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High-Risk Medications and Medicare Members
Just like you, our members’ health and safety are our highest priority. We would like to work with you to avoid prescribing drugs considered high-risk for our members over the age of 65. High-risk medications are those identified by AGS Beers Criteria and by the Pharmacy Quality Alliance that tend to cause adverse drug events in older adults due to their pharmacologic properties and the physiologic changes of aging.
The table below is a list of High-Risk Medications and their alternatives provided by Samaritan Health Plans as recommendations to improve medication management with elderly patients. It is not intended to substitute the clinical judgment of the attending physician.
Medications | Potential Risks | Potential Alternative(s) | |
---|---|---|---|
Insomnia medications | zolpidem CR (Ambien CR), zolpidem tartrate (Ambien), zaleplon (Sonata), eszopiclone (Lunesta) | Chronic use in the elderly has been associated with an increased risk of diminished mental alertness, fall risk, sleep walking and abnormal behavior | Low dose trazodone, melatonin*, ramelteon |
Antiemetic medications | promethazine (Phenergan), doxylamine succinate | Anticholinergic effects | ondansetron, granisetron, metoclopramide (avoid use long term and in Parkinson patients) |
Antidepressants | amitriptyline (Elavil), clomipramine (Anafranil), doxepin (Silenor), imipramine (Tofranil) | Increases risk of causing anticholinergic effects, cognitive impairment, delirium, sedation, orthostatic hypotension | nortriptyline, desipramine, trazodone |
Diabetes medications | glyburide (Diabeta) | Prolonged half-life in older adults; can cause prolonged hypoglycemia | glimepiride, glipizide |
Allergy medications | brompheniramine, chlorpheniramine, clemastine, cyproheptadine, dexchlorpheniramine, diphenhydramine (Benadryl), hydroxyzine (Vistaril) | Anticholinergic side effects: worsened cognition and behavioral problems (especially in dementia); urinary retention or incontinence; confusion; enhance sedation | cetirizine*, fexofenadine*, loratadine*, desloratadine, levocetirizine* |
Urinary tract infection medications | nitrofurantoin (Macrobid, Macrodantin) | Potentially less effective with compromised renal function. Increased risk of pulmonary toxicity | sulfamethoxazole/trimethoprim, ciprofloxacin, levofloxacin, amoxicillin-clavulanate, cefdinir, cephalexin |
Anticoagulation medications | ticlopidine (Ticlid), dipyridamole (Persantine) | May cause orthostatic hypotension | clopidogrel |
Parkinson disease medications | benztropine (Cogentin), trihexphenidyl (Artane) | Highly anticholinergic | carbidopa/levodopa, ropinirole, pramipexole, entacapone |
Hypertension medications | methyldopa (Aldomet), nifedipine (Procardia, Procardia XL, Afeditab CR, Nidediac, Nifedical XL) | Increased risk of hypotension | Thiazides (HCTZ); generic ACE-inhibitors (lisinopril, ramipril); ARB’s (losartan); beta-blockers (atenolol); CCB’s (amlodipine) |
Antipsychotic medications | thioridazine (Mellaril) | Highly anticholinergic and risk of QT prolongation; increased risk of cerebrovascular accident and mortality in persons with dementia | aripiprazole (Abilify), olanzapine (Zyprexa), lurasidone (Latuda), asenapine (Saphris), paliperidone (Invega), quetiapine (Seroquel), risperidone (Risperdal), ziprasidone (Geodon) |
Barbiturates | phenobarbital, butabarbital (Butisol), secobarbital (Seconal), pentobarbital (Nembutal) | High rate of physical dependence; tolerance to sleep benefits; risk of prolonged sedation, falls | Seizures: divalproex, levetiracetam, lamotrigine, carbamazepine. Difficulty sleeping: Rozerem, low dose trazodone, melatonin* |
Anxiety medications | chlordiazepoxide (Librium), clonazepam (Klonopin), diazepam (Valium), flurazepam (Dalmane), lorazepam (Ativan), oxazepam (Serax), temazepam (Restoril), triazolam (Halcion), meprobamate (Equanil) | High rate of physical dependence; very sedating; increase risk of cognitive impairment, delirium, falls | buspirone |
Hormones | Products containing estrogens with or without progesterone | Increased risk of breast and/or endometrial cancer; Not cardioprotective | For hot flashes: SSRI (fluoxetine), venlafaxine, gabapentin For bone density: bisphosphonates (alendronate), raloxifene, calcium*, vitamin D* Vaginal atrophy: Estrace topical cream, Premarin topical cream |
Pain medications | meperidine (Demerol), butalbital/APAP/caffeine with or without codeine (Fioricet), butalbital/ASA/caffeine with or without codeine (Fiorinal) | Meperidine-Enhanced CNS effects: confusion, hallucinations, falls, fractures Butalbital/combinations-Higher risk of side effects: falls; fractures; confusion; cognitive impairment; dependence |
Mild to moderate pain: codeine/APAP, celecoxib (avoid in patients with heart failure or high GI/cardiovascular risks), topical NSAID (voltaren), tramadol, ibuprofen Moderate to severe pain: hydrocodone/APAP, oxycodone/APAP |
NSAID’s for pain | indomethacin (Indocin, Indocin SR), ketorolac (Acular) | Increases risk or GI bleeding/peptic ulcer disease in high risk groups | celecoxib (avoid in patients with heart failure or high GI/cardiovascular risks), topical NSAID (Voltaren) |
Skeletal muscle relaxants | carisoprodol (Soma), cyclobenzaprine (Flexeril), methocarbamol (Robaxin), metaxalone (Skelaxin) | Anticholinergic side effects: worsened cognition and behavioral problems (especially in dementia); urinary retention or incontinence; confusion; sedation; weakness; questionable efficacy (at lower doses) | baclofen, tizanidine, dantrolene |
*Drugs not covered by Part D
This list of High-Risk Medications is provided by SHPO as recommendations to improve medication management with elderly patients. It is not intended to substitute the clinical judgment of the attending physician.
References:
- Pharmacy Quality Alliance. Use of High‐Risk Medications in the Elderly (HRM). www. pqaalliance.org
- National Committee for Quality Assurance. HEDIS 2014. www.ncqa.org
- Product Information: Ambien CR® oral extended release tablets, zolpidem tartrate oral extended release.
- Product Information: Ambien® oral tablets, zolpidem tartrate oral tablets. Sanofi‐Aventis U.S. LLC. Bridgewater, NJ, 2013
- U.S. Food and Drug Administration. Risk of next‐morning impairment after use of insomnia drugs; FDA requires lower recommended doses for certain drugs containing zolpidem. Drug Safety Communications. January & May 2013.
- PL Detail‐Document, STARTing and STOPPing Medications in the Elderly. Pharmacist’s Letter/Prescriber’s Letter. September 2011.
- American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatric Society 2012. 60(4):616‐631.
- Product Information: amitriptyline hcl oral tablets. Vintage Pharmaceuticals, LLC, Huntsville, AL, 2006.
- Product Information: hydroxyzine pamoate oral capsules. Watson Laboratories, Inc, Corona, CA,2003.
- Product Information: SILENOR(R) oral tablets, doxepin oral tablets. Somaxon Pharmaceuticals, Inc., San Diego, CA, 2010.
- Nicolle LE. Urinary tract infections in the elderly. Clinics in Geriatric Medicine 2009;25:423‐36.
- Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin. Infect. Dis. 2011;52:e103‐