Download The following are considered high risk medications in

The following are considered high risk medications in the patients over 65 due to their
increased association with functional dependence and unplanned revisits to urgent care
and the emergency room.
The following medications should generally be avoided in the urgent care setting.
1. Skeletal Muscle Relaxants Cyclobenzaprine (Flexeril) and methocarbamol (Robaxin) and
(carisoprodol) Soma (all SMRs are contraindicated).
Non Pharmacologic alternatives might include:
1. Physical Therapy
2. Heating packs/Ice
3. Exercise handouts
Pharmcologic Alternatives might include:
1. Acetaminophen
2. Narcotics (ensuring proper bowel regimen and discussion on potential side effects)
3. NSAIDs (recognizing renal and ulcer risk factors and consideration of the use of
concomitant omeprazole in the geriatric patient, especially if the NSAID is likely to be used for
chronic pain management)
2. Avoid : Promethazine (Phenergan) products for cough
Non-Pharmacologic alternatives might include:
1. No cough medication
2. Reassurance
Pharmacologic alternatives might include:
1. Guaifenesin (Robitussin) OTC
2. Benzonatate (Tessalon)
3. Guaifenesin (Robitussin) with Codeine
4. Treatment of gerd, reactive airways or post nasal drip
3. Nitrofurantoin (Macrobid) in patients with renal insufficiency (GFR < 60)
Pharmacologic alternatives include
1. See KP-SCal ID Gold Card
4. Avoid: Diazepam (Valium) and chlordiazepoxide (Librium)
Non pharmacologic alternatives might include:
1. follow up with psychiatry
2. follow up with mental health
3. follow up with primary care physician
4. relaxation techniques
5. non pharmacologic handouts for insomnia
Pharmacologic alteratives might include: (Please give warning of side effects and risk when
driving while using these medications)
1. For anxiety: SSRIs (preferred); Lorazepam (Ativan) - if a benzo must be given
2. For pre-procedure: Lorazepam
3. For insomnia: Trazodone
5. Avoid: Diphenhydramine (Benadryl) and hydroxyzine (Atarax)
Non-pharmacologic alternatives might include:
1. Treatment of underlying cause
2. Evaluation of prescribed medications
3. Emollients
Pharmacologic alternatives might include:
1. Cetirazine (Zyrtec)
2. Fexofenadine (Allegra)
3. Loratadine (Claritin)
4. Steroid creams
6.
Avoid: Meclizine and diazepam (Valium) for vertigo
Non Pharmacologic alternatives may include:
1. Modified therapeudic epley (NEJM 11/18/99)
2. PT referral
3. Home epley exercises
7. Avoid: Dicyclomaine (Bentyl), hyoscyamine (Levbsin), and
(Belladonna/Phenobarbital/Atropine/Scopolamine) Donnatol
Non pharmacologic might alternatives
1. reassurance if there is no evidence of an acute GI process
2. stress management
3. diet / fiber
8. Avoid: Trimethobenzamide (Tigan) and (promethazine) Phenergan
Pharmacologic alternatives might include:
Ondansetron (Zofran)
9. Patients with a history of falls and hip fractures should avoid
1. TCAs
2. Sleep agents such as zolpidem (Ambien), Lunesta, and Sonata
3. Antipsycotics unless they have a history of documented dementia WITH behavioral
disturbances or a primary psychotic disorder
Alternatives would include
1. TCAs for neuropathy - effexor or nortriptyline 10 to 20mg a day (which is considered a
"safer" TCA)
2. Trazodone for insomnia
3. Antipsychotics should be avoided unless the patient has a documented dementia with
behavioral disturbances or a psycotic disorder.
10. Patients with a history of dementia should avoid
1. TC As
2. Anticholinergics (listed above)
Alternatives: see above