HIGH RISK MEDICATIONS IN THE ELDERLY
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Therapeutic
Class
Medication(s)
Reason for Risk
Alternative
Medication
Analgesics
Antiinflammatories
(includes
combination drugs)
APAP-diphenhydramine (Tylenol PM) (Also PQA)
(Beers overall)
• Aspirin >325 mg/day (Beers Drug/Disease in
history of gastric or duodenal ulcers)
• Diclofenac (Voltaren)
• Diflunisal (Dolobid)
• Etodolac (Lodine)
• Ibuprofen (Advil)
• Indomethacin (Indocin) (Also PQA)
• Ketorolac (Toradol) (Also PQA) (Beers overall,
includes parenteral)
• Ketoprofen (Orudis)
• Mefenamic acid (Ponstel)
• Meloxicam (Mobic)
• Nabumetone (Relafen)
• Naproxen (Aleve)
• Oxaprozin (Daypro)
• Piroxicam (Feldene)
• Sulindac (Clinoril)
NSAIDS:
1. Peptic ulcer disease or gastrointestinal bleeding
without H2 antagonist, PPI, or misoprostol
2. moderate-severe hypertension (moderate:
160/100mmHg – 179/109mmHg; severe:
≥180/110mmHg)
3. Heart Failure
4. Long-term use (>3 months) for mild joint pain in
•
Increases risk of GI bleeding/peptic
ulcer disease in high-risk groups:
• >75 years old
• taking oral or parenteral
corticosteroids
• anticoagulants or antiplatelet
agents.
• Use of proton pump inhibitor or
misoprostol reduces but does not
eliminate risk.
• Avoid chronic use unless other
alternatives are not effective and
patient can take gastroprotective
agent (proton-pump inhibitor or
misoprostol)
• Of all the NSAIDs, indomethacin has
the most adverse effects
1. peptic ulcer relapse
2. exacerbation of hypertension
3. exacerbation of heart failure
4. simple analgesics preferable and
usually as effective for pain relief
5. gastrointestinal bleeding
6. deterioration in renal function
7. major systemic corticosteroid sideeffects
8. allopurinol first choice prophylactic
•
Mild pain:
• APAP
Moderate/severe pain:
• tramadol
• morphine sulfate*
• hydrocodone/APAP*
• oxycodone*
• oxycodone/APAP*
• fentanyl patch*
*limit duration
5.
6.
7.
8.
Narcotics
(includes all
combination drugs)
•
•
•
•
1.
2.
3.
4.
osteoarthritis
With warfarin
Chronic Renal Failure (estimated GFR 20-50
mL/min)
Long-term corticosteroids (>3 months) as
monotherapy for rheumatoid arthritis or
osteoarthritis
Long-term NSAID or colchicine for chronic
treatment of gout where there is no
contraindication to allopurinol
APAP/pentazocine (Talacen) (Also PQA) (Beers
overall)
Meperidine (Demerol) (Also PQA) (Beers overall)
(Beers Drug/Disease in delirium)
Naloxone/pentazocine (Talwin NX)
Tramadol (Ultram) (Beers Drug/Disease in
chronic seizures or epilepsy)
Long-term opiates in those with recurrent falls
Use of long-term powerful opiates e.g. morphine
or fentanyl as first line therapy for mildmoderate pain
Regular opiates for more than 2 weeks in those
with chronic constipation without concurrent
use of laxatives
Long-term opiates in those with dementia unless
indicted for palliative care or management of
moderate/severe chronic pain syndrome
drug in gout
•
•
•
•
1.
2.
3.
4.
Enhanced CNS effects: confusion,
hallucinations; falls, fractures;
seizure risk
Pentazocine: CNS adverse effects,
including confusion and
hallucinations, more commonly than
other narcotic drugs; is also a mixed
agonist and antagonist; safer
alternatives available.
Meperidine: Not an effective oral
analgesic in dosages commonly
used; may cause neurotoxicity; safer
alternatives available.
Tramadol: Lowers seizure threshold;
may be acceptable in patients with
well-controlled seizures in whom
alternative agents have not been
effective.
drowsiness, postural hypotension,
vertigo
WHO analgesic ladder not observed
severe constipation
exacerbation of cognitive
impairment
Antihistamines
Mild pain:
• APAP
• Ibuprofen
• meloxicam
Moderate/severe pain:
• Tramadol
• morphine sulfate*
• hydrocodone/APAP*
• oxycodone*
• oxycodone/APAP*
• fentanyl patch*
*limit duration
Antihistamine
(includes
combination drugs)
Phenothiazines in patients with epilepsy
•
•
•
•
•
•
•
•
•
•
Benztropine (Cogentin) (Beers overall)
Brompheniramine (Bromfed, Bromax, Dimetapp,
lodrane, LoHist-12) (Beers overall) (Beers
Drug/Disease in chronic constipation)
Codeine/phenylephrine/promethazine (Beers
Drug/Disease in Parkinson disease/chronic
constipation)
Codeine/promethazine (Beers Drug/Disease in
Parkinson disease/chronic constipation)
Cyproheptadine (Periactin) (PQA) (Beers overall)
(Beers Drug/Disease in chronic constipation)
Dextromethorphan/promethazine(PQA) (Beers
overall) (Beers Drug/Disease in Parkinson
disease/chronic constipation)
Diphenhydramine (Benadryl, Excedrin PM,
Tylenol PM) (PQA) (Beers overall)
Hydroxyzine HCL (Atarax, Vistaril) (PQA) (Beers
overall) (Beers Drug/Disease in chronic
constipation)
Promethazine (Phenergan) (PQA) (Beers overall)
(Beers Drug/Disease in Parkinson
disease/chronic constipation)
Trihexyphenidyl (Artane, Trihexane) (Beers
overall)
•
•
•
•
•
Phenothiazines: may lower seizure
threshold
Clearance reduced with advanced
age
Anticholinergic side effects,
especially with prolonged use (>1
week): worsened cognition &
behavioral problems (especially in
dementia), urinary retention OR
incontinence, confusion, enhanced
sedation, dry mouth, constipation,
and other anticholinergic
effects/toxicity.
Tolerance develops to hypnotic
effect
Use of diphenhydramine may be
appropriate in special situations
such as acute treatment of severe
allergic reaction
•
•
•
fexofenadine
(Allegra)
desloratadine
(Clarinex)
loratadine (Claritin)
Consider a topical
agent, where
appropriate.
Anti-infectives
Anti-infectives
•
Nitrofurantoin (Furadantin, Macrodantin,
Macrobid) (Beers overall) (PQA only includes
when cumulative day supply is >90 days)
•
Nitrofurantoin: nephrotoxicity
Potential for pulmonary toxicity;
safer alternatives
Nitrofurantoin:
• Trimethoprim/sulfa
DS
• Ciprofloxacin
Cardiovascular
Alpha 1 Blockers
•
Doxazosin (Cardura) (Beers Drug/Disease in
Syncope)
•
•
Avoid use as an antihypertensive.
High risk of orthostatic hypotension;
Selective alpha 1
blockers:
Prazosin (Minipress) (Beers Drug/Disease in
Syncope)
• Terazosin (Hytrin) (Beers Drug/Disease in
Syncope)
Alpha Blockers
1. Males with frequent incontinence i.e. one or
more episodes of incontinence daily (Beers
Drug/Disease in Syncope)
2. Long-term urinary catheter in situ (> 2 months)
• Clonidine (Catapres)
• Guanfacine (Intuniv, Tenex) (Also PQA)
• Methyldopa (Aldomet) (Also PQA)
•
Alpha Blockers,
Central
alternative agents have superior
risk/benefit profile.
1. risk of urinary frequency and
worsening of incontinence
2. drug not indicated
•
•
Antiarrhythmics
(Class Ia, Ic, and III)
•
•
•
•
•
•
Amiodarone (Cordarone)
Dofetilide (Tikosyn)
Dronedarone (Multaq) (Beers Drug/Disease in
heart failure)
Flecainide (Tambocor)
Propafenone (Rythmol)
Sotalol (Betapace, Sorine)
•
•
•
•
Anticoagulants
Ticlopidine (Ticlid) (Beers overall)
Dabigatran (Pradaxa) (use with caution)
Dipyridamole (Persantine) as monotherapy for
cardiovascular secondary prevention
• Prasugrel (Effient) (use with caution)
Aspirin:
•
•
•
•
•
High risk of adverse CNS effects; may
cause bradycardia and orthostatic
hypotension
Not recommended as routine
treatment for hypertension. Avoid
Clonidine as a first line
antihypertensive.
Avoid antiarrhythmic drugs as firstline treatment of atrial fibrillation
(AF). Data suggest that rate control
yields better balance of benefits.
Amiodarone: multiple toxicities,
including thyroid disease, pulmonary
disorders, and QT interval
prolongation.
Dronedarone: Worse outcomes have
been reported in patients who have
permanent AF or heart failure.
In general, rate control is preferred
over rhythm control for AF
Ticlopidine: Safer, effective
alternatives available.
Dabigatran: Increased risk of
bleeding compared with warfarin in
adults ≥75 years old; lack of
evidence for efficacy and safety in
patients with CrCl <30 mL/min
•
•
Tamsulosin (Flomax)
Sildosin (Rapaflo)
•
•
•
ACE inhibitors/ARBs
Calcium Channel
Blocker
Beta-Blocker
•
•
•
Beta-Blockers
Diltiazem
Verapamil
Stroke prevention:
• Aspirin
• Clopidogrel (Plavix)
• Aspirin and
extended-release
dipyridamole
(Aggrenox)
Beta Blockers
Cardiovascular,
other
1. no history of coronary, cerebral or peripheral
arterial symptoms or occlusive arterial event
2. To treat dizziness not clearly attributable to
cerebrovascular disease
3. Dose > 150mg day
4. Past history of peptic ulcer disease without
histamine H2 receptor antagonist or Proton
Pump Inhibitor
5. Aspirin and warfarin in combination without H2
antagonist (except cimetidine because of
interaction with warfarin) or PPI
6. Aspirin, clopidogrel (Plavix), dipyridamole, or
warfarin with concurrent bleeding disorder
7. Aspirin for primary prevention of cardiac events
(use with caution)
Warfarin:
8. Longer than 6 months duration for first,
uncomplicated DVT
9. longer than 12 months duration for first
uncomplicated PE
10. Warfarin and NSAID together
1. Non-cardioselective beta-blocker with COPD
2. Beta-blocker in combination with verapamil
3. Beta-blockers in those with diabetes mellitus
and frequent hypoglycemic episodes (i.e. ≥ 1
episode per month)
• Disopyramide (Norpace) (Beers overall)
• Digoxin (>0.125mg/day) (Lanoxin) (STOPP )
•
Dipyridamole: no evidence for
efficacy
• Prasugrel: Increased risk of bleeding
in older adults; risk may be offset by
benefit in highest-risk older patients
(e.g., those with prior myocardial
infarction or diabetes).
1. not indicated
2. not indicated
3. increased bleeding risk, no evidence
for increased efficacy
4. risk of bleeding
5. high risk of gastrointestinal bleeding
6. high risk of bleeding
7. Lack of evidence of benefit versus
risk in individuals ≥80 years old. Use
with caution in adults ≥80 years old.
8. no proven added benefit
9. no proven benefit
10. risk of gastrointestinal bleeding
•
1. risk of bronchospasm
2. risk of symptomatic heart block
3. risk of masking hypoglycemic
symptoms
•
•
Disopyramide may induce heart
failure in older adults; strongly
anticholinergic; other antiarrhythmic
drugs preferred.
Digoxin: In heart failure, higher
dosages associated with no
additional benefit and may increase
risk of toxicity; decreased renal
clearance (estimated GFR
<50ml/min.) may lead to increased
•
Ticagrelor (Brilinta)
Prasugrel (Effient)
Calcium channel
blockers
Vasodilators
• Nifedipine (Procardia) (short-acting only) (PQA)
1. Calcium channel blockers with chronic
constipation (Beers Drug/Disease in chronic
constipation)
2. Use of diltiazem (Cardizem, Cartia Tiazac, Dilt) or
verapamil (Calan, Verelan) with NYHA Class III or
IV heart failure
• Dipyridamole(Persantine)—short-acting
only(Also PQA) (Beers overall)
• Isoxsuprine (Vasodilan) (Also PQA) (Beers
overall)
• Vasodilator drugs in those with persistent
postural hypotension i.e. recurrent > 20mmHg
drop in systolic blood pressure
• Cilostazol in heart failure
risk of toxic effects.
• Potential for hypotension;
constipation; risk of precipitating
myocardial ischemia.
1. may exacerbate constipation
2. may worsen heart failure
•
•
•
•
Orthostatic hypotension; ineffective
for stroke prevention; unproven
and/or questionable efficacy
Dipyridamole: orthostatic
hypotension; more effective
alternatives available; IV form
acceptable for use in cardiac stress
testing.
Isoxsuprine: lack of efficacy
Cilostazol: Potential to promote fluid
retention and/or exacerbate heart
failure.
•
•
Nifedipine ER
Amlodipine
(Norvasc)
Stroke prevention:
• Aspirin
• Clopidogrel (Plavix)
• Aspirin and
extended-release
dipyridamole
(Aggrenox)
• Ticagrelor (Brilinta)
• Prasugrel (Effient)
Central Nervous System
Amphetamines
•
•
•
•
•
•
Anticonvulsants
•
•
•
•
•
•
Amphetamine/dextroamphetamine (Adderall)
(Beers Drug/Disease in insomnia)
Benzphetamine (Didrex)
Dexmethylphenidate (Focalin)
Dextroamphetamine (Dexedrine, ProCentra)
Diethylpropion (Tenuate)
Methylphenidate (Ritalin, Concerta, Daytrana,
Methylin) (Beers Drug/Disease in insomnia)
Pemoline in insomnia
Phendimetrazine (Bontril)
Phentermine(Adipex-P, Suprenza)
Oral decongestants with insomnia
Anticonvulsants in history of falls or fractures
Carbamazepine (Tegretol) (use with caution)
•
CNS stimulation: agitation, insomnia, N/A
hypertension, myocardial ischemia,
dependence, appetite suppression
•
Ability to produce ataxia, impaired
psychomotor function, syncope, and
•
Levetiracetam
(Keppra)
•
Antidepressants
•
•
•
Antipsychotic,
typical
•
•
•
Selective serotonin re-uptake inhibitors (SSRI’s)
with a history of clinically significant
hyponatremia (non-iatrogenic hyponatremia
<130mmol/l within the previous 2 months).
Bupropion in chronic seizures or epilepsy
Mirtazapine (Remeron) (use with caution)
•
Phenothiazines in patients with epilepsy
Antipsychotics, chronic and as-needed use, in
dementia and cognitive impairment/history of
falls or fractures
All antipsychotics with Parkinson disease except
clozapine and quetiapine
•
•
•
•
•
•
•
•
•
•
Chlorpromazine (Thorazine) (Beers Drug/Disease
in Syncope/chronic seizures or
•
epilepsy/delirium)
Fluphenazine (Permitil, Prolixin)
Haloperidol (Haldol)
•
Perphenazine (Trilafon)
Pimozide (Orap)
Thioridazine (Mellaril) (Also PQA) (Beers overall)
(Beers Drug/Disease in Syncope/chronic seizures •
or epilepsy/delirium)
additional falls. Avoid unless safer
alternatives are not available; avoid
anticonvulsants except for seizures
Carbamazepine: May exacerbate or
cause SIADH or hyponatremia; need
to monitor sodium level closely
when starting or changing dosages
in older adults due to increased risk.
Bupropion: Lowers seizure
threshold; may be acceptable in
patients with well-controlled
seizures in whom alternative agents
have not been effective.
SSRIs, SNRIs, TCAs, Mirtazapine: May
exacerbate or cause SIADH or
hyponatremia; need to monitor
sodium level closely when starting or
changing dosages in older adults due
to increased risk. Use with caution.
Phenothiazines: may lower seizure
• Risperidone*
threshold
• Aripiprazole
(Abilify)*
CNS side effects: seizure risk, EPS
effects, tremor, slurred speech,
• Iloperidone
muscular rigidity, dystonia,
(Fanapt)*
bradykinesia, akathisia
• Ziprasidone
Increased risk of stroke and
(Geodon)*
mortality in persons with dementia.
• Paliperidone
Avoid use for behavioral problems of
(Invega)*
dementia unless non-pharmacologic • Quetiapine
options have failed and patient is
(Seroquel)*
threat to self or others.
• Olanzapine
Thioridazine: Highly anticholinergic
(Zyprexa)*
and greater risk of QT-interval
prolongation.
*atypical antipsychotics
Chlorpromazine/thioridazine:
associated w/ increased
Lowers seizure threshold; may be
mortality when used to
1. Neuroleptics as long-term hypnotics (i.e. > 1
month)
2. Long-term neuroleptics ( > 1 month) in those
with parkinsonism
•
3. Neuroleptic drugs in fall prone patients (>1 fall in
the past 3 months)
1.
2.
3.
Antipsychotic,
atypical
Antipsychotics, chronic and as-needed use, in
dementia and cognitive impairment/history of
falls or fractures
• All antipsychotics with Parkinson disease except
clozapine and quetiapine
• Aripiprazole (Abilify)
• Asenapine (Saphris)
• Clozapine (Clozaril) (Beers Drug/Disease in
chronic seizures or epilepsy)
• Iloperidone (Fanapt)
• Lurasidone (Latuda)
• Olanzapine (Zyprexa) (Beers Drug/Disease in
Syncope)
• Paliperidone (Invega)
1. Neuroleptics as long-term hypnotics (i.e. > 1
month)
2. Long-term neuroleptics ( > 1 month) in those
with parkinsonism
3. Neuroleptic drugs in fall prone patients (>1 fall in
the past 3 months)
•
•
•
•
•
1.
2.
3.
acceptable in patients with welltreat behavioral issues
controlled seizures in whom
in elderly w/dementia.
alternative agents have not been
effective.
Parkinson’s: Quetiapine and
clozapine appear to be less likely to
precipitate worsening of Parkinson
disease.
risk of confusion, hypotension,
extra-pyramidal side effects, falls
likely to worsen extra-pyramidal
symptom
may cause gait dyspraxia,
Parkinsonism
Increased risk of stroke and
mortality in persons with dementia.
Avoid use for behavioral problems of
dementia unless non-pharmacologic
options have failed and patient is
threat to self or others.
Clozapine/olanzapine: Lowers
seizure threshold; may be
acceptable in patients with wellcontrolled seizures in whom
alternative agents have not been
effective.
Parkinson’s: Quetiapine and
clozapine appear to be less likely to
precipitate worsening of Parkinson
disease.
risk of confusion, hypotension,
extra-pyramidal side effects, falls
likely to worsen extra-pyramidal
symptom
may cause gait dyspraxia,
Parkinsonism
Barbiturates
•
•
Butalbital (Butisol Sodium) (Beers overall)
Phenobarbital (Luminal, Solfoton) (Also PQA)
(Beers overall)
•
Higher risk of side effects in elderly:
falls, fractures, confusion, cognitive
impairment; dependence
Benzodiazepines
(includes all
combination drugs)
•
Beers Criteria blanket recommends
benzodiazepines as a whole class to avoid (Beers
Drug/Disease in delirium/history of falls or
fractures)
Long term use (>1 month) of long-acting
benzodiazepines and benzodiazepines with longacting metabolites
Alprazolam (Xanax)
Chlordiazepoxide (Librium) (Beers overall)
Chlordiazepoxide/amitriptyline (Limbitrol)
(Beers overall)
Chlordiazepoxide/clidinium (Librax) (Beers
overall)
Clonazepam (Klonopin)
Diazepam (Valium, Diastat) (Beers overall)
Estazolam (Promsom)
Flurazepam (Dalmane) (Beers overall)
Lorazepam (Ativan)
Oxazepam (Serax)
Temazepam (Restoril)
Triazolam (Halcion)
•
Older adults have increased
sensitivity to benzodiazepines and
decreased metabolism of long-acting
agents.
In general, all benzodiazepines
increase risk of cognitive
impairment, delirium, depression,
falls, fractures, respiratory
depression (especially in COPD), and
motor vehicle accidents in older
adults.
Risk of dependence
Avoid benzodiazepines (any type) for
treatment of insomnia, agitation, or
delirium.
Short and intermediate acting: May
be appropriate for seizure disorders,
rapid eye movement sleep
disorders, benzodiazepine
withdrawal, ethanol withdrawal,
severe generalized anxiety disorder,
periprocedural anesthesia, end-oflife care.
Fall Risk: Ability to produce ataxia,
impaired psychomotor function,
syncope, and additional falls;
shorter-acting benzodiazepines are
•
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•
•
For sleep:
• Zolpidem (Ambien)
• Zaleplon (Sonata)
• Eszopiclone
(Lunesta)
• Ramelteon
(Rozerem)
• Behavioral
modification
For anxiety:
• Buspirone (Buspar)
For sleep:
• Zolpidem (Ambien)
• Zaleplon (Sonata)
• Eszopiclone
(Lunesta)
• Ramelteon
(Rozerem)
• Behavioral
modification
Nonbenzodiazepine •
hypnotics (include
when continuous
day supply is >90
•
days)
•
Eszopiclone (Lunesta) (Beers overall) (Beers
Drug/Disease in delirium/history of falls or
fractures)
Zolpidem (Ambien) (Beers overall) (Beers
Drug/Disease in delirium/dementia and
cognitive impairment)/ history of falls or
fractures)
Zaleplon(Sonata) (Beers overall) (Beers
Drug/Disease in delirium/ history of falls or
fractures))
Chloral hydrate (Noctec, Somnote) (Beers
overall)
Central Nervous
System, other
•
TCAs (as a single
agent or as part of
a combination
product)
Phenothiazines in patients with epilepsy
Amitriptyline (Elavil) (Beers overall)
Amitriptyline/chlordiazepoxide (Limbitrol)
Amitriptyline/perphenazine (Etrafon)
Clomipramine (Anafranil) (Beers overall)
Doxepin (Sinequan, Adapin) (>6mg/day) (Beers
overall)
• Imipramine (Tofranil) (Beers overall)
All TCAs:
1. with dementia (Beers Drug/Disease in delirium)
2. with glaucoma
3. with cardiac conductive abnormalities
4. with constipation (Beers Drug/Disease in chronic
constipation)
5. with an opiate or calcium channel blocker
6. with prostatism or prior history of urinary
retention
7. with Syncope (Beers Drug/Disease in Syncope)
8. with history of falls or fractures
9. SIADH or hyponatremia (use with caution)
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1.
2.
3.
4.
5.
6.
7.
8.
9.
not safer than long-acting ones.
Benzodiazepine-receptor agonists
have adverse events similar to those
of benzodiazepines in older adults
(e.g., delirium, falls, fractures);
minimal improvement in sleep
latency and duration. Avoid chronic
use > 90 days
tolerance occurs within 10 days and
risk outweighs the benefits in light of
overdose
SSRIs, SNRIs
Phenothiazines: may lower seizure
threshold
Highly anticholinergic, sedating, and
cause orthostatic hypotension; the
safety profile of low-dose doxepin
(≤6 mg/day) is comparable to that of
placebo.
worsening cognitive impairment
likely to exacerbate glaucoma
pro-arrhythmic effects
likely to worsen constipation
risk of severe constipation
risk of urinary retention
orthostatic hypotension or
bradycardia
Ability to produce ataxia, impaired
psychomotor function, syncope, and
additional falls
May exacerbate or cause SIADH or
hyponatremia; need to monitor
sodium level closely when starting or
changing dosages in older adults due
to increased risk.
Endocrine
Corticosteroids
Estrogens, oral
(includes all
combination drugs)
Hypoglycemics,
oral
Avoid in older adults with or at high
risk of delirium because of inducing
or worsening delirium in older
adults; if discontinuing drugs used
chronically, taper to avoid
withdrawal symptoms.
Beers (Also PQA) does not distinguish between oral • Increased risk of breast and/or
and topical estrogens with or without progesterones
endometrial cancer, not cardio• Conjugated estrogen (Premarin)
protective and may increase risk of
pulmonary embolism, stroke, and
• Conjugated
coronary artery disease
estrogen/medroxyprogesterone(Prempro)
• Avoid oral and topical patch.
• Esterified estrogen (Menest)
• Topical vaginal cream: Acceptable to
• Esterified estrogen/methyltestosterone
use low-dose intravaginal estrogen
(Estratest)
for the management of dyspareunia,
• Estropipate (Ogen)
lower urinary tract infections, and
1. Estrogens with a history of breast cancer or VTE
other vaginal symptoms.
2. Estrogens without progesterone in patients with
• Evidence that vaginal estrogens for
intact uterus
treatment of vaginal dryness is safe
3. Estrogen oral and transdermal (excludes
and effective in women with breast
intravaginal estrogen) in Urinary incontinence
cancer, especially at dosages of
(all types) in women
estradiol <25 mcg twice weekly.
1. increased risk of recurrence
2. risk of endometrial cancer
3. Aggravation of incontinence
•
•
•
Corticosteroids in Delirium
Glyburide (Diabeta, Micronase, glynase) (STOPP)
Pioglitazone/rosiglitazone in heart failure
•
•
•
Higher risk of severe prolonged
hypoglycemia in older adults.
Pioglitazone/rosiglitazone: Potential
to promote fluid retention and/or
exacerbate heart failure.
•
Topical estrogens
For Hot Flashes: *nondrug therapy should be
emphasized.
• Venlafaxine
(Effexor)
• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Desvenlafaxine
(Pristiq)
Bone Density:
• Calcium
• Vitamin D
• Alendronate
(Fosamax)
• Risedronate
(Actonel)
• Ibandronate
(Boniva)
• Raloxifene (Evista)
• Glimepiride (Amaryl)
• Glipizide (Glucotrol)
• Metformin
• DPPIV inhibitors
• Alternative oral
hypoglycemic
classes
Growth hormone
•
Growth hormone (Humatrope, Nutropin,
Genotropin)
•
•
Insulin, sliding scale •
Insulin, sliding scale
Miscellaneous
•
Methyltestosterone (Testred, Android,
Methitest) (Beers overall)
Testosterone
Thyroid, desiccated (Armour Thyroid, Westhroid,
•
Nature-Throid) (Also PQA) (Beers overall)
Megestrol (Megace) (Beers overall)
•
•
•
•
•
•
Impact on body composition is small
and associated with edema,
arthralgia, carpal tunnel syndrome,
gynecomastia, impaired fasting
glucose.
Avoid, except as hormone
replacement following pituitary
gland removal.
Higher risk of hypoglycemia without
improvement in hyperglycemia
management regardless of care
setting.
Methyltestosterone: cardiac side
effects and prostatic enlargement in
men. Avoid unless indicated for
moderate to severe hypogonadism.
Thyroid desiccated: cardiac adverse
events; safer alternatives available.
Megestrol: Minimal effect on
weight; increases risk of thrombotic
events and possibly death in older
adults.
Testosterone:
N/A
Armour Thyroid:
• Levothyroxine
(Synthroid)
• Levoxyl
Gastrointestinal
Antiemetics
•
Scopolamine (Transderm Scop) (Beers overall)
(Beers Drug/Disease in chronic constipation)
•
•
Belladonna
alkaloids
•
•
Atropine
Atropine/hyoscyamine/PB/scopolamine
•
Anticholinergic side effects:
worsened cognition & behavioral
problems (especially in dementia),
urinary retention OR incontinence,
questionable efficacy
Avoid except in short-term palliative
care to decrease oral secretions.
Anticholinergic adverse effects:
worsened cognition & behavioral
•
•
•
•
Ondansetron
Granisetron
Prochlorperazine
Metoclopramide *
*avoid using long
term and/or in
Parkinson’s disease
Constipation:
• psyllium fiber
(includes all
combination drugs)
•
•
•
•
Gastrointestinal
antispasmodics
(Donnatal, Barbidonna, Spasmolin, Chardonna)
Atropine/diphenoxylate (Lomotil)
Belladonna/ergotamine/phenobarbital
(Bellergamin) (Beers overall) (Beers
Drug/Disease in chronic constipation)
Clidinium/chlordiazepoxide (Librax) (Beers
Drug/Disease in chronic constipation)
Hyoscyamine (Anaspaz, Daturine, Hyomax,
Levsin, Levsinex, Symax) (Beers overall) (Beers
Drug/Disease in chronic constipation)
Diphenoxylate, loperamide (Imodium) or codeine
phosphate for
1. diarrhea of unknown cause
2. severe infective gastroenteritis i.e. bloody
diarrhea, high fever or severe systemic toxicity
• Dicyclomine (Bentyl) (Beers overall)
• Anticholinergic antispasmodic drugs with
chronic constipation
•
problems (especially in dementia),
urine retention, agitation & delirium
• Uncertain effectiveness.
• Avoid except in short-term palliative
care to decrease oral secretions.
1. delayed diagnosis, may exacerbate
constipation with overflow diarrhea,
may precipitate toxic megacolon in
inflammatory bowel disease, may
delay recovery in unrecognized
gastroenteritis
2. exacerbation or protraction of
infection
•
•
•
Gastrointestinal,
Miscellaneous
Metoclopramide(Reglan) (Beers Drug/Disease in
Parkinson disease)
1. Prochlorperazine (Stemetil) or metoclopramide
with Parkinsonism
2. PPI for peptic ulcer disease at full therapeutic
dosage for > 8 weeks
3. H2-receptor antagonists in delirium/dementia
and cognitive impairment
•
•
•
•
Anticholinergic side effects:
worsened cognition & behavioral
problems (especially in dementia),
urinary retention OR incontinence,
questionable efficacy
Uncertain effectiveness.
Avoid except in short-term palliative
care to decrease oral secretions.
risk of exacerbation of constipation
Metoclopramide: Can cause
extrapyramidal effects including
tardive dyskinesia; risk may be
further increased in frail older
adults.
• Avoid, unless for gastroparesis.
1. risk of exacerbating Parkinsonism
2. earlier discontinuation or dose
reduction for maintenance/
prophylactic treatment of peptic
•
•
(Metamucil)
Polyethylene glycol
(Miralax)
docusate
Diarrhea:
• loperamide
(Imodium)
• Aluminum
hydroxide
Constipation:
• psyllium fiber
(Metamucil)
• Polyethylene glycol
(Miralax)
Diarrhea:
• loperamide
(Imodium)
• Aluminum
hydroxide
ulcer disease, esophagitis or GERD
indicated
3. H2-receptor antagonists: Avoid in
older adults with or at high risk of
delirium because of inducing or
worsening delirium in older adults; if
discontinuing drugs used chronically,
taper to avoid withdrawal
symptoms.
Musculoskeletal
Skeletal muscle
relaxants
(includes all
combination drugs)
•
•
•
•
•
•
Carisoprodol (Soma) (PQA) (Beers overall)
Chlorzoxazone (Paraflex, Lorzone) (PQA) (Beers
overall)
Cyclobenzaprine (Flexeril) (PQA) (Beers overall)
Metaxalone (Skelaxin) (PQA) (Beers overall)
Methocarbamol (Robaxin) (PQA) (Beers overall)
Orphenadrine (Norflex, Orphengesic) (PQA)
(Beers overall)
•
•
•
Most muscle relaxants poorly
tolerated by older adults, because of
anticholinergic adverse effects,
sedation, increased risk of fractures
Effectiveness at dosages tolerated
by older adults is questionable.
Anticholinergic side effects:
worsened cognition & behavioral
problems (esp. in dementia), urinary
retention OR incontinence,
questionable efficacy (at lower
doses)
Oncology
Antineoplastics
•
•
•
Carboplatin (use with caution)
Cisplatin(use with caution)
vincristine(use with caution)
•
May exacerbate or cause SIADH or
hyponatremia; need to monitor
sodium level closely when starting or
changing dosages in older adults due
to increased risk.
Renal/Urogenital
Antimuscarinics
Bladder antimuscarinic drugs (Beers Drug/Disease in
chronic constipation)
1. dementia
2. chronic glaucoma
3. chronic constipation
1. increased confusion, agitation
2. acute exacerbation of glaucoma
3. Exacerbation of constipation
antimuscarinics overall differ in
incidence of constipation; response
•
•
Baclofen
Tizanidine (Zanaflex)
4. chronic prostatism
Diuretics
• Spironolactone (Aldactone) > 25 mg/day
1. Loop diuretic for dependent ankle edema only
(i.e. no clinical signs of heart failure)
2. Loop diuretic as first-line monotherapy for
hypertension
3. Thiazide diuretic with a history of gout
4. Triamterene (alone or in combination) (Beers
Drug/Disease in chronic kidney disease stages IV
and V)
4.
