Potentially Harmful Drugs in the Elderly: Beers List and More

1 Detail-Document #230907. This Detail-Document accompanies the related article published in . PHARMACIST'S LETTER / PRESCRIBER'S LETTER. September 2007 ~ Volume 23 ~ Number 230907. Potentially Harmful Drugs in the Elderly: Beers List and More (B= Beers list drug; C=Canadian list drug). Drug Concern Alternative Treatment Analgesics Ketorolac (Toradol) GI Mild pain: APAP, short-acting NSAID ( , (B); long-term use (C) ibuprofen). Meperidinea Not effective at (Demerol) (B); long- commonly used oral Moderate or severe pain: morphine, term use (C) doses; confusion, hydrocodone/APAP (Vicodin, etc), oxycodone falls, factures, (OxyContin, etc), oxycodone/APAP (Percocet, etc), dependency, fentanyl patch (Duragesic)19.

2 Withdrawal5,15. Pentazocine (Talwin) More CNS effects Topicals (neuropathic pain, arthritis): lidocaine (B); long-term use (C) ( , confusion, (Lidoderm), capsaicin (Zostrix, etc). hallucinations) than other opioids; ceiling to analgesic effect5. Propoxyphene ( , No better than Darvon, etc) (B) acetaminophen, but has narcotic AE5. Antidepressants Amitriptyline (Elavil) Anticholinergic AE, Tricyclic without active metabolites (Nortriptyline (B, C), doxepin sedation, urinary [Pamelor], desipramine [Norpramin])15. (Sinequan, etc) (B), retention or Trazodone (for insomnia)19. imipramine incontinence, SSRI15. (Tofranil)(C) constipation, Bupropion (Wellbutrin) (for cardiac patient)19.

3 Arrhythmias, falls5,15 Mirtazapine (Remeron) (for insomnia or anorexia)19. Neuropