nortriptyline, Protriptyline, Antidepressants - Doxepin (>6 mg/day) adverse events including urine Desipramine, Amoxapine) 1,2 retention, confusion, and sedation. (TCAs) - Imipramine - SSRIs (Fluoxetine, Citalopram, Paroxetine, Sertraline) - SNRIs (Venlafaxine, Cymbalta) - Trimipramine - Bupropion For neuropathic pain / fibromyalgia: - Gabapentin, Cymbalta, Lyrica For prevention of migraine:

High Risk Medications in the Elderly (Age≥65) and Suggested Alternatives

- Propranolol, Divalproex sodium, Topiramate

Therapeutic Class High Risk Medications Potential Risks Safer Treatment Options†

Anti-Psychotics1,2 - Thioridazine (Mellaril) Thioridazine has a high potential - Atypical antipsychotics: Risperidone, Olanzapine, Abilify, Geodon, - Mesoridazine for CNS and extrapyramidal Saphris, Seroquel adverse events. It has been (Please note, all antipsychotics have been associated with associated with tremor, slurred increased mortality when used to treat psychosis related to speech, muscle rigidity, dystonia, dementia.) bradykinesia, and akathisia. Antiparkinson - Benztropine Elderly patients are more - Carbidopa / levodopa, Pramipexole, Ropinirole, Bromocriptine, 1,2 Agents - Trihexyphenidyl susceptible to anticholinergic Amantadine, Selegiline adverse events including urine retention, confusion, hallucinations and psychotic-like symptoms Thyroid - Dessicated thyroid (Armour thyroid, Dessicated thyroid may increase - Levothyroxine, Levoxyl, Levothroid, Unithroid 1,2,9 Hormones NP Thyroid, Nature-Throid, the risk of cardiovascular events in Current guidelines recommend starting at a low dose and, once Westhroid) the elderly, especially those with cardiovascular tolerance is established, slowly increasing until coronary artery disease. adequate replacement is achieved. Oral Hypo- - Chlorpropamide (Diabinese) Associated with an increased risk - Glipizide 1,2 glycemics - Glyburide (Diabeta) of hypoglycemia compared to other - Glimepiride oral diabetes agents. Chlorpropamide has also been associated with hyponatremia and SIADH in the elderly. Antithrombotics1,2 - Dipyridamole (Persantine, NOTE: These agents been shown to be no For prevention of thromboembolic complications of cardiac does NOT include combination better than aspirin in preventing valve replacement: Warfarin, Jantoven product with aspirin) clotting and may be considerably For prevention of stroke: Clopidogrel, Aggrenox, Aspirin - Ticlopidine (Ticlid) more toxic. Dipyridamole is associated with an increased risk of orthostatic hypotension in the elderly. Ticlopidine is associated with an increased risk of hematologic effects (e.g., neutropenia, thrombocytopenia, aplastic anemia), increased cholesterol and triglycerides, and GI bleed). Peripheral - Ergoloid mesylates These agents are associated with For prevention of stroke: Clopidogrel, Aggrenox, Aspirin 1,2 Vasodilators - Isoxsuprine increased risk of orthostatic hypo- Peripheral Vascular Disease: cilostazol tension in the elderly. In addition, For treatment of Alzheimer’s / dementia: they have not been shown to be - Galantamine

High Risk Medications in the Elderly (Age≥65) and Suggested Alternatives

effective for stroke prevention. - Rivastigmine - Donepezil

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