You are on page 1of 16

PL Detail-Document #280610

−This PL Detail-Document gives subscribers
additional insight related to the Recommendations published in−

PHARMACIST’S LETTER / PRESCRIBER’S LETTER
June 2012

Potentially Harmful Drugs in the Elderly: Beers List
In 1991, Dr. Mark Beers published a methods paper describing the development of a consensus list of
medicines considered to be inappropriate for long-term care facility residents.1 The Beers criteria or
“Beers list” is now in its fourth permutation.2 The latest version is intended for use by clinicians in
outpatient as well as inpatient settings to improve the care of patients age 65 years and older. The new
version includes medications that should be used with extra caution, as well as medications that should be
avoided, either in all elderly or in certain populations.2 An additional tool for improving prescribing in the
elderly is the START and STOPP criteria. Neither has been convincingly shown to reduce morbidity,
mortality, or cost but are often used by organizations as measures of the quality of prescribing. Use these
criteria to identify red flags that might require intervention or close monitoring, not the final word on
medication appropriateness. Prescribing decisions must be individualized.2 The following chart
summarizes the updated Beers list and provides potential therapeutic alternatives and other
considerations.
C=Drug on the “to be used with caution” list.2
H=High-risk meds in the elderly per CMS Quality Measure (CMS156v1) and Star Ratings Measure (D11). f

Drug2

Concern(s)2

Considerations

Analgesics (also see NSAIDs, below)
Meperidine (H)
(Demerol)

Neurotoxicity, delirium,
cognitive impairment, poor
efficacy (orally)

Pentazocine (H)
(Talwin)

More CNS effects (e.g.,
confusion, hallucinations) than
other opioids; ceiling to
analgesic effect

Tramadol (Ultram, etc) Lowers seizure threshold. May
in patients with seizures be acceptable if seizures are
well controlled and alternative
cannot be used.2

Alternatives for mild to moderate pain:
codeine, acetaminophen, short-term
NSAID (see NSAIDs, below), topical
capsaicin or NSAIDs (osteoarthritis),
salicylates3,4,10,26
Alternatives for moderate to moderately
severe pain: hydrocodone/APAP
(Vicodin, etc [U.S.]), oxycodone/APAP
(Percocet, etc)4
Alternatives for neuropathic pain:
duloxetine, venlafaxine, pregabalin,
gabapentin (see Anticonvulsants, below),
topical lidocaine, capsaicin, desipramine,
nortriptyline (see Tricyclics, below)6,10

Antidepressants
Bupropion in patient
with seizures

Lowers seizure threshold

Alternatives for depression: SSRI, SNRI,
mirtazapine5

Mirtazapine
(Remeron) (C)
Paroxetine in patient
with dementia,
cognitive impairment,
chronic constipation,
BPH, delirium, or high
risk of delirium

SIADH

Check sodium when starting or changing
dose.2
Alternatives: another SSRI, SNRI,
mirtazapine, bupropion (not for anxiety)5

Cause or worsen delirium,
worsen constipation, worsen
urinary retention, worsen
cognitive impairment due to
anticholinergic activity

More. . .
Copyright © 2012 by Therapeutic Research Center
P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com ~ www.pharmacytechniciansletter.com

cognitive impairment. urinary retention). Benzodiazepine Toolkit.com ~ www. delirium.S. fexofenadine (Allegra).5 ramelteon (U. capsaicin6. clemastine. orthostatic hypotension Alternative tricyclics: nortriptyline (Aventyl.g. diphenhydramine (oral).pharmacytechniciansletter. below). constipation). Box 8190. confusion. doxepin (>6 mg/day). low-dose trazodone. delirium. mirtazapine.g. constipation. hydroxyzine triprolidine Alternative antihistamines: cetirizine. cognitive impairment.pharmacistsletter. dry mouth. Xyzal) More. dexbrompheniramine. and our PL Chart. .. cognitive impairment. trimipramine Tricyclic antidepressants in patient with dementia. desloratadine (Clarinex [U. clearance reduced in elderly Diphenhydramine may be appropriate in some situations (e. worsen urinary retention. zolpidem. low-dose doxepin. dexchlorpheniramine. BPH. or history of falls or fractures Anticholinergic effects (e.O.g.]. carbinoxamine.S. CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 www. levocetirizine (U. short-term use of eszopiclone. pregabalin. worsen cognitive impairment.com . syncope. or zaleplon (see entries under Hypnotics. tertiary (H): amitriptyline. topical lidocaine. cyproheptadine. syncope.S. chronic constipation. falls Alternatives for depression: SSRI.prescribersletter.. Copyright © 2012 by Therapeutic Research Center P. falls Tricyclic antidepressant.2 Anticholinergic effects (e. loratadine (Claritin. dry mouth. trazodone Cause or worsen delirium. delirium. mirtazapine..10 Alternatives for insomnia: nondrug therapy. . Stockton. worsen constipation. bupropion5 SSRIs in patient with history or falls or fracture Unsteady gait. Aerius [Canada]).2 Alternatives: SNRI. severe allergic reaction).). doxylamine. SNRI. below. venlafaxine. for geriatric dosing) Antihistamines Anticholinergic antihistamines (H): Brompheniramine. high risk of delirium. etc). psychomotor impairment. desipramine. imipramine. confusion. sedation.(PL Detail-Document #280610: Page 2 of 16) Drug2 Concern(s)2 Considerations SSRI or SNRI (C) SIADH Check sodium when starting or changing dose. bupropion5 Tricyclic antidepressant (C) SIADH Check sodium when starting or changing dose. gabapentin (see Anticonvulsants. etc).com ~ www. clomipramine.. Alternatives for neuropathic pain: duloxetine. chlorpheniramine. unsteady gait.

delirium. ARB. amiloride. urinary incontinence Alternative antihypertensives: thiazide.com ~ www. or combination7 Antihypertensives Alpha-blockers (doxazosin [Cardura]. or combination7 Antiplatelet Agents and Anticoagulants Aspirin for primary prevention in patients age 80 years and up (C) Dabigatran in patients >75 years of age. BPH. ACE inhibitor. Aerius [Canada]). worsen constipation.e.8 Alternative antihypertensives: thiazide. as first-line antihypertensive Guanabenz (H) Guanfacine (H) Methyldopa (H) Nifedipine.com ~ www. bradycardia.)33 Alternative: warfarin More. cognitive impairment. dabigatran contraindicated if CrCl <30 mL/min.]. CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 www. beta-blocker. frequent potassium monitoring. myocardial ischemia Orthostatic hypotension.prescribersletter. beta-blocker. worsen urinary retention Alternative antihistamines: cetirizine. lack of efficacy/safety evidence in CrCl<30 mL/min Use with caution in this population. . ACE inhibitor. .O.1 mg (H) Triamterene in patients with CrCl <30 mL/min.2 Use with caution in this population.pharmacytechniciansletter. short-acting (H) Reserpine >0. desloratadine (Clarinex [U.. ARB. fexofenadine (Allegra).. and in patients with CrCl <30 mL/minc (C) Lack of evidence of benefit for primary prevention in patients 80 years and older Higher bleeding risk in patients 75 years of age and older. Box 8190.pharmacistsletter. CNS adverse effects Kidney injury More frequent episodes of syncope Use potassium-sparing diuretics (e. chronic constipation. bradycardia.S. Stockton.2 (In Canada. calcium channel blocker. bradycardia. slow titration) if CrCl <30 mL/min. or high risk of deliriumb Concern(s)2 Considerations Cause or worsen delirium.(PL Detail-Document #280610: Page 3 of 16) Drug2 Loratadine in patient with dementia. levocetirizine (U. Xyzal) Orthostatic hypotension.S. bradycardia. prazosin [Minipress]. CNS adverse effects Orthostatic hypotension. terazosin [Hytrin]) Clonidine (Catapres). CNS adverse effects Hypotension. Vasodilators in patient with history of syncope (C) Orthostatic hypotension. calcium channel blocker.g.com . CNS adverse effects Orthostatic hypotension. spironolactone) with caution (i. CNS adverse effects Orthostatic hypotension. Copyright © 2012 by Therapeutic Research Center P. bradycardia.. cognitive impairment. low dose.

. SIADH Check sodium when starting or changing dose. or Parkinson’s disease Unsteady gait. Latuda). worsen constipation. chronic constipation. Box 8190.pharmacistsletter. Stockton. history of fall or fracture.S. for alternatives. worsen cognitive impairment. syncope. unless nondrug therapy has failed and patient may harm self or others Stroke.S.O.S.S. high risk of delirium. worsen Parkinson’s disease Chlorpromazine in patient with dementia. BPH.pharmacytechniciansletter. .com ~ www. Antipsychotic in patient with dementia.2 See our PL Chart. Fanapt). More. CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 www. lowers seizure threshold Antipsychotics Continued… All antipsychotics associated with increased stroke and mortality risk when used to treat behavioral problems in elderly with dementia. oral short-acting (H) (Persantine [U. chronic constipation. worsen constipation. Pharmacotherapy of Dementia Behaviors. Quetiapine or clozapine may be the best choice for Parkinson’s disease patients if antipsychotic needed. for dementia-related behavioral problems. asenapine (Saphris). Alternatives (less anticholinergic): aripiprazole (Abilify). cognitive impairment. haloperidol. ziprasidone (Geodon [U. low-dose aspirin. cognitive impairment. syncope. or cilostazol9 Prasugrel (Effient) (C) Bleeding risk Use caution in patients 75 years of age and older. delirium. aspirin/dipyridamole (Aggrenox)(preferred).com ~ www. cognitive impairment..]. ticagrelor (Brilinta)(post-ACS)31 Antipsychotics (any).com . quetiapine. delirium. risperidone. worsen urinary retention. Benefit may balance bleeding risk in patients with high cardiac risk. ticagrelor (Brilinta)(post-ACS) Ticlopidine (Ticlid) (H) Safer alternatives available Alternatives: clopidogrel (Plavix). orthostatic hypotension For secondary prevention of noncardioembolic stroke or TIA: clopidogrel (Plavix) (preferred).(PL Detail-Document #280610: Page 4 of 16) Drug2 Concern(s)2 Considerations Dipyridamole. paliperidone (Invega). All antipsychotics associated with increased stroke and mortality risk when used to treat behavioral problems in elderly with dementia. lurasidone (U. death.2 See our PL Chart. Pharmacotherapy of Dementia Behaviors. Copyright © 2012 by Therapeutic Research Center P. or seizures Orthostatic hypotension.]) More effective options available. prasugrel (Effient)(post-ACS) (C). bradycardia. iloperidone (U. falls. for alternatives. May be acceptable for patient with seizures if seizures are well controlled and safer alternative cannot be used. Alternatives: clopidogrel (Plavix).prescribersletter. .

