Detail-Document #230907 −This Detail-Document accompanies the related article published in− PHARMACIST’S LETTER / PRESCRIBER’S LETTER September 2007 ~ Volume 23 ~ Number 230907 Potentially Harmful Drugs in the Elderly: Beers List and More (B=Beers list drug; C=Canadian list drug) Drug Concern Alternative Treatment Analgesics Ketorolac (Toradol) GI bleeding.5 Mild pain: APAP, short-acting NSAID (e.g., (B); long-term use (C) ibuprofen) Meperidinea Not effective at (Demerol) (B); long- commonly used oral Moderate or severe pain: morphine, term use (C) doses; confusion, hydrocodone/APAP (Vicodin, etc), oxycodone falls, factures, (OxyContin, etc), oxycodone/APAP (Percocet, etc), dependency, fentanyl patch (Duragesic)19 withdrawal5,15 Pentazocine (Talwin) More CNS effects Topicals (neuropathic pain, arthritis): lidocaine (B); long-term use (C) (e.g., confusion, (Lidoderm), capsaicin (Zostrix, etc) hallucinations) than other opioids; ceiling to analgesic effect5 Propoxyphene (e.g., No better than Darvon, etc) (B) acetaminophen, but has narcotic AE5 Antidepressants Amitriptyline (Elavil) Anticholinergic AE, Tricyclic without active metabolites (Nortriptyline (B, C), doxepin sedation, urinary [Pamelor], desipramine [Norpramin])15 (Sinequan, etc) (B), retention or Trazodone (for insomnia)19 imipramine incontinence, SSRI15 (Tofranil)(C) constipation, Bupropion (Wellbutrin) (for cardiac patient)19 arrhythmias, falls5,15 Mirtazapine (Remeron) (for insomnia or anorexia)19 Neuropathic pain: topicals (lidocaine [Lidoderm], capsaicin [Zostrix, etc]) Bupropion May cause seizure5 Tricyclic without active metabolites (Nortriptyline (Wellbutrin), seizure [Pamelor], desipramine [Norpramin])15 disorder (B) Trazodone (for insomnia)19 SSRI15 Mirtazapine (Remeron) (for insomnia or anorexia)19 Fluoxetine (Prozac) Long half-life; SSRI with shorter half-life (e.g., escitalopram used daily (B) agitation, insomnia, [Lexapro], sertraline [Zoloft]) anorexia5 Tricyclic for Fall risk; urinary SSRI, with blood pressure monitoring15 depression in patient retention; worsening with postural glaucoma, heart hypotension, BPH, block15 glaucoma, heart block (C) More. Copyright © 2007 by Therapeutic Research Center Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 www.pharmacistsletter.com ~ www.prescribersletter.com (Detail-Document #230907: Page 2 of 12) Drug Concern Alternative Treatment Antidepressants, cont. Tricyclic in patient Urinary retention or Antidepressant with little anticholinergic or alpha- with stress incontinence5 blocking effect (e.g., citalopram [Celexa]), bupropion incontinence or [Wellbutrin]) bladder outflow obstruction (B) SSRIs in patient with May cause or worsen Tricyclic without active metabolites (Nortriptyline SIADH (B) SIADH5 [Pamelor], desipramine [Norpramin])15 Trazodone (for insomnia)19 Bupropion (Wellbutrin) (for cardiac patient)19 Mirtazapine (Remeron) (for insomnia or weight loss)19 SSRI in patient on Enhanced SSRI side Avoid combination. If switching from MAOI to MAOI (C) effects15 another antidepressant, ensure a 14-day washout. If switching from another antidepressant to an MAOI, minimum washout is 2 weeks for drug without long half-life and 5 weeks for drug with long half-life (e.g., fluoxetine).30 Antihistamines Antihistamines, anticholinergic Anticholinergic AE, Cetirizine (Zyrtec), fexofenadine (Allegra), (B): urine retention, loratadine (Claritin), desloratadine Chlorpheniramine (Chlor- confusion, sedation5 (Clarinex), levocetirizine (Xyzal), low-dose Trimeton, etc), diphenhydramine19,26 Cyproheptadine (Periactin), Dexchlorpheniramine (Polaramine), Diphenhydramine (Benadryl, etc), Hydroxyzine (Vistaril, Atarax), Promethazine (Phenergan, etc) Antihypertensives Alpha-blockers Hypotension, dry mouth, Thiazide, ACE inhibitor, beta-blocker, (doxazosin [Cardura], incontinence5 calcium channel blocker22 prazosin [Minipress], terazosin [Hytrin])(B) Clonidine (Catapres) Orthostatic hypotension, CNS Thiazide, ACE inhibitor, beta-blocker, (B) AE5 calcium channel blocker22 Ethacrynic acid Hypotension; fluid, electrolyte Furosemide (Lasix), bumetanide (Bumex) (Edecrin) (B) imbalances5 Guanethidine (B) Orthostatic hypotension, Thiazide, ACE inhibitor, beta-blocker, depression5 calcium channel blocker22 Methyldopa Bradycardia; depression5 Thiazide, ACE inhibitor, beta-blocker, (Aldomet) (B) calcium channel blocker22 Nifedipine, short- Hypotension, constipation5 Another calcium channel blocker or long- acting (Procardia, acting nifedipine Adalat) (B) More. Copyright © 2007 by Therapeutic Research Center Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 Phone: 209-472-2240 ~ Fax: 209-472-2249 www.pharmacistsletter.com ~ www.prescribersletter.com (Detail-Document #230907: Page 3 of 12) Drug Concern Alternative Treatment Antihypertensives, cont. Reserpine >0.25mg Depression, impotence, Thiazide, ACE inhibitor, beta-blocker, (B, C) sedation, orthostatic calcium channel blocker22 hypotension, extrapyramidal effects5,15 Thiazide in patient May precipitate gout attack15 ACE inhibitor, beta-blocker, calcium with gout (C) channel blocker22 Antiplatelet Drugs Dipyridamole, short- Ineffective for stroke For stroke prevention: low-dose aspirin, clopidogrel acting (Persantine) prevention & (Plavix), aspirin/dipyridamole (Aggrenox)19 (B); for dementia or dementia; orthostatic stroke (C) hypotension5,15 Ticlopidine (Ticlid) Not more effective Low dose aspirin, clopidogrel (Plavix), (B) than aspirin, but more aspirin/dipyridamole (Aggrenox)19 toxic5 Antipsychotics Mesoridazine CNS AE, seizures, Risperidone (Risperdal)*, haloperidol (Haldol)26 (Serentil) (B), extrapyramidal effects5 Thioridazine *Atypicals associated with increased mortality when (Mellaril) (B) used to treat behavioral problems in elderly with dementia31 Chlorpromazine Fall risk15 Haloperidol, with blood pressure monitoring15 (Thorazine) in patient with history of postural hypotension (C) Clozapine (Clozaril) Lower seizure Risperidone (Risperdal)*, haloperidol (Haldol)26 in patient with threshold5 seizures (B) *Atypicals associated with increased mortality when used to treat behavioral problems in elderly with dementia31 Olanzapine (Zyprexa), Increased appetite, Risperidone (Risperdal)*, haloperidol (Haldol)26 obesity (B) weight gain *Atypicals associated with increased mortality when used to treat behavioral problems in elderly with dementia31 Thiothixene Lower seizure Risperidone (Risperdal)*, haloperidol (Haldol)26 (Navane), in patient threshold5 with seizure disorder *Atypicals associated with increased mortality when (B) used to treat behavioral problems in elderly with dementia31 More. Copyright © 2007 by Therapeutic Research Center Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 Phone: 209-472-2240 ~ Fax: 209-472-2249 www.pharmacistsletter.com ~ www.prescribersletter.com (Detail-Document #230907: Page 4 of 12) Drug Concern Alternative Treatment Anxiolytics Long-acting Dependence, For anxiety: shorter acting benzodiazepines benzodiazepines (B, depression, prolonged (appropriately dosed) (alprazolam C): sedation, confusion, [Xanax],lorazepam [Ativan], oxazepam [Serax]; clorazepate falls, fractures, buspirone (Buspar)15,19 (Tranxene, etc), respiratory depression chlordiazepoxide in COPD, For sleep: nondrug therapy (See our Detail- (Librium), diazepam incontinence5,15 Document #211015 [U.S.]/#210918 [Canada]); (Valium), quazepam temazepam (Restoril) 7.5 mg*, zolpidem (Ambien) (Doral) 5 mg*, Ambien CR 6.25 mg, zaleplon (Sonata) 5 mg*, ramelteon (Rozerem) 8 mg, eszopiclone (Lunesta) 1 mg* for difficulty falling asleep, 2 mg 15,19,32 for difficulty staying asleep *Initial dose Short-acting Falls5 For anxiety: shorter acting benzodiazepines benzodiazepines, (appropriately dosed) (alprazolam daily doses greater [Xanax],lorazepam [Ativan], oxazepam [Serax]; than (B): buspirone (Buspar)15,19 alprazolam (Xanax) 2 mg, lorazepam For sleep: nondrug therapy (See our Detail- (Ativan) 3 mg, Document #211015 [U.S.]/#210918 [Canada]); oxazepam (Serax) temazepam (Restoril) 7.5 mg*, zolpidem (Ambien) 60 mg 5 mg*, Ambien CR 6.25 mg, zaleplon (Sonata) Meprobamate Dependence, sedation5 5 mg*, ramelteon (Rozerem) 8 mg, eszopiclone (Miltown) (B) (Lunesta) 1 mg* for difficulty falling asleep, 2 mg for difficulty staying asleep15,19,32 *Initial dose Cardiac Drugs Amiodarone QT prolongation, Depends on type of arrhythmia; flecainide (Cordarone, torsades de pointes, (Tambocor), sotalol (Betapace), beta-blocker, Pacerone) (B) lack of efficacy in dofetilide (Tikosyn)27 elderly5 Beta-blockers in Worsening disease15 Alternate antihypertensive; nitrate or calcium patient with asthma, channel blocker15 COPD, or Raynaud’s disease (C)15 Calcium channel Worsening heart Diuretic, ACE inhibitor, appropriately titrated beta- blocker in patient failure; blocker15 with systolic heart constipation5,15 failure (C) or chronic constipation (B, C) Digoxin (Lanoxin) Toxicity due to Dose reduction, with monitoring19 doses >0.125 mg/d reduced renal except for atrial clearance5 arrhythmias (B) Disopyramide Negative inotrope; Depends on type of arrhythmia; for atrial fibrillation, (Norpace) (B, C) anticholinergic; digoxin, quinidine, procainamide, sotalol, sudden death5,15 flecainide15,27 More. Copyright © 2007 by Therapeutic Research Center Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 Phone: 209-472-2240 ~ Fax: 209-472-2249 www.pharmacistsletter.com ~ www.prescribersletter.com