CMS: High-Risk Medications (Relevant for older people defined as greater than 65 years of age) Drug High-risk agents to Avoid Non-high risk alternatives Reason for Risk classification (H) = considered Highest-risk¹ Drug Amphetamines amphetamine & dextroamphetamine (H) CNS stimulation: agitation, insomnia; Consider discontinuing (ADDERALL/XR ) hypertension, myocardial ischemia; benzphetamine (H) (DIDREX ) dependence; appetite suppression dexmethylphenidate (H) (FOCALIN/XR ) dextroamphetamine (H) (DEXADRINE, DEXTROSTAT ) diethylpropion (H) (DURAD, TENUATE, TEPANIL ) INTUNIV (H) methamphetamine (H) (DESOXYN ) methylphenidate (H) (RITALIN/LA, CONCERTA, DAYTRANA, METADATE CD ) phendimetrazine (H) (BONTRIL ) phentermine (H) (ADIPEX-P ) Drug High-risk agents to Avoid Non-high risk alternatives Reason for Risk classification (H) = considered Highest-risk¹ Drug Analgesics indomethacin (INDOCIN) Ketorolac: Gastrointestinal bleeding risk mild pain: ketorolac (H) (TORADOL ) increased in elderly. APAP ibuprofen Indomethacin: GI bleeding/peptic ulcer in high- naproxen risk patients.a Has more adverse effects than meloxicam other NSAIDs. Edema may worsen heart failure. moderate/severe pain: tramadol morphine sulfate (MS CONTIN) hydrocodone/APAP(V ICODIN , etc) oxycodone (OXYIR) oxycodone/APAP (PERCOCET) fentanyl patch (DURAGESIC) OXYCONTIN AVINZA use lowest dose possible to avoid side effects and reduce pain Anti-adrenergics guanabenz Orthostatic hypotension, bradycardia, CNS HCTZ guanfacine (TENEX) adverse effects lisinopril methyldopa (ALDOMET) enalapril methyldopa/HCTZ (ALCOLOR, ALDORIL) losartan metoprolol Anti-anxiety meprobamate (H) (EQUINIL ) Dependence; sedation; depression; confusion; anxiety: aspirin/meprobamate (H) (EQUAGESIC ) falls; fractures; respiratory depression buspirone (BUSPAR) (especially in COPD) sleep: ROZEREM Drug High-risk agents to Avoid Non-high risk alternatives Reason for Risk classification (H) = considered Highest-risk¹ Drug Anti-emetics trimethobenzamide (H) (TIGAN ) Anticholinergic side effects: worsened TRANSDERM-SCOP promethazine (H) (PHENERGAN) cognition & behavioral problems (especially in ondansetron (ZOFRAN) dementia); urinary retention OR incontinence; granisetron (KYTRIL) questionable efficacy prochlorperazine (COMPAZINE) metoclopramide (REGLAN)* *avoid using long-term and/or in Parkinson’s disease Antihistamines APAP/dextromethorphan/diphenhydramine (H) Anticholinergic side effects: worsened Levocetirizine (XYZAL) APAP/diphenhydramine/phenylephrine (H) cognition & behavioral problems (especially in CLARINEX APAP= APAP/diphenhydramine/PSE (H) dementia); urinary retention OR incontinence; acetaminophen APAP & diphenhydramine (H) confusion; enhanced sedation; PSE= Brompheniramine / combination products (H) pseudoephedrine carbetapentane/diphenhydramine/ phenylephrine (H) carbinoxamine / combination products (H) chlorpheniramine / combination products (H) clemastine (H) codeine/promethazine/phenylephrine (H) codeine & promethazine (H) cyproheptadine (H) dexbrompheniramine-Pyrilamine (H) dexchlorpheniramine dexchlorpheniramine/dextromethorphan/PSE (H) dexchlorpheniramine/guaifenesin/PSE (H) dexchlorpheniramine/hydrocodone/ phenylephrine (H) dexchlorpheniramine/methscopolamine/PSE (H) dexchlorpheniramine & PSE (H) dextromethorphan & promethazine (H) diphenhydramine (H) diphenhydramine/hydrocodone/ phenylephrine (H) diphenhydramine & phenylephrine (H) diphenhydramine & PSE (H) diphenhydramine & magnesium salicylate (H) doxylamine hydroxyzine hydrochloride (H) hydroxyzine pamoate (H) phenylephrine & promethazine (H) promethazine (H) triprolidine Note: Various brand name drugs apply. Antihistamines APAP/dextromethorphan/diphenhydramine (H) Anticholinergic side effects: worsened Levocetirizine (XYZAL) APAP/diphenhydramine/phenylephrine (H) cognition & behavioral problems (especially in CLARINEX APAP= APAP/diphenhydramine/PSE (H) dementia); urinary retention OR incontinence; acetaminophen APAP & diphenhydramine (H) confusion; enhanced sedation; PSE= Brompheniramine / combination products (H) pseudoephedrine carbetapentane/diphenhydramine/ phenylephrine (H) carbinoxamine / combination products (H) chlorpheniramine / combination products (H) clemastine (H) codeine/promethazine/phenylephrine (H) codeine & promethazine (H) cyproheptadine (H) dexbrompheniramine-Pyrilamine (H) dexchlorpheniramine dexchlorpheniramine/dextromethorphan/PSE (H) dexchlorpheniramine/guaifenesin/PSE (H) dexchlorpheniramine/hydrocodone/ phenylephrine (H) dexchlorpheniramine/methscopolamine/PSE (H) dexchlorpheniramine & PSE (H) dextromethorphan & promethazine (H) diphenhydramine (H) diphenhydramine/hydrocodone/ phenylephrine (H) diphenhydramine & phenylephrine (H) diphenhydramine & PSE (H) diphenhydramine & magnesium salicylate (H) doxylamine Drug High-risk agents to Avoid Non-high risk alternatives hydroxyzine hydrochloride (H) Reason for Risk classification hydroxyzine(H) =pamoate considered (H) Highest-risk¹ Drug phenylephrine & promethazine (H) promethazine (H) triprolidine Note: Various brand name drugs apply. Antiparkinson/ benztropine (COGENTIN) Delirium, worsen cognitive impairment, worsen Consider discontinuing or using atypical antipsychotics trihexyphenidyl constipation, worsen urinary retention; not antipsychotic recommended to prevent antipsychoticassociated extrapyramidal effects; not very effective for Parkinson’s disease Antipsychotics thioridazine (H) (MELLARIL ) CNS side effects; seizure risk; extrapyramidal haloperidol (HALDOL) effects: tremor, slurred speech, muscular risperidone (RISPERDAL)* rigidity, dystonia (involuntary muscle ABILIFY* contractions), bradykinesia (slowing of FANAPT* movement), akathisia (inability to sit/stand still) GEODON* INVEGA* SEROQUEL* ZYPREXA* *atypical antipsychotics associated w/ increased mortality when used to treat behavioral issues in elderly w/ dementia Drug High-risk agents to Avoid Non-high risk alternatives Reason for Risk classification (H) = considered Highest-risk¹ Drug Barbiturates butabarbital (H) (BUTISOL ) Higher risk of side effects: falls; fractures; sleep: butalbital / combinations (H) (FIORICET, confusion; cognitive impairment; dependence ROZEREM FIORINAL, DOLGIC, ESGIC) mephobarbital (H) (MEBARAL ) mild pain: pentobarbital (H) (NEMBUTAL ) APAP phenobarbital (H) (LUMINAL) ibuprofen naproxen secobarbital (H) (SECONAl) meloxicam moderate/severe pain: tramadol morphine sulfate (MS CONTIN) hydrocodone/APAP (VICODIN, etc) oxycodone (OXYIR) oxycodone/APAP (PERCOCET) fentanyl patch (DURAGESIC) OXYCONTIN AVINZA Belladona alkaloids atropine/hyoscyamine/phenobarbital/ Anticholinergic AEs: worsened cognition & constipation: scopolamine (H) (BELLADONNA ALKALOIDS, behavioral problems (especially in dementia); psyllium fiber (METAMUCIL) CPM= DONNATAL, ANTISPASMODIC ELIXIR) urine retention; agitation & delirium polyethylene glycol (MIRALAX) chlorpheniramine atropine & edrophonium (ENLON) docusate belladonna (H) PE=phenylephrine belladonna/ergotamine/phenobarbital (H) diarrhea: (BELLAMINE ) loperamide (IMODIUM) butabarbital/hyoscyamine/phenazopyridine (H) aluminum hydroxide (PHENAZOPYRIDEINE PLUS, atropine & difenoxin (MOTOFEN ) PHENAZOFORTE PLUS) atropine & diphenoxylate digestive- enzymes/ hyoscyamine/ (LOMOTIL, LONOX, LOGEN, phenyltoloxamine (H) (DIGEX NF) LOMANATE ) Benzodiazepines amitriptyline & chlordiazepoxide (H) (LIMBITROL Dependence; depression; prolonged sedation; buspirone (BUSPAR) (long-acting) DS ) confusion; falls; fractures; respiratory chlordiazepoxide (H) (LIBRIUM ) depression (especially in COPD); accumulation diazepam (VALIUM ) of drug flurazepam (DALMANE ) Drug High-risk agents to Avoid Non-high risk alternatives Reason for Risk classification (H) = considered Highest-risk¹ Drug Calcium channel nifedipine (short-acting immediate release only) Hypotension; constipation nifedipine ER (PROCARDIAXL) blockers (H) (ADALAT CC, PROCARDIA ) Cardiac glycosides digoxin (LANOXIN, DIGITEK, LANOXICAPS) No additional efficacy vs lower doses; toxicity Consider discontinuing or dose reduction due to reduced renal clearance (e.g. 0.125mg) with monitoring Drug High-risk agents to Avoid Non-high risk alternatives Reason for Risk classification (H) = considered Highest-risk¹ Drug Estrogens and Oral Increased risk of breast &/or endometrial Hot flashes*: progestins ANGELIQ cancer; NOT cardioprotective venlafaxine (EFFEXOR) conjugated estrogen (PREMARIN, ESTINYL) paroxetine (PAXIL) conjugated estrogen & medroxyprogesterone fluoxetine (PROZAC) (PREMPRO, PREMPHASE) sertraline (ZOLOFT) esterified estrogen (MENEST ) gabapentin esterified estrogen & methyltestosterone (H) * nondrug therapy should be emphasized (COVARYX, ESTRATEST) Bone density: estropipate (OGEN, ORTHO-EST) Calcium vitamin D estradiol (H) (ESTRACE, GYNODIOL) (H) alendronate (FOSAMAX) estradiol/norethindrone (H) (ACTIVELLA, ACTONEL MIMVEY) Ibandronate (BONIVA) FEMHRT (H) EVISTA JEVANTIQUE (H) JINTELI (H) Genitourinary symptoms: Megestrol (MEGACE/ES) (H) Femring ORTHOPREFEST (H) Premarin vaginal cream PREFEST (H) Vagifem Transdermal estradiol patch (H) ALORA patch (H) ESTRASORB (H) ESCLIM patch (H) CLIMARA PRO patch (H) COMBIPATCH (H) VIVELLE-DOT patch (H) MENOSTAR patch (H) DIVIGEL topical gel (H) ELESTRIN topical gel (H) EVAMIST topical spray (H) Drug High-risk agents to Avoid Non-high risk alternatives Reason for Risk classification (H) = considered Highest-risk¹ Drug Narcotics ASA/caffeine/propoxyphene (DARVON Enhanced CNS effects: confusion, mild pain: COMPOUND ) hallucinations; falls;