Medications to Avoid in the Elderly Adapted from NCQA’s HEDIS® measure, Use of High-Risk Medications in the Elderly Description Prescription Adverse Side Formulary Alternatives1 Effects/Concerns Anti-anxiety • aspirin-meprobamate • meprobamate Addictive and sedating Low-dose short-acting (includes anxiolytic benzodiazepines, combination drugs) lorazepam, buspirone Anti-emetics • scopolamine • trimethobenzamide Extra pyramidal adverse Ondansetron, dolasetron effects (Anzemet) Analgesics • ketorolac Potential for GI bleeding, Acetaminophen, Trisalicylate (includes renal failure, high blood (Trilisate), Topicals combination drugs) pressure and heart failure (capsaicin) Antidepressant • amitriptyline • perphenazine-amitriptyline Anti-cholinergic and Condition dependent: SSRIs, • Chlordiazepoxide • doxepin sedative effects; increased bupropion, mirtazapine, amitriptyline risk of falls and fractures nortriptyline, desipramine Weight management: diet and lifestyle modifications Antihistamines • APAP/dextromethorphan/ • dexchlorpheniramine/ Anti-cholinergic effects and Fexofenadine, azelastine (includes diphenhydramine methscopolamine/PSE sedation, weakness, blood (Astelin) combination drugs) • APAP/diphenhydramine/ • dexchlorpheniramine- pressure changes, dry phenylephrine pseudoephedrine mouth, urinary retention • APAP/diphenhydramine/ • dextromethorphan- pseudoephedrine promethazine • acetaminophen- • diphenhydramine diphenhydramine • diphenhydramine/ • carbetapentane/diphen- hydrocodone/phenylephrine hydramine/phenylephrine • diphenhydramine- • codeine/phenylephrine/ magnesium salicylate promethazine • diphenhydramine- • codeine-promethazine phenylephrine • cyproheptadine • diphenhydramine- • dexchlorpheniramine pseudoephedrine • dexchlorpheniramine/ • hydroxyzine hydrochloride dextromethorphan/PSE • hydroxyzine pamoate • dexchlorpheniramine/ • phenylephrine-promethazine guaifenesin/PSE • promethazine • dexchlorpheniramine/ hydrocodone/phenylephrine Antipsychotic, • thioridazine Central nervous system olanzapine (Zyprexa), typical (CNS) and extra pyramidal quetiapine (Seroquel), effects risperidone (Risperdal), pimozide (Orap), trifluoperazine Printed with permission from National Committee for Quality Assurance (NCQA) – HEDIS measure 651ALL0111-E Medications to Avoid in the Elderly Adapted from NCQA’s HEDIS® measure, Use of High-Risk Medications in the Elderly Description Prescription Adverse Side Formulary Alternatives1 Effects/Concerns Amphetamines • amphetamine- • methamphetamine Addictive properties, angina, Condition dependent: dextroamphetamine • methylphenidate hypertension and myocardial Depression: SSRIs, • benzphetamine • phendimetrazine infarction bupropion, mirtazapine, • dexmethylphenidate • phentermine nortriptyline, desipramine • dextroamphetamine • diethylpropion Barbiturates • butabarbital • phenobarbital Condition-dependent • mephobarbital • secobarbital Insomnia: zolpidem • pentobarbital Long-acting • amitriptyline- • chlordiazepoxide-clidinium Causes prolonged sedation, Low-dose short–acting benzodiazepines chlordiazepoxide • diazepam increased risk of falls and benzodiazepines, if they (includes • chlordiazepoxide • flurazepam fractures must be used combination drugs) Calcium channel • nifedipine − short-acting only Potential for hypotension. Use Felodipine, nifedipine-long- blockers long-acting formulation to acting (nifedipine ER) avoid adverse effects. Cardiovascular • amiodarone Anti-arrhythmia (amiodarone) Metoprolol, Atenolol; Sotalol associated with prolonged QT intervals; possible torsades de pointes, bradycardia and thyroiditis Gastrointestinal • dicyclomine • propantheline Anti-cholinergic effects Duodenal ulcer: omeprazole anti-spasmodics Constipation: psyllium, PEG, stool softener, lubiprostone (Amitiza) Diarrhea: loperamide, aluminum hydroxide Belladonna • atropine • atropine-edrophonium Anti-cholinergic effects Constipation: psyllium, alkaloids (includes • atropine/CPM/hyoscyamine/ • belladonna PEG, stool softener, combination drugs) PE/scopolamine • belladonna/ergotamine/ lubiprostone (Amitiza) • atropine/hyoscyamine/PB/ phenobarbital Diarrhea: loperamide, aluminum hydroxide scopolamine • butabarbital/hyoscyamine/ • atropine-difenoxin phenazopyridine • atropine-diphenoxylate • digestive enzymes/hyos- cyamine/phenyltoloxamine • hyoscyamine • hyoscyamine/methenam/ m-blue/phenyl salicylate Printed with permission from National Committee for Quality Assurance (NCQA) – HEDIS measure 651ALL0111-E Medications to Avoid in the Elderly Adapted from NCQA’s HEDIS® measure, Use of High-Risk Medications in the Elderly Description Prescription Adverse Side Formulary Alternatives1 Effects/Concerns Skeletal muscle • ASA/caffeine/orphenadrine • chlorzoxazone Anti-cholinergic effects, Baclofen, tizanidine relaxants (includes • ASA/carisoprodol/codeine • cyclobenzaprine sedation and weakness. combination drugs) • aspirin-carisoprodol • metaxalone Poorly tolerated • aspirin-methocarbamol • methocarbamol • carisoprodol • orphenadrine Oral estrogens • conjugated estrogen • esterified estrogen Cardio-protective properties Hot flashes: nondrug (includes • conjugated estrogen- • esterified estrogen- are absent; high carcinogenic comfort therapy, SSRIs, combination drugs) medroxyprogesterone methyl-testosterone effects (breast cancer and venlafaxine • estropipate endometrial cancer) Bone density: calcium, vitamin D, alendronate Oral hypoglycemics • Chlorpropamide Prolonged half-life causing Glipizide prolonged hypoglycemia. Causes syndrome of inappropriate anti-diuretic hormone secretion (SIADH) Narcotics (includes • ASA/caffeine/propoxyphene • meperidine-promethazine • Pentazocine produces high Hydrocodone, morphine combination drugs) • acetaminophen-pentazocine • naloxone-pentazocine CNS adverse effects oxycodone, fentanyl • acetaminophen- • pentazocine • Propoxyphene produces transdermal patch, propoxyphene • propoxyphene similar effects as other acetaminophen (not in • belladonna-opium hydrochloride narcotic medications combination product) • meperidine • propoxyphene napsylate Respiratory • theophylline Delirium, seizures and status Inhaled corticosteroid (e.g., epilepticus Flovent HFA or QVAR) with or without Serevent. Note: Long-acting beta agonists (LABAs) should be used in combination with ICS, for asthma maintenance therapy. LABAs are NOT indicated as monotherapy for asthma. Vasodilators • Dipyridamole − short-acting • isoxsuprine Orthostatic hypotension Aspirin/Dipyridamole only extended-release capsules, • ergot mesyloid low-dose aspirin Printed with permission from National Committee for Quality Assurance (NCQA) – HEDIS measure 651ALL0111-E Medications to Avoid in the Elderly Adapted from NCQA’s HEDIS® measure, Use of High-Risk Medications in the Elderly Description Prescription Adverse Side Formulary Alternatives1 Effects/Concerns Others (including • methyltestosterone • nitrofurantoin Prostatic hypertrophy and Danazol androgens and • nitrofurantoin macrocrystals- cardiac concerns; anabolic steroids, • nitrofurantoin macrocrystals monohydrate nitrofurantoin causes renal thyroid drugs, • thyroid desiccated impairment urinary anti- infectives) 1Source: Potentially Harmful Drugs in the Elderly: Beers List and More. Pharmacist's Letter/Prescriber's Letter 23.9. (2007):230907. Printed with permission from National Committee for Quality Assurance (NCQA) – HEDIS measure 651ALL0111-E .