Download High risk medications

High risk medications
updated January 2016
Alternatives*
Classification
Drug name
Risk
First-generation
antihistamines
brompheniramine
carbinoxamine
chlorpheniramine
clemastine
cyproheptadine (PERIACTIN)
dexbrompheniramine
dexchlorpheniramine
diphenhydramine (oral) (BENADRYL)
doxylamine
hydroxyzine (ATARAX, VISTARIL)
promethazine (PHENERGAN)
triprolidine
saline
Highly anticholinergic (risk of confusion, dry mouth,
constipation, blurred vision, drowsiness, hallucinations, intranasal saline
second-generation antihistamines
difficulty urinating)
cetirizine (generic for Zyrtec)
Clearance reduced with advanced age (risk of toxicity) fexofenadine (generic for Allegra)
loratadine (generic for Claritin)
Tolerance develops when used as hypnotic
CLARINEX SYRUP
desloratadine (generic for Clarinex)
desloratadine ODT (generic for Clarinex RediTab)
levocetirizine (generic for Xyzal)
benztropine (oral) (COGENTIN)
trihexyphenidyl (ARTANE)
Not recommended for prevention of extrapyramidal
symptoms with antipsychotics
Parkinson disease
Drug
Tier
OTC¹
OTC¹
4
2
2
2
intranasal steroids
BECONASE AQ
fluticasone nasal spray (generic for Flonase)
NASONEX
OMNARIS
QNASAL
triamcinolone acetonide (generic for Nasacort AQ)
carbidopa/levodopa (generic for Sinemet)
carbidopa/levodopa ER (generic for Sinemet CR)
carbidopa/levodopa ODT (generic for Parcopa)
4
1
4
4
4
2
2
2
2
clopidogrel (generic for Plavix)
aspirin/dipyridamole (generic for Aggrenox)
2
2
More effective agents available for treatment of
Parkinson disease
Antiplatelets
Anti-infective
dipyridamole (PERSANTINE)
ticlopidine (TICLID)
nitrofurantoin (MACROBID, MACRODANTIN)
Immediate release may cause orthostatic hypotension
Safer, effective alternatives available
Potential for plumonary toxicity, hepatoxicity, and
Nitrofurantoin is included in CMS's 5-star measure if peripheral neuropathy, especially with long-term use.
beneficiary has two or more fills and receives 90 or
more cumulative days of treatment in a calendar
year.
Alpha blockers
(central)
guanfacine (INTUNIV, TENEX)
methyldopa (ALDOMET)
reserpine (>0.1 mg/day)*
None recommended by The American Geriatrics Society; however,
may consider the following:
ciprofloxacin (generic for Cipro)
MONUROL
trimethoprim (generic for Proloprim)
trimethoprim/sulfamethoxazole (generic for Bactrim)
trimethoprim/sulfamethoxazole DS (generic for Bactrim DS)
High risk of adverse CNS effects (may cause
bradycardia and orthostatic hypotension)
*Reserpine is included in CMS's 5 -star measure for
any beneficiary with two or more fills in a calendar
year.
* Alternatives are recommended by The American Geriatrics Society, unless otherwise noted.
¹ OTC (over-the-counter) drugs are not covered by Medicare Part D
2
2
2
2
2
Thiazide-type diuretics
(preferred for black individuals and heart failure)
chlorthalidone (generic for Thalitone)
hydrochlorothiazide (generic for Hydrodiuril, Microzide)
indapamide (generic for Lozol)
metolazone (generic for Zaroxolyn)
2
1
1
2
Alpha blockers
High
risk medications
(central)
High risk of adverse CNS effects (may cause
bradycardia and orthostatic hypotension)
updated January 2016
Classification
First-generation
antihistamines
Drug name
Risk
Alternatives*
Drug
Highly anticholinergic (risk of confusion, dry mouth,
ACEsaline
inhibitors
(preferred for heart failure, diabetes mellitus, and chronic kidney disease)
constipation, blurred vision, drowsiness, hallucinations,
difficulty urinating)
benazepril (generic for Lotensin)
captopril (generic for Capoten)
Clearance reduced with advanced age (risk of toxicity) enalapril (generic for Vasotec)
fosinopril (generic for Monopril)
Tolerance develops when used as hypnotic
lisinopril (generic for Prinivil, Zestril)
moexipril (generic for Univasc)
perindopril (generic for Aceon)
quinapril (generic for Accupril)
ramipril (generic for Altace)
trandolapril (generic for Mavik)
Tier
1
1
1
2
1
2
2
2
2
2
Angiotensin Receptor Blocker (ARB)
(preferred for heart failure, diabetes mellitus, and chronic kidney disease)
BENICAR
candesartan (generic for Atacand)
EDARBI
eprosartan (generic for Teveten)
irbesartan (generic for Avapro)
losartan (generic for Cozaar)
telmisartan (generic for Micardis)
valsartan (generic for Diovan)
NF
2
NF
2
2
1
2
2
Calcium Channel Blockers
Afeditab CR (generic for Adalat CC)
amlodipine (generic for Norvasc)
AZOR
CARDIZEM LA
Dilt-XR (generic for Dilacor XR)
diltiazem (generic for Cardizem)
diltiazem CD (generic for Cardizem CD)
diltiazem ER (generics for Cardizem LA and Tiazac)
felodipine ER (generic for Plendil)
isradipine (generic for DynaCirc)
nicardipine (generic for Cardene)
nifedipine ER (generic for Procardia XL)
nisoldipine ER (generic for Sular)
verapamil (generic for Calan)
verapamil ER (generic for Calan SR, Isoptin SR)
verapamil SR (generic for Verelan)
* Alternatives are recommended by The American Geriatrics Society, unless otherwise noted.
¹ OTC (over-the-counter) drugs are not covered by Medicare Part D
2
1
4
4
2
2
2
2
2
2
2
2
2
2
2
2
High risk medications
updated January 2016
Classification
Drug name
Risk
First-generation
Cardiovascular
(other)
antihistamines
disopyramide (NORPACE, NORPACE CR)
Highly anticholinergic
(risk
of confusion,
dryand
mouth,
Disopyramide
is a potent
negative
inotrope
may
constipation,
blurred
vision,
drowsiness,
hallucinations,
induce heart failure in older adults.
difficulty urinating)
Strongly anticholinergic (risk of confusion, dry mouth,
Clearance reduced
advanced
age (risk
of toxicity)
constipation,
blurredwith
vision,
drowsiness,
hallucinations,
difficulty urinating)
Tolerance develops when used as hypnotic
Alternatives*
Drug
Tier
saline
For atrial fibrillation rate control:
diltiazem (generic for Cardizem)
diltiazem CD (generic for Cardizem CD)
diltiazem ER (generic for Cardizem LA, Tiazac)
verapamil (generic for Calan, Isoptin)
verapamil ER (generic for Calan SR, Isoptin SR)
verapamil SR (generic for Verelan)
digoxin (>0.125 mg/day) (LANOXIN)
Cardiovascular
(other)
Tertiary tricyclic
antidepressants (single
agent and combination
products)
Digoxin is not a first-line drug for use in atrial fibrillation.
For atrial fibrillation rhythm control:
The risk of death may be higher with digoxin compared
Digoxin is included in CMS's 5-star measure only
to other more-effective alternatives.
flecainide (generic for Tambocor)
when a beneficiary has 2 or more fills with an
propafenone (generic for Rythmol)
average daily dose > 0.125 mg.
TIKOSYN
nifedipine (immediate-release)
Risk of precipitating myocardial ischemia and possible amlodipine (generic for Norvasc)
hypotension
felodipine ER (generic for Plendil)
nifedipine ER (generic for Procardia XL)
For depression:
amitriptyline (ELAVIL)
These drugs are highly anticholinergic (risk of
bupropion
amitriptyline/chlordiazepoxide (LIMBITROL) confusion, dry mouth, constipation, blurred vision,
drowsiness, hallucinations, difficulty urinating) and
amitriptyline/perhenazine (TRIAVIL)
bupropion (generic for Wellbutrin)
cause orthostatic hypotension.
clomipramine (ANAFRANIL)
bupropion SR (generic for Wellbutrin SR)
doxepin (>6 mg/day)* (SINEQUAN)
bupropion XL (generic for Wellbutrin XL)
Does higher than 6 mg/day are included in CMS's 5FORFIVO XL
2
2
2
2
2
2
star measure for beneficiaries with two or more fills
in a calendar year. Doses of doxepin less than 6
mg/day are not included because its side effect
profile is similar to placebo.
imipramine (TOFRANIL, TOFRANIL-PM)
trimipramine (SURMONTIL)
2
2
4
1
2
2
2
2
2
4
SSRI's
citalopram (generic for Celexa)
escitalopram (generic for Lexapro)
fluoxetine (generic for Prozac)
fluoxetine delayed-release (generic for Prozac Weekly)
sertraline (generic for Zoloft)
VIIBRYD
1
2
1
2
1
4
SNRI's
DESVENLAFAXINE ER
duloxetine (generic for Cymbalta)
FETZIMA
KHEDEZLA
PRISTIQ
venlafaxine (generic for Effexor)
venlafaxine extended-release (generic for Effexor XR)
venlafaxine ER tablet
VENLAFAXINE ER TABLET 225 MG
* Alternatives are recommended by The American Geriatrics Society, unless otherwise noted.
¹ OTC (over-the-counter) drugs are not covered by Medicare Part D
4
2
4
4
4
2
2
4
4
High risk medications
updated January 2016
Classification
Drug name
First-generation
antihistamines
Risk
Alternatives*
Drug
saline pain:
Highly anticholinergic (risk of confusion, dry mouth,
For neuropathic
constipation, blurred vision, drowsiness, hallucinations, DESVENLAFAXINE ER
difficulty urinating)
duloxetine (generic for Cymbalta)
FETZIMA
Clearance reduced with advanced age (risk of toxicity) KHEDEZLA
PRISTIQ
Tolerance develops when used as hypnotic
venlafaxine (generic for Effexor)
venlafaxine extended-release (generic for Effexor XR)
venlafaxine ER tablet
VENLAFAXINE ER TABLET 225 MG
gabapentin
capsaicin topical
LYRICA
lidocaine 5% patch (for diabetic neuropathy only)
Tier
4
2
4
4
4
2
2
4
4
2
OTC¹
4
4
For epilepsy:
lamotrigine (generic for Lamictal)
levetiracetam (generic for Keppra)
other anticonvulsants
Antipsychotics, firstgeneration
(conventional)
thioridazine (MELLARIL)
Barbiturates
amobarbital (AMYTAL)
butabarbital (BUTISOL)
butalbital (FIORICET, FIORINAL, ETC.)
pentobarbital (NEMBUTAL)
phenobarbital (LUMINAL)
secobarbital (SECONAL)
For schizophrenia, use nonanticholinergic antipsychotics:
Increased risk of stroke, cognitive decline, and mortality
in persons with dementia. Avoid use for behavioral
aripiprazole (generic for Abilify)
problems related to dementia or delirium unless there is haloperidol tablet (generic for Haldol)
threat of substantial harm to self or others.
risperidone (generic for Risperdal)
risperidone ODT (generic for Risperdal M-Tab)
thiothixene (generic for Navane)
ziprasidone (generic for Geodon)
For epilepsy:
High rate of physical dependennce, tolerance to sleep
benefits, and a greater risk of overdose at low doses
lamotrigine (generic for Lamictal)
levetiracetam (generic for Keppra)
other anticonvulsants
* Alternatives are recommended by The American Geriatrics Society, unless otherwise noted.
¹ OTC (over-the-counter) drugs are not covered by Medicare Part D
2
2
3
1
2
2
2
2
2
2
High risk medications
updated January 2016
Classification
Drug name
Risk
First-generation
CNS
(other)
antihistamines
chloral hydrate (SOMNOTE)
meprobamate (MILTOWN)
Highlyin
anticholinergic
(riskorofatconfusion,
mouth,
Avoid
older adults with
high risk ofdry
delirium
constipation,
blurred
vision,
drowsiness,
hallucinations,
because of the potential of inducing or worsening
difficulty urinating)
delirium.
Avoid antipsychotics for behavioral problems
of dementia or delirium unless nonpharmalogical
Clearance
reduced
with advanced
age have
(risk of
toxicity)
options
(e.g.,
behavioral
interventions)
failed
or
are not possible and the older adult is threatening
Tolerance develops
when
asAntipsychotics
hypnotic
substantial
harm to self
or used
others.
are
associated with greater risk of cerebrovascular
accident (stroke) and mortality in persons with
dementia.
Meprobamate has a high rate of physical dependence
and is very sedating.
Nonbenzodiazepine
hypnotics
Alternatives*
Drug
Forsaline
anxiety:
buspirone (generic for Buspar)
2
SSRI's
citalopram (generic for Celexa)
escitalopram (generic for Lexapro)
fluoxetine (generic for Prozac)
fluoxetine delayed-release (generic for Prozac Weekly)
sertraline (generic for Zoloft)
VIIBRYD
1
2
1
2
1
4
SNRI's
DESVENLAFAXINE ER
duloxetine (generic for Cymbalta)
FETZIMA
KHEDEZLA
PRISTIQ
venlafaxine (generic for Effexor)
venlafaxine extended-release (generic for Effexor XR)
venlafaxine ER tablet
VENLAFAXINE ER TABLET 225 MG
eszopiclone (LUNESTA)
zolpidem (AMBIEN, AMBIEN CR)
zaleplon (SONATA)
None recommended by The American Geriatrics Society; however,
Risk of: delirium, falls, and fractures; increased
BEERS
, and trazodone.
emergency department visits and hospitalizations; and may consider Rozerem, temazepam
motor vehicle crashes.
Included in CMS's 5-star measure with two or more
fills with 90 or more cumulative days of any
combination of these drugs.
These drugs produce minimal improvement in sleep
latency and duration.
Vasodilators for
dementia
ergoloid mesylates (HYDERGINE)
isoxsuprine (VASODILAN)
Lack of efficacy
Endocrine
desiccated thyroid (ARMOUR THYROID)
4
2
4
4
4
2
2
4
4
BEERS
Not recommeded by The American Geriatrics Soceity bcause of increased risk for cognitive
impairment, delirium, falls, fractures, and motor vehicle accidents. .
donepezil (generic for Aricept)
EXELON PATCH
galantamine (generic for Razadyne)
rivastigmine (generic for Exelon)
memantine (generic for Namenda)
NAMENDA
NAMENDA XR
There are concerns about cardiac effects with
levothyroxine (generic for Levoxyl, Synthroid)
desiccated thyroid and safer alternatives are available. LEVOXYL
liothyronine (generic for Cytomel)
SYNTHROID
THYROLAR
TIROSINT
UNITHROID
* Alternatives are recommended by The American Geriatrics Society, unless otherwise noted.
¹ OTC (over-the-counter) drugs are not covered by Medicare Part D
Tier
2
3
2
2
2
3
3
1
2
2
4
4
4
2
Endocrine
High risk medications
updated January 2016
Alternatives*
Classification
Drug name
Risk
First-generation
antihistamines
estrogens
saline
Highly is
anticholinergic
(risk of confusion,
mouth,
For dyspareunia
and vulvovaginitis:
There
evidence of potential
breast anddry
endometrium
constipation,
blurred
vision,
drowsiness,
hallucinations,
cancer. There is a lack of cardioprotective effect and
ESTRING
difficulty urinating)
cognitive
protection in older women.
FEMRING
PREMARIN VAGINAL CREAM
Clearance reduced with advanced age (risk of toxicity) VAGIFEM
CONJUGATED ESTROGEN
CENESTIN, ENJUVIA, PREMARIN
CONJUGATED ESTROGEN COMBINATIONS
DUAVEE, PREMPHASE, PREMPRO
ESTERIFIED ESTROGEN
MENEST
Tolerance develops when used as hypnotic
ESTERIFIED ESTROGEN & METHYLTESTOSTERONE
COVARYX, COVARYX H.S., EEMT, EEMT HS,
ESSIAN, ESSIAN HS, ESTRATEST, ESTRATEST
HS, SYNTEST DS, SYNTEST HS
ESTRADIOL
ALORA, CLIMARA, DELESTROGEN,
DEPGYNOGEN, DEPO-ESTRADIOL, DEPOGEN,
DIVIGEL, ELESTRIN, ESCLIM, ESTRACE,
ESTRADERM, ESTRASORB, ESTRING,
ESTROGEL, EVAMIST, FEMPATCH, FEMRING,
GYNODIOL, GYNOGEN LA, MENOSTAR,
MINIVELLE, VALERGEN, VIVELLE, VIVELLE DOT
Sulfonylureas,
long-duration
chlorpropamide (DIABINESE)
glyburide (DIABETA, GLYNASE, MICRONASE)
Gastrointestinal
trimethobenzamide (TIGAN)
Tier
3
3
3
3
For vasomotor symptoms:
SSRI's
citalopram (generic for Celexa)
escitalopram (generic for Lexapro)
fluoxetine (generic for Prozac)
fluoxetine delayed-release (generic for Prozac Weekly)
sertraline (generic for Zoloft)
VIIBRYD
1
2
1
2
1
4
SNRI's
DESVENLAFAXINE ER
duloxetine (generic for Cymbalta)
FETZIMA
KHEDEZLA
PRISTIQ
venlafaxine (generic for Effexor)
venlafaxine extended-release (generic for Effexor XR)
venlafaxine ER tablet
VENLAFAXINE ER TABLET 225 MG
ESTRADIOL COMBINATIONS
ACTIVELLA, COMBIPATCH, LOPREEZA,
MIMVEY, MIMVEY LO
megestrol (MEGACE, MEGACE ES)
Drug
Megestrol has minimal effect on weight and increases None recommended by The American Geriatrics Society.
risk of thrombotic events, and possibly death, in older
adults.