com . or seizures Fluphenazine in patient with dementia. Fanapt). Pharmacotherapy of Dementia Behaviors.]. worsen constipation.]. CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 www. Alternatives (less anticholinergic): aripiprazole (Abilify).. BPH.pharmacistsletter. Pharmacotherapy of Dementia Behaviors. for alternatives. worsen constipation. cognitive impairment. worsen constipation. iloperidone (U. . cause or worsen delirium. Alternatives (less anticholinergic): aripiprazole (Abilify). chronic constipation. worsen cognitive impairment. ziprasidone (Geodon [U. delirium. chronic constipation. asenapine (Saphris).prescribersletter. cognitive impairment. lowers seizure threshold Cause or worsen delirium. asenapine (Saphris).S.com ~ www. paliperidone (Invega). BPH.S. delirium. worsen cognitive impairment.. worsen urinary retention May be acceptable if seizures are well controlled and alternative cannot be used. Clozapine (Clozaril) in patient with dementia. Latuda).2 See our PL Chart. cognitive impairment. or high risk of delirium Olanzapine (Zyprexa) in patient with syncope.S. Fanapt). Cause or worsen delirium.com ~ www. delirium. haloperidol. or high risk of delirium Cause or worsen delirium. for alternatives. dementia. Copyright © 2012 by Therapeutic Research Center P. Pharmacotherapy of Dementia Behaviors. worsen constipation.pharmacytechniciansletter. worsen urinary retention More. worsen urinary retention. paliperidone (Invega). chronic constipation. quetiapine.S. lurasidone (U.S.S. quetiapine. lurasidone (U. bradycardia.O. cognitive impairment. delirium. worsen cognitive impairment. chronic constipation. or high risk of delirium Perphenazine in patient with dementia.. worsen urinary retention Orthostatic hypotension.. Latuda). delirium. Zeldox [Canada]) All antipsychotics associated with increased stroke and mortality risk when used to treat behavioral problems in elderly with dementia. continued Considerations Zeldox [Canada]) All antipsychotics associated with increased stroke and mortality risk when used to treat behavioral problems in elderly with dementia. BPH. ziprasidone (Geodon [U. worsen cognitive impairment. Box 8190. . iloperidone (U. BPH. cognitive impairment. for alternatives. chronic constipation.2 See our PL Chart. or high risk of delirium Loxapine (Canada) in patient with dementia. risperidone. haloperidol. high risk of delirium. Zeldox [Canada]) All antipsychotics associated with increased stroke and mortality risk when used to treat behavioral problems in elderly with dementia. risperidone.(PL Detail-Document #280610: Page 5 of 16) Drug2 Concern(s)2 Chlorpromazine. Stockton.2 See our PL Chart.

. confusion. BPH. Pharmacotherapy of Dementia Behaviors. chronic constipation. cognitive impairment..]. orthostatic hypotension. May be acceptable in patient with seizure disorder if seizures are well controlled and alternative cannot be used. for alternatives. Latuda) may pose relatively lower torsades risk vs other antipsychotics based on product labeling and literature review.S. haloperidol..com ~ www. chronic constipation. dry mouth.pharmacistsletter.. risperidone. Zeldox [Canada]) Thiothixene (Navane). worsen cognitive impairment.11 Alternatives (less anticholinergic): aripiprazole (Abilify).2 See our PL Chart. Latuda).. lowers seizure threshold. Box 8190.. More. Zeldox [Canada]) All antipsychotics associated with increased stroke and mortality risk when used to treat behavioral problems in elderly with dementia. delirium. Pharmacotherapy of Dementia Behaviors.S. olanzapine. haloperidol. cause or worsen delirium.) Concern(s)2 Considerations See above See above QT prolongation. Latuda). Alternatives (less anticholinergic): aripiprazole (Abilify). cognitive impairment. quetiapine. or high risk of delirium Lowers seizure threshold.g.S. Stockton. lurasidone (U. worsen cognitive impairment.com ~ www. paliperidone (Invega). asenapine (Saphris).S. dementia. worsen constipation. worsen urinary retention All antipsychotics associated with increased stroke and mortality risk when used to treat behavioral problems in elderly with dementia. quetiapine. delirium. cause or worsen delirium. paliperidone (Invega). and lurasidone (U.S.2 See our PL Chart.pharmacytechniciansletter.].. Fanapt).O. iloperidone (U. or high risk of delirium Thioridazine (H) (U. . Risperidone may pose more moderate risk vs higher-risk atypical antipsychotics. risperidone. Copyright © 2012 by Therapeutic Research Center P. for alternatives. ziprasidone (Geodon [U.S.(PL Detail-Document #280610: Page 6 of 16) Drug2 Pimozide (Orap) in patient with dementia.prescribersletter. urinary retention) Aripiprazole (Abilify). Fanapt). constipation. anticholinergic effects (e. ziprasidone (Geodon [U.com . iloperidone (U.S.S. asenapine (Saphris). in patient with seizure disorder. lurasidone (U. bradycardia. CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 www. BPH.

delirium. haloperidol. Anxiolytics Benzodiazepines (any) for agitation or delirium. ACE inhibitor.pharmacistsletter.2 May worsen heart failure Intermittent claudication: pentoxifylline14 No additional efficacy vs lower doses.].125 mg/day.O. in patient with dementia. unsteady gait.S. with monitoring15 Alternatives for heart failure: Diuretic. propafenone. appropriately titrated beta-blocker16 More. buspirone12 Cardiac Drugs Amiodarone (Cordarone) Antiarrhythmics. worsen cognitive impairment. risperidone. Pletal) in patient with heart failure Digoxin (Lanoxin) doses >0.prescribersletter. cognitive impairment.S. quinidine. in heart failure (H) Diltiazem in patient with systolic heart failure or chronic constipation QT prolongation. pulmonary toxicity Rate control preferred over rhythm control in elderly (better risk/benefit ratio) Rate control preferred for atrial fibrillation. iloperidone (U..pharmacytechniciansletter. buspirone12 Alternatives for anxiety: SSRI. worsen constipation. lurasidone (U. Latuda. quetiapine.S. paliperidone (Invega). toxicity due to reduced renal clearance May worsen systolic heart failure or constipation Rate control preferred for atrial fibrillation.com ~ www. syncope. Zeldox [Canada]) All antipsychotics associated with increased stroke and mortality risk when used to treat behavioral problems in elderly with dementia. aspirin/dipyridamole (Aggrenox)(preferred). falls. or at high risk of delirium Concern(s)2 Cause or worsen delirium. ibutilide. Pharmacotherapy of Dementia Behaviors. accidents.S. BPH. cognitive impairment. firstline for atrial fibrillation: dofetilide. for alternatives. ARB. asenapine (Saphris). sedation Benzodiazepines may be appropriate for severe anxiety. . fractures Dependence.. REM sleep disorders. Box 8190. end-of-life care. ziprasidone (Geodon [U. procainamide.2 See our PL Chart. worsen urinary retention Considerations Alternatives (less anticholinergic): aripiprazole (Abilify). or perioperative anesthesia. Copyright © 2012 by Therapeutic Research Center P. or a history of falls Meprobamate (H) Cognitive impairment. CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 www. SNRI. Stockton. Fanapt). sotalol Cilostazol (U.or hyperthyroidism..com . . low-dose aspirin9 Dose reduction.(PL Detail-Document #280610: Page 7 of 16) Drug2 Trifluoperazine. hypo.2 For secondary prevention of noncardioembolic stroke or TIA: clopidogrel (Plavix) (preferred). or in patients with dementia. benzodiazepine or alcohol withdrawal. chronic constipation. flecainide. Alternatives for anxiety: SSRI. delirium. seizure disorders.com ~ www. SNRI.

13 Alternative antihypertensives: thiazide..com ~ www.S. dihydropyridine calcium channel blocker.2 Hyperkalemia. ACEI. ARB. constipation.prescribersletter. confusion. donepezil. appropriately titrated beta-blocker16 Rate control preferred for atrial fibrillation. ACE inhibitor. dry mouth. . Ebixa [Canada]) Unsteady gait. urinary retention) Worse outcome Rate control preferred for atrial fibrillation.2 Alternatives for Meniere’s disease: Sodium restriction.2 Carbamazepine (C) SIADH Dimenhydrinate in patient with dementia. syncope.e May worsen systolic heart failure or constipation Alternatives for heart failure: Diuretic.com .O.g. cognitive impairment Check sodium when starting or changing dose. worsen urinary retention. ACE inhibitor.e. Acetylcholinesterase inhibitors (e. .S. delirium or high risk of delirium Cause or worsen delirium. or combination7 Negative inotrope. cognitive impairment. chronic constipation. ACE inhibitor. ARB. in patient with syncope Anticonvulsants in patient with history of fall or fracture Orthostatic hypotension or bradycardia Alternative: memantine (Namenda [U. Stockton. especially with NSAID. worsen urinary retention. BPH. cognitive impairment Alternatives for Meniere’s disease: Sodium restriction.. worsen constipation. or potassium supplement Use with caution (i. misc. diuretics18 Meclizine (U. Box 8190. BPH. continued Disopyramide (H) (Norpace [U. Copyright © 2012 by Therapeutic Research Center P. delirium. or high risk of delirium Cause or worsen delirium.2 Consider amiodarone if rhythm control is needed. anticholinergic effects (e. dihydropyridine calcium channel blocker. worsen constipation.pharmacytechniciansletter.com ~ www. frequent potassium monitoring. cognitive impairment.]. Rythmodan [Canada]) Dronedarone (Multaq) in permanent atrial fibrillation or heart failure Spironolactone >25 mg/day in heart failure or CrCl <30 mL/min Verapamil in patient with systolic heart failure or chronic constipation Considerations Alternative antihypertensives: thiazide.) in patient with dementia. etc). falls Acceptable for seizure disorders or if safer alternative cannot be used. beta-blocker. chronic constipation.8. beta-blocker. diuretics18 More. or combination7 Central Nervous System Agents.g. ARB. low dose. CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 www.(PL Detail-Document #280610: Page 8 of 16) Drug2 Concern(s)2 Diltiazem..pharmacistsletter. slow titration) if CrCl <30 mL/min.]. psychomotor impairment. ARB.S.

prescribersletter. . sliding scale Hypoglycemia.2 Alternatives for chronic constipation: fiber.S. dolasetron (Anzemet) More.com ~ www.pharmacistsletter.2 Check sodium when starting or changing dose. Levsin. .com ~ www. Alternatives for nausea: prochlorperazine (see below)..15 gliclazide (Canada)32 Avoid Glucotrol XL (U. Box 8190.) due to hypoglycemia risk. dry mouth. etc). glipizide (Glucotrol [U.g.. Glynase [U. insulin17 Gastrointestinal Drugs Antispasmodics: belladonna alkaloids (Donnatal [U. dicyclomine (Bentyl). granisetron (Kytril).19 Alternative sulfonylureas: Glimepiride (Amaryl).com . premixed insulin daily or twice daily20 Alternatives: metformin (if heart failure stable).S. scopolamine Anticholinergic effects (e.S.S. SIADH5 Glyburide (H) (Diabeta. lactulose Alternatives for diarrhea: loperamide (Imodium.15 gliclazide (Canada)32 Avoid Glucotrol XL (U. other oral agent. urinary retention). Stockton. aluminum hydroxide.S.S. confusion.S.21 Alternatives: antacid or proton pump inhibitor Acceptable for gastroparesis. poor efficacy Pioglitazone (Actos) in heart failure Edema may worsen heart failure Considerations Check sodium when starting or changing dose. CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 www.2 Alternative sulfonylureas: Glimepiride (Amaryl).O. delirium. etc).2 Check sodium when starting or changing dose.S. ondansetron (Zofran). etc).]) Cause or worsen delirium.) due to hypoglycemia risk. questionable efficacy H2-blocker in patient with dementia.]) Prolonged hypoglycemia Insulin.(PL Detail-Document #280610: Page 9 of 16) Drug2 Concern(s)2 Chemotherapy Carboplatin (C) SIADH Cisplatin (C) SIADH Vincristine (C) SIADH Diabetes Drugs Chlorpropamide (H) (Diabinese [U. fluids.S.]).). hyoscyamine (U. worsen cognitive impairment Extrapyramidal side effects.]) Long half-life. delirium. Lax-A-Day [Canada]. tardive dyskinesia Acceptable to reduce oral secretions in palliative care patients. Copyright © 2012 by Therapeutic Research Center P. GLP-1 receptor agonist.]. cognitive impairment. constipation. glipizide (Glucotrol).S. cholestyramine15.19 Alternatives: Basal insulin with or without rapid-acting mealtime insulin. etc). propantheline (U. psyllium. prolonged hypoglycemia. or high risk of delirium Metoclopramide (Reglan [U. polyethylene glycol (Miralax [U.pharmacytechniciansletter.]. clidinium (in Librax).

etc) Trimethobenzamide (H) (U. carpal tunnel syndrome. venlafaxine22. mirtazapine for depressed patient24 Acceptable for moderate to severe hypogonadism. granisetron (Kytril).]. worsen Parkinson’s disease.S. with or without progestin (Premarin. methyltestosterone (U. Euthyrox [Canada]. oral Aspiration Alternatives: fiber. minimal effect on weight Testosterone. liberalizing food choices. worsen incontinence.]. layered clothing). gabapentin. granisetron (Kytril). raloxifene (Evista) Vaginal symptoms. not cardioprotective. arthralgia.S.. . clearance reduced in elderly Extrapyramidal side effects. granisetron (Kytril). gynecomastia. ondansetron (Zofran). fluids. dolasetron (Anzemet) Promethazine (H) Anticholinergic effects (e. transdermal). except after pituitary removal Edema.S. worsen constipation.(PL Detail-Document #280610: Page 10 of 16) Drug2 Concern(s)2 Considerations Mineral oil. vitamin D.S.com ~ www.O.) Thyroid. insulin resistance. environment conducive to optimal oral intake. lacks cognitive protection Hot flashes: nondrug therapy (cool environment.com ~ www. Box 8190. nutritional supplements or snacks between meals. . chronic constipation. dry mouth. confusion. cognitive impairment. endometrial cancer.com . little effect on muscle mass Alternatives: feeding assistance.prescribersletter. Tigan) Alternatives for nausea: prochlorperazine (see above). Copyright © 2012 by Therapeutic Research Center P. liberalizing food choices. Stockton.. LaxA-Day [Canada]. cardiac events Alternatives: feeding assistance.g. etc) Cause or worsen delirium Alternatives depend on indication. etc). environment conducive to optimal oral intake. delirium. dolasetron (Anzemet) Corticosteroids in patient with delirium or high risk of delirium Estrogen (H) (oral. worsen Parkinson’s disease Alternatives for nausea: ondansetron (Zofran). nutritional supplements or snacks between meals. bisphosphonates. polyethylene glycol (Miralax [U. constipation). Parkinson’s disease. recurrent UTI: vaginal estrogen cream2 Growth hormone. psyllium.pharmacytechniciansletter. cognitive impairment.pharmacistsletter. lactulose21 Prochlorperazine in patient with dementia. ondansetron (Zofran). CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 www. desiccated (H) Prostatic hyperplasia.2 Cardiac adverse effects (safer alternatives available) Levothyroxine (Levoxyl [U.23 Bone density: calcium. mirtazapine for depressed patient24 Megestrol (H) Thrombosis. cognitive impairment. poor efficacy Alternatives for nausea: prochlorperazine (see above). or high risk of delirium Cause or worsen delirium. SSRIs. death. dolasetron (Anzemet) Hormones More. Breast cancer. delirium.

motor vehicle accidents.) More. short-term use of eszopiclone (U.S. fractures.). fractures. delirium. for geriatric dosing) Alternatives for insomnia: nondrug therapy.S. delirium.pharmacistsletter.].5 low-dose doxepin.).prescribersletter. minimal benefit Zolpidem (Ambien [U. Sublinox [Canada]. below. Box 8190. risk of overdose (narrow therapeutic window) Eszopicloned (U. low-dose trazodone. falls. .5 low-dose doxepin. and our PL Chart. unsteady gait. Copyright © 2012 by Therapeutic Research Center P..S.pharmacytechniciansletter. zolpidem.O.). ramelteon (U. risk of overdose (narrow therapeutic window) Cognitive impairment.com ~ www. cognitive impairment. fractures. zaleplon (U. delirium.S. motor vehicle accidents. falls. Sonata) use for more than 90 days (H) or in patient with history of falls or fracture Cognitive impairment. minimal benefit Alternatives for insomnia: nondrug therapy. falls. or zopiclone (Canada) (see entries under Hypnotics. Lunesta) use for more than 90 days (H) or in patient with history of falls or fracture Cognitive impairment.. fractures Chloral hydrate (H) Tolerance. syncope. syncope. etc) use for more than 90 days (H) or in patients with dementia. minimal benefit Zaleplon (U. unsteady gait. unsteady gait. low-dose trazodone. . delirium. Benzodiazepine Toolkit.(PL Detail-Document #280610: Page 11 of 16) Drug2 Concern(s)2 Considerations Hypnotics Barbiturates (any) (H) Benzodiazepines (any) for insomnia Dependence. unsteady gait.com ~ www.S.S.com . syncope. delirium. ramelteon (U. accidents. Stockton.S. or history of falls or fracture Cognitive impairment. motor vehicle accidents. syncope. tolerance. falls. delirium. CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 www.

cyclobenzaprine (Flexeril [U. worsen constipation. physiotherapy. celecoxib (except in heart failure. proper seating and footwear.pharmacytechniciansletter. above. not recommended to prevent antipsychoticassociated extrapyramidal effects.S.com ~ www. delirium. constipation. cognitive impairment. short-term NSAID (see NSAIDs. topical capsaicin or NSAIDs (osteoarthritis). CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 www. delirium. sedation. chronic constipation. orphenadrine (Norflex) Anticholinergic effects (e. BPH.com .25 atypical antipsychotic (see Antipsychotics section. worsen urinary retention. nerve blocks15 NSAIDs Aspirin at doses over 325 mg daily (chronic use) Celecoxib in heart failure Edema may worsen heart failure More. salicylates3. correct seating and footwear15. Copyright © 2012 by Therapeutic Research Center P.]).S.25 atypical antipsychotic (see Antipsychotics section.(PL Detail-Document #280610: Page 12 of 16) Drug2 Concern(s)2 Considerations Musculoskeletal Agents Benztropine (H) (oral.. not very effective for Parkinson’s disease Decrease antipsychotic dose or discontinue. not recommended to prevent antipsychoticassociated extrapyramidal effects.. U. Box 8190. urinary retention). . application of heat or cold. Soma).O.S.prescribersletter. tizanidine [see below]). baclofen. cognitive impairment. also consider GI and CV risk).4.. chlorzoxazone.) Delirium. nerve blocks15 Trihexyphenidyl (H) Delirium. worsen urinary retention. tramadol.S.g. methocarbamol (Robaxin). Stockton. not very effective for Parkinson’s disease Decrease antipsychotic dose or discontinue. or high risk of delirium Cause or worsen delirium. Skelaxin). cognitive impairment.pharmacistsletter.10. metaxalone (U. above.26 Continued… For spasticity: antispasmodics (e. worsen urinary retention Alternatives: treat contributing problems.25 Tizanidine (Zanaflex) in patient with dementia.. worsen cognitive impairment. confusion. fractures.com ~ www. baclofen. worsen constipation. .a Alternatives for mild to moderate pain: codeine. for more information) Muscle relaxants (H): carisoprodol (U. dry mouth. questionable efficacy at doses tolerated in elderly Alternatives: treat underlying problem. for more information) GI bleeding/peptic ulcer in high-risk patients. worsen cognitive impairment.g. acetaminophen. below). worsen constipation.

oxycodone/APAP (Percocet.. prednisone28 If chronic NSAID use is necessary. Kidney injury in advanced renal disease.com .pharmacistsletter.(PL Detail-Document #280610: Page 13 of 16) Drug2 Concern(s)2 Indomethacin (H) GI bleeding/peptic ulcer in high-risk patients. topical lidocaine. use in patients with heart failure. colchicine. delirium. worsen cognitive impairment Acceptable to reduce oral secretions in palliative care patients.38 Respiratory Drugs Anticholinergics.inhaled corticosteroid29 Atropine or homatropine in patient with dementia.g.prescribersletter.a Edema may worsen heart failure.2 Or use celecoxib (except in heart failure. etc). celecoxib (except in heart failure. avoid ketorolac and indomethacin.10 Alternatives for coronary event prevention: aspirin 81 mg (see aspirin under Antiplatelet agents.com ~ www.com ~ www. high risk of delirium Anticholinergic effects (e. for more information)27 Alternatives for acute gout: alternative NSAID (i. ipratropium) in men with BPH Urinary retention Alternatives for COPD: albuterol asneeded. confusion. Stockton. Edema may worsen heart failure. . above). NSAIDs. GI bleeding/peptic ulcer in high-risk patients. CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 www. not indomethacin or ketorolac).pharmacytechniciansletter. constipation. capsaicin. nortriptyline (see Tricyclics. pregabalin. urinary retention). etodolac.e. misoprostol or proton pump inhibitor). diclofenac. ibuprofen. also consider GI and CV risk). non-COX-2 selective (e. and use gastroprotection (i.. dry mouth. chronic constipation.a Has more adverse effects than other NSAIDs.S.g. Copyright © 2012 by Therapeutic Research Center P. nabumetone. gabapentin (see Anticonvulsants. long-acting beta-2 agonist with albuterol as needed +/.. also consider GI and CV risk). cognitive impairment. venlafaxine. etc [U. meloxicam. nasal steroids30 More. worsen constipation.e.. above)6. inhaled (tiotropium.O. chronic use. Box 8190.2 Phenylephrine in patient with insomnia CNS stimulation Alternatives: saline nasal spray or irrigation.a Edema may worsen heart failure. delirium. Ketorolac (H) GI bleeding/peptic ulcer in high-risk patients.]). above. desipramine. . etc)4 Alternatives for neuropathic pain: duloxetine. or use in patients with Class IV or V chronic kidney disease Considerations Alternatives for moderate to moderately severe pain: hydrocodone/APAP (Vicodin.

but prudent to consider same precautions as for eszopiclone. See our PL Charts. Vasodilators (CNS) Ergot mesylate (H) Isoxsuprine (H) Lack of efficacy See our PL Detail-Document. trazodone5 Methylphenidate in patient with insomnia CNS stimulation Alternatives for depression: mirtazapine.S.S. Information and internet links in this article were current as of the date of publication. delirium. trazodone5 Pulmonary toxicity. government agencies. c. long-acting beta-2 agonist with albuterol as needed +/.2 Urinary Drugs Nitrofurantoin.pharmacistsletter. d. . Also use caution with rivaroxaban (Xarelto) in the elderly.37 f. a.com . Stockton.g. trospium. and national organizations. Note that product labeling contraindicates spironolactone in “significant” renal impairment. impairment etc) in patient with dementia.com ~ www. or high risk of delirium See our PL Chart.O. Urinary antimuscarinics Cause or worsen delirium. Box 8190. High-risk: age over 75 years. darifenacin. cognitive impairment. nasal steroids30 Theophylline in patient with insomnia CNS stimulation Alternatives for COPD: albuterol asneeded.36. Our editors have researched the information with input from experts. subscribers. Antimuscarinic Medications for Overactive Bladder (U. Canadian subscribers). Consider trying another agent if constipation occurs.2 Some experts do not feel loratadine exhibits significant anticholinergic activity. cognitive oxybutynin. . More.prescribersletter. (e. subscribers. Users of this PL Detail-Document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical judgments based on the content of this document. CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 www. or antiplatelet agent. e. b.35 Zopiclone (Canada. anticoagulant.com ~ www.pharmacytechniciansletter. inadequate concentration in urine if CrCl <60 mL/min. Choosing a UTI Antibiotic for Elderly Patients and Prevention of Recurrent Urinary Tract Infections (U. Pharmacotherapy of Dementia Behaviors.inhaled corticosteroid29 CNS stimulation For weight control: Diet and lifestyle modification Stimulant Drugs Amphetamines in patient with insomnia Alternatives for depression: mirtazapine. use of systemic corticosteroid. Incidence of constipation differs among antimuscarinics. Canadian subscribers). chronic use (H) or use in patients with CrCl <60 mL/min.. Rhovane. Designated CMS high-risk meds current as of April 2014.(PL Detail-Document #280610: Page 14 of 16) Drug2 Concern(s)2 Considerations Pseudoephedrine in patient with insomnia CNS stimulation Alternatives: saline nasal spray or irrigation. Copyright © 2012 by Therapeutic Research Center P. Imovane) not included in Beers. worsen constipation. chronic constipation.

Executive summary: standards of medical care in diabetes2012. Kroenke K. 13. 8. UCLA Division of Geriatric Medicine. 6. Abraham WT. Christian JB. Bridges R.prescribersletter. Overview of diagnosis and drug treatments of anxiety disorders. http://psychiatryonline.pdf. 9 ed: American College of Chest Physicians evidence-based clinical practice guidelines. et al. Treatment of unintentional weight loss in the elderly.pdf. Diabetes Care 2012. Huang AR. August 2004. Wann LS.com ~ www.61(3):138-45.mcmaster. Arch Intern Med 1991. PL Detail-Document.60:616-31. Agency for Healthcare Research and Quality. Pentoxifylline for intermittent claudication. Alternatives for potentially inappropriate medications in the elderly population: treatment algorithms for use in the Fleetwood Phase III study. 16. 2012). Ouslander JG. American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. http://nationalpaincentre.ca/documents/o pioid_guideline_part_b_v5_6. Pharm.kidney.gov/guidelines/hypertension/jn c7full. 2012). American Diabetes Association. Thurtell MJ. Gayton DC.aspx?bookid=28 &sectionid=1667485#654260. Chou R.O. Pare P. Bair MJ. January 2012. Tamblyn RM. Hickman D.com . Insulin use in patients with type 2 diabetes. Beers MH.123:104-23. Pharmacist's Letter/Prescriber's Letter. et al. O’Donnell MJ. Part B. http://www. http://www. Nutt DJ. Practice guideline for the treatment of patients with major rd depressive disorder (3 Edition). Pharmacist’s Letter/Prescriber’s Letter. Pharmacotherapy of chronic pain: a synthesis of recommendations from systematic reviews. Cameron KA. Abdel-Hadi M. Champion MC.6:3101. Stockton.(PL Detail-Document #280610: Page 15 of 16) Project Leader in preparation of this PL DetailDocument: Melanie Cupp. 11. The American Geriatrics Society 2012 Beers Criteria Update Expert Panel.com ~ www. et al.35(Suppl1):S4-S10. Prolonged hypoglycaemia secondary to extended-release form glipizide. (Accessed May 5. Lung. Hunt SA. 19.com/health/hotflashes/DS01143/METHOD=print. 2011. Evaluation.nih. Senanayake E. CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 www. 14.151:1825-32.19:1011-28. April 30. 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of chronic heart failure in adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the International Society for Heart and Lung Transplantation. Can J Gastroenterol 2007. 17. 20. J Neurol 2011.57:1331-46. J Am Coll Cardiol 2009. (Accessed May 5. including nystagmus. Chin MH.org/content. Pharmacotherapy of vestibular and ocular motor disorders. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc 2012. Shaikh AG. More. et al. 26. Lansberg MC. Choosing nonopioid analgesics for osteoarthritis. Detection. Strupp M. http://www.mayoclinic. National Opioid Use Guideline Group. Antithrombotic and thrombolytic therapy for ischemic stroke: antithrombotic therapy and th prevention of thrombosis. Gen Hosp Psychiatry 2009. 4.. et al. Hot flashes. American Psychiatric Association. (Accessed May 6. and Blood Institute.31:206-19. 5.10:49-56. Curtis AB.1:CD005262.htm. Explicit criteria for determining inappropriate medication use in nursing home residents.156:385-91. CMAJ 1997. Consult Pharm 2004.org/?id=3264&sid=1. Drug-induced Long QT Interval. http://www. Pain management algorithm. 25. et al. National Heart. Circulation 2011. J Fam Pract 2012. Clinician's Guide. 2012). 24.258:1207-22.bjc. BCPS References 1. Menopause management: how you can do better. (Accessed May 5. Defining inappropriate practices in prescribing for elderly people: a national consensus panel. 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (updating the 2006 guideline).org/professionals/KDOQI/guideli nes_bp/guide_12. Cakir M. et al. Akin M. January CT. 2012).21(Suppl B):3B-22B. 2. The Seventh Report of the Joint National Committee on Prevention. 21. Krebs EE.nhlbi.pharmacytechniciansletter. June 11. Chest 2012. 15. Karayalcin U. Recommendations for practice. Dickson GM. . Khatri P.pharmacistsletter.D. 10. 9. Cochrane Database Syst Rev 2012. Salhiyyah K. 18. Canadian guideline for safe and effective use of opioids for chronic non-cancer pain. and Treatment of High Blood Pressure (JNC 7). PL Detail-Document. 2012). McLeod PJ. American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults. March 2009. Box 8190. CNS Spectr 2005. Mayo Clinic staff. 2002. (Accessed May 5. PL Detail-Document. Copyright © 2012 by Therapeutic Research Center P. Pharmacist's Letter/Prescriber's Letter. Vanhaaren A. King V. et al. BJC HealthCare. (Accessed May 5. Guideline 12: use of diuretics in CKD. . 7. Lapane KL. November 2008. 2010. Diabetes Obes Metab 2004. J Am Geriatr Soc 2009.141(Suppl 2):e601S-36S. 2012). 23. June 2009. Rollingher I. October 2010. 3. Recommendations on chronic constipation (including constipation associated with irritable bowel syndrome) treatment. 12.53:e1-e90. K/DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. 22.

effectivehealthcare. 37. 2012). Montreal. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis. 33. PL Detail-Document. P. Product information for Aldactone. Management. 30. PL Detail-Document.goldcopd. Pharmacist’s Letter/Prescriber’s Letter. July 2011. http://www. Pharmacist’s Letter/Prescriber’s Letter. Box 8190. 32. Selecting a Sulfonylurea. Pharmacist’s Letter/Prescriber’s Letter. www. Boehringer Ingelheim Canada. Evidence and Recommendations You Can Trust… 3120 West March Lane.pdf. 38. 36. Pfizer Canada. Vandvik PO.prescribersletter.pharmacistsletter. Revised 2011. May 2012.141(Suppl 2):e637S-68S. NY 10017. Alternatives to pseudoephedrine. (Reference removed from chart April 2014. Potentially Harmful Drugs in the Elderly: Beers List.pharmacytechniciansletter. CA 95208 ~ TEL (209) 472-2240 ~ FAX (209) 472-2249 Copyright  2012 by Therapeutic Research Center Subscribers to the Letter can get PL Detail-Documents. or www. PL Detail-Document. like this one.) 35. Pharmacist’s Letter/Prescriber’s Letter. Bayer. Product monograph for Aldactone. April 2009. Chest 2012. January 2012. on any topic covered in any issue by going to www. Product monograph for Sublinox. 28. Management of Gout. July 2012. 31. Managing NSAID Risks.com. Cite this document as follows: PL Detail-Document. February 2012. Kirkland. http://www. Pharmacist’s Letter/Prescriber’s Letter. Pharmacist’s Letter/Prescriber’s Letter. Lincoff AM.org/uploads/users/files/GOLD _Report_2011_Feb21. Valeant Canada. Pfizer. QC H4R 2P9.com. PL Detail-Document. (Accessed May 7. June 2012. QC H9J 2M5. Product monograph for Pradax. 2010). 9 ed: American College of Chest Physicians evidence-based clinical practice guidelines.gov/ehc/produc ts/2/5/Osteoarthritis_Clinician_Guide.pdf. (Accessed November 8. ON M9W 1G6. August 2011. September 2005. December 2010. 34. Stockton. and Prevention of Chronic Obstructive Pulmonary Disease.(PL Detail-Document #280610: Page 16 of 16) 27. 29. November 2010. New York.ahrq. Toronto. PL Detail-Document. ON L7L 5H4. Primary and secondary prevention of cardiovascular disease: antithrombotic therapy and prevention of th thrombosis. Antiplatelets After Acute Coronary Syndrome or Coronary Stent.com . Gore JM. Product monograph for Xarelto.O. Burlington. et al.