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:

  1. Pharmacy Quality Alliance. Use of High‐Risk Medications in the Elderly (HRM). www. pqaalliance.org
  2. National Committee for Quality Assurance. HEDIS 2014. www.ncqa.org
  3. Product Information: Ambien CR® oral extended release tablets, zolpidem tartrate oral extended release.
  4. Product Information: Ambien® oral tablets, zolpidem tartrate oral tablets. Sanofi‐Aventis U.S. LLC. Bridgewater, NJ, 2013
  5. 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.
  6. PL Detail‐Document, STARTing and STOPPing Medications in the Elderly. Pharmacist’s Letter/Prescriber’s Letter. September 2011.
  7. 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.
  8. Product Information: amitriptyline hcl oral tablets. Vintage Pharmaceuticals, LLC, Huntsville, AL, 2006.
  9. Product Information: hydroxyzine pamoate oral capsules. Watson Laboratories, Inc, Corona, CA,2003.
  10. Product Information: SILENOR(R) oral tablets, doxepin oral tablets. Somaxon Pharmaceuticals, Inc., San Diego, CA, 2010.
  11. Nicolle LE. Urinary tract infections in the elderly. Clinics in Geriatric Medicine 2009;25:423‐36.
  12. 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‐