Chlorpropamide has a prolonged half-life in older adults glimepiride (generic for Amaryl)
that can cause prolonged hypoglycemia.
glipizide (generic for Glucotrol)
glipizide extended-release (generic for Glucotrol XL)
Causes syndrome of inappropriate antidiuretic
GLUMETZA
hormone secretion.
metformin (generic for Glucophage)
Glyburide has a higher risk of severe prolonged
metformin extended-release (generic for Glucophage XR)
hypoglycemia in older adults.
One of the least effective antiemetic drugs; can cause None recommended by The American Geriatrics Society.
extrapyramidal adverse effects (agitation, abnormal or
involuntary movement, and psuedoparkinsonism)
* Alternatives are recommended by The American Geriatrics Society, unless otherwise noted.
¹ OTC (over-the-counter) drugs are not covered by Medicare Part D
4
2
4
4
4
2
2
4
4
1
1
2
4
1
2
High risk medications
updated January 2016
Classification
Drug name
Risk
First-generation
Pain
medications
antihistamines
meperidine (DEMEROL)
Highly
anticholinergic
of confusion,
dry used
mouth,
Not
effective
as a pain(risk
reliever
in commonly
constipation,
blurred
vision,
drowsiness,
hallucinations,
doses. Meperidine may have a higher risk of
difficulty urinating)
neurotoxicity,
including delirium, compared to other
opioids.
Clearance reduced with advanced age (risk of toxicity)
Alternatives*
Drug
saline
morphine sulfate immediate-release
(generic for MSIR)
morphine sulfate extended-release 12-hour capsule
(generic for Kadian)
morphine sulfate extended-release tablet
(generic for MS Contin)
pentazocine
(TALACEN, TALWIN, TALWIN COMPOUND, TALWIN NX)
Non-COX-selective
NSAIDS
indomethacin (INDOCIN)
ketorolac (SPRIX, TORADOL)
Skeletal muscle
relaxants
carisoprodol (SOMA)
chlorzoxazone (LORSONE, PARAFON FORTE DSC)
cyclobenzaprine (FLEXERIL)
metaxalone (SKELAXIN)
methocarbamol (ROBAXIN)
orphenadrine (NORFLEX)
Causes
CNS
adverse
effects
more
commonly than
Tolerance
develops
when
used
as hypnotic
other opioid analgesics, including confusion and
hallucinations. This drug is also a mixed agonist and
antagonist.
oxycodone/acetaminophen
(generic for Percocet)
tramadol
(generic for Ultram)
Increased risk of gastrointestinal bleeding, peptic ulcer acetominophen (generic for Tylenol)
disease, and acute kidney injury in older adults
ibuprofenBEERS (generic for Motrin)
compared to other NSAID's.
naproxenBEERS (generic for Naprosyn)
salsalate (generic for Disalcid)
Most muslcle relaxants are poorly tolerated by older
acetominophen (generic for Tylenol)
adults because some have anticholinergic adverse
ibuprofenBEERS (generic for Motrin)
effects, sedation, and increased risk of fractures.
naproxenBEERS (generic for Naprosyn)
salsalate (generic for Disalcid)
BEERS
Use only if no heart failure and estimated GFR > 30 mL/min.
BEERS
Use PPI combination if used > 7 days.
Tier
2
4
2
2
2
OTC¹
1
1
2
OTC¹
1
1
2
The following may also be considered, but are not recommended by
the American Geriatrics Society:
baclofen
tizanidineBEERS
BEERS
Avoid use of tizanidine in men because of urinary retention.
References
1. Pharmacy Quality Alliance. Use of High-Risk Medications in the Elderly (HRM) . Available at: http://pqaalliance.org/images/uploads/files/HRM2015.pdf, last accessed Jan. 5, 2016.
2. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults . JAGS 2015; 1-20.
3. Hanlon JT, Semla TP, Schmader KE. Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug-Disease Interactions in the Elderly Quality Measures. JAGS 2015; 1-11.
4. Clinical Pharmacology . Elsevier Gold Standard. Available at: https://www.clinicalpharmacology.com/.
* Alternatives are recommended by The American Geriatrics Society, unless otherwise noted.
¹ OTC (over-the-counter) drugs are not covered by Medicare Part D