Higgh Risk Medication Therapeuttic Alterrnativess Guide The Centers for M
Medicare & Medicaid Se
ervices (CMSS) endorses sseveral criticcal patient saafety measures. One of these measures,, High Risk M
Medication, includes seve
eral therapeutic categorries associateed with poteential clinical conccerns when u
used in the e
elderly, espe
ecially in patiients over 655 years old. TThe list of m
medications in this measure was derived from the Beers’ Lisst and recom
mmendation from the Am
merican Gerriatrics Socieety. Some of the mosst commonlyy prescribed
d high risk medications innclude zolpid
dem tartratee, hydroxyzin
ne, amittriptyline, do
oxepin, and n
nitrofurantoin. This guid
de provides fformulary an
nd over‐the‐ counter theerapeutic alterrnatives thatt may be use
ed in place of a high risk drug. If meddically appro
opriate, please consider prescribing a saffer alternativve for the paatients. We rrecognize thaat prescribers are in the best positio
on to determ
mine the rightt treatment regimen for the patient and we lookk forward to working witth you to ensure optimaal outcomes for o
our patients. Commonly prescribed
d high‐risk me
edications on‐benzodiazzepine zolpidem tartrate and other no
mbien®, zalep
plon, etc.) sedattives (e.g., Am
Elavill®, Vanatrip® (amitriptylin
ne) Clinical con
ncerns Chroniic use in the eelderly has beeen associateed with an increassed risk of dim
minished mental alertnesss, fall risk, sleep w
walking, and abnormal behavior. 1,2,3,4,5,,6 Increases risk of cau
using anticho
olinergic effeccts, cognitive um, and sedattion in the eld
derly. impairrment, deliriu
Neuroleptic malignant syndromee has also beeen reported duringg post‐marketting surveillan
nce. 1,2,7,8 May innduce strong anticholinerggic effects, coggnitive impairrment and deelirium in the elderly 7 Hydroxyzine may
y .
Vistaaril®, Atarax®,, Hyzine® (hyydroxyzine) cause confusion and over‐sedatiion,9 which in
ncreases the patiennt’s fall risk. Increases risk of cau
using anticho
olinergic effeccts, cognitive Silenor®, Prudoxin
n®, Sinequan®, or Zonalon
n® (doxepin)
impairrment, deliriu
um and over‐ssedation in th
he elderly.7 Doxeppin may put th
he patient at increased riskk of engagiing in compleex sleep‐relateed behaviors with no memoory afterwardss (e.g., sleep‐‐driving, preparing and eaating food, making phone calls or having sex.)10 Contrainndicated in paatients with siignificant renal ment (i.e., CrCl of less than 60 milliliters//minute) or impairm
with clinnically significant elevated serum creatin
nine due to paired excretio
on. Elderly increaseed risk of toxiccity from imp
acrodantin® o
or Macrobid® (nitrofuranto
oin) patients have higher risk of develo
Furaadantin®, Ma
oping acute, ssubacute or chronnic pulmonaryy reactions. Faatalities havee been reportedd. In addition,, hepatotoxiccity and irreveersible 11,12
peripheral neuropathy may occur and can be fatal The medications in the list below are included in the Pharmacy Quality Alliance (PQA) list of High Risk Medications to avoid in the elderly based on recommendations from the American Geriatric Society. Please consider prescribing the formulary or over‐the‐counter (OTC) alternatives if clinically appropriate. High Risk Medications Formulary and OTC Alternative(s) Insomnia medications: Ambien®, Ambien CR®, Edluar®, Intermezzo®, Zolpimist®, Sonata®, zolpidem tartrate, zaleplon, chloral hydrate Antiemetic medications: Antinaus 50®, Phenadoz®, Phenergan®, Promacot®, Promethegan®, Prorex®, Benzacot®, Tigan®, Tebamide®, Arrestin®, Stemetic®, Ticon®, Tribenzagan®, Diclegis®, Unisom®, Aldex AN®, Doxytex®, trimethobenzamide, doxylamine succinate Antidepressants: Elavil®, Vanatrip®, Anafranil®, Silenor®, Prudoxin®, Sinequan®, Zonalon®, Tofranil®, Surmontil®, amitriptyline, clomipramine, doxepin, imipramine Diabetes medications: chlorpropamide Rozerem®, low dose trazodone, melatonin prochlorperazine, ondansetron, granisetron nortriptyline, desipramine, trazodone glimepiride, glipizide Allergy medications: brompheniramine, chlorpheniramine, clemastine, cyproheptadine, dexchlorpheniramine, cetirizine, fexofenadine, loratadine, desloratadine, diphenhydramine, hydroxyzine, triprolidine, doxylamine levocetirizine Urinary tract infection medication: Furadantin®, Macrobid®, Macrodantin®, nitrofurantoin sulfamethoxazole/trimethoprim, ciprofloxacin, levofloxacin, ofloxacin, amoxicillin‐clavulanate, cefdinir, cefaclor, cefpodoxime, cephalexin, ceftriaxone High Risk Medications Anticoagulation medications: Ticlid® ( ticlopidine), Persantine® (dipyridamole) Parkinsons disease medications: Cogentin® (benztropine) Formulary and OTC Alternative(s) clopidogrel, prasugrel, ticagrelor carbidopa/levodopa, ropinirole, pramipexole, entacapone Urinary analgesic: Urelief Plus®, (phenazopyridine‐butabarbital‐ hyoscyamine)
phenazopyridine (Azo®, Uristat®, Pyridium®) Hypertension medications: Aldomet® (methyldopa), Procardia®, Procardia XL®, Afeditab CR®, Nifediac CC®, Nifedical XL®, nifedipine Cardiovascular medication: Digitek®, Digox®, Lanoxicaps®, Lanoxin®, digoxin thiazides such as hydrochlorothiazide; generic ACE inhibitors such as lisinopril, ramipril; generic ARBs such as losartan; beta‐blockers such as atenolol, metoprolol; a calcium channel blocker such as amlodipine Consider lowering dose to 0.125 mg daily or lower aripiprazole, olanzapine, lurasidone, asenapine, haloperidol, iloperidone, paliperidone, quetiapine, risperidone, ziprasidone Antipsychotic medications: Mellaril®, thioridazine Seizures: divalproex, levetiracetam, lamotrigine, Barbituates: carbamazepine Butisol®, Seconal®, Nembutal®, phenobarbital, butabarbital, Difficulty sleeping: Rozerem, low dose trazodone, secobarbital, pentobarbital melatonin buspirone; SSRI such as fluoxetine, or paroxetine; SNRI such as venlafaxine or Cymbalta® Anxiety medications: Mb‐Tab®, Miltown®, Trancot®, meprobamate Dementia medications: Hydergine®, Vasodilan®, ergoloid mesylates, isoxsuprine Hormones: Products containing estrogens with or without progesterone
Pain medications: Demerol®, Meperitab®, Talwin®, meperidine, pentazocine, butalbital/acetaminophen/ caffeine (with or without codeine), butalbital/aspirin/ caffeine (with or without codeine) galantamine, rivastigmine, donepezil For hot flashes: SSRI such as fluoxetine; venlafaxine; gabapentin For bone density: bisphosphonates such as alendronate; raloxifene; calcium; vitamin D For vaginal symptoms or recurrent urinary infections: Estrace® topical cream or Premarin® topical cream Mild to moderate pain: codeine/acetaminophen, celecoxib, topical non‐steroidal anti‐inflammatory (NSAID) such as Voltaren® gel, tramadol Moderate to moderately severe pain: hydrocodone/ acetaminophen, oxycodone/acetaminophen. Mild to m
moderate pain
n: codeine/accetaminophen
n, celecoxib (avoid inn patients with
h heart failuree or high GI/ccardiovascularr risks), toopical non‐steeroidal anti‐infflammatory (NSAID) such a
as Voltarenn® gel, tramad
dol NSAIDs for pain: Indoccin®, Indocin SR®, Tivorbexx®, Acular®, A
Acular LS®, Aculaar PF®,Torado
ol®, Acuvail®, Sprix®, indom
methacin, ketorrolac Skeleetal muscle rellaxants: Somaa®, Vanadom®, Lorzone®, Flexeril®, Amrix®, Fexmid®
®, Robaaxin®, Norflexx®, Orfro®, Orphenate®, Mio‐Rel®, Antifflex®, carisoprrodol, chlorzo
oxazone, cyclo
obenzaprine, meth
hocarbamol, o
orphenadrine
e Baclofeen, tizanidine
Refeerence: 1 Pharmacy Qu
uality Alliancce. Use of Hiigh‐Risk Med
dications in tthe Elderly ((HRM). www
w. pqaalliance.org. Last accessed Jan
nuary 15, 201
14. 2 National Com
mmittee for Quality Assu
urance. HEDIIS 2014. ww
ww.ncqa.org. Last accesseed January 1
15, 2014. 3 Product Information: Am
mbien CR® orral extended
d release tabblets, zolpideem tartrate o
oral extended release tablets. Sano
ofi‐Aventis U
U.S. LLC. Bridggewater, NJ,, 2013. mbien® oral ttablets, zolpiidem tartratte oral tabletts. Sanofi‐Avventis U.S. LLLC. 4 Product Information: Am
Bridgewater,, NJ, 2013. 5 U.S. Food and Drug Adm
ministration. Risk of next‐‐morning im
mpairment affter use of in
nsomnia drugs; FDA requires lowe
er recomme
ended doses for certain d
drugs containing zolpideem. Drug Saffety Communications. January & M
May 2013. ARTing and SSTOPPing Me
edications inn the Elderly.. Pharmacistt’s Letter/Preescriber’s 6 PL Detail‐Document, STA
Letter. Septe
ember 2011. 7 American Ge
eriatrics Society 2012 Be
eers Criteria Update Expeert Panel. Am
merican Gerriatrics Socieety Updated Beers Criteria for Potentially Inappro
opriate Mediication Use iin Older Adu
ults. J Am Geeriatr Soc. 20
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31. 8 Product Information: am
mitriptyline h
hcl oral tablets.Vintage PPharmaceuticcals, LLC, Hu
untsville, AL, 2006. 9 Product Information: hyd
droxyzine paamoate oral capsules. W
Watson Laborratories, Inc, Corona, CA,, 2003. 10 Product Information: SILLENOR(R) oraal tablets, do
oxepin oral ttablets. Somaxon Pharm
maceuticals, Inc., San Diego, CA, 20
010. n the elderly.. Clin Geriatrr Med. 20099;25:423‐36. 11 Nicolle LE. Urinary tract infections in
12 Gupta K, Hooton TM, Naaber KG, et al. Internatiional clinicall practice gu
uidelines for the treatmeent of acute
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Hill Circle | Ch
hattanooga, TTN 37402 bcbstmedicaare.com ueCross BlueSShield of Tenn
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nd BlueCare P
Plus Blu
Te
ennessee, Ind
dependent Licensees of tthe BlueCrosss BlueShield A
Association
Y001
14_15_HRMA
ALTMA (10/2014)