•
1.
2.
3.
4.
variable; consider alternative agent
if constipation develops.
urinary retention
Spironolactone: Avoid in patients
•
with heart failure or with a CrCl <30 •
mL/min. The risk of hyperkalemia is
higher in older adults taking >25
•
mg/day.
no evidence of efficacy, usually more
appropriate
safer, more effective alternatives
available
may exacerbate gout
May increase risk of acute kidney
injury
compression hosiery
fluid/sodium
restriction
hydrochlorothiazide
Respiratory System
Respiratory,
miscellaneous
1. Theophylline (Aerolate) as monotherapy for
COPD (Beers Drug/Disease in insomnia)
2. Systemic corticosteroids instead of inhaled
corticosteroids for maintenance therapy in
moderate-severe COPD
3. Nebulized ipratropium (Atrovent) with glaucoma
1. safer, more effective alternatives;
narrow therapeutic index
2. unnecessary exposure to long-term
side-effects of systemic steroids
3. may exacerbate glaucoma
Miscellaneous
Duplicate Drug
Classes
•
Any regular duplicate drug class prescription e.g.
two concurrent opiates, NSAID’s, SSRI’s, loop
diuretics, ACE inhibitors. This excludes duplicate
prescribing of drugs that may be required on a
PRN basis e.g. inhaled beta2 agonists (long and
short acting) for asthma or COPD, and opiates
for management of breakthrough pain.
•
optimization of monotherapy within
a single drug class should be
observed prior to considering a new
class of drug
•
inhaled
corticosteroids,
antimuscarinics, or
beta agonists
Antihistamines
Brompheniramine
Carbinoxamine
Chlorpheniramine
Clemastine
Cyproheptadine
Dimenhydrinate
Diphenhydramine
Hydroxyzine
Loratadine
Meclizine
Table 9. Drugs with Strong Anticholinergic Properties
Antiparkinson agents
Skeletal Muscle Relaxants
Benztropine
Trihexyphenidyl
Antidepressants
Amitriptyline
Amoxapine
Clomipramine
Desipramine
Doxepin
Imipramine
Nortriptyline
Carisoprodol
Cyclobenzaprine
Orphenadrine
Tizanidine
Antipsychotics
Paroxetine
Protriptyline
Trimipramine
Chlorpromazine
Clozapine
Fluphenazine
Loxapine
Olanzapine
Perphenazine
Pimozide
Prochlorperazine
Promethazine
Thioridazine
Trifluoperazine
Antimuscarinics (urinary incontinence) Antispasmodics
Darifenacin
Solifenacin
Atropine products
Hyoscyamine products
Fesoterodine
Tolterodine
Belladonna alkaloids
Loperamide
Flavoxate
Trospium
Dicyclomine
Propantheline Br
Oxybutynin
Homatropine
Scopolamine
Compilation of the Anticholinergic Risk Scale, Anticholinergic Drug Scale, and Anticholinergic Burden Scale
The 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 Geriatr Soc 2012; 60(4): 616
National Committee for Quality Assurance/Centers for Medicare and Medicaid Services. High Risk Medications in the Elderly (DAE).
Available at http://www.ncqa.org/tabid/1442/Default.aspx. Accessed 7 August, 2012.
The Pharmacy Quality Alliance. Table HRM-A: High-Risk Medications. Available at: http://www.pqaalliance.org/files/Table-HRMarcticle_JUN2012NL.pdf Accessed 7 August, 2012.
Table 2. 2012 American Geriatrics Society Beers Criteria for potentially Inappropriate Medication Use in Older Adults. The 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 Geriatr Soc 2012; 60(4): 616-631.
Table 3. 2012 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to DrugDisease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome. The 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 Geriatr Soc 2012; 60(4): 616-631.
Appendix 1: STOPP (Screening Tool of Older People’s potentially inappropriate Prescriptions). Appendix to: Gallagher P, O’Mahony
D. STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions): application to acutely ill elderly patients and
comparison with Beers’ criteria. Age Ageing 2008 Nov;37(6):673-679.
BLACK=National Committee for Quality Assurance/Centers for Medicare and Medicaid Services
BLUE=The Pharmacy Quality Alliance
GREEN= 2012 American Geriatrics Society Beers Criteria for potentially Inappropriate Medication Use in Older Adults.
ORANGE= 2012 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to DrugDisease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome
RED= STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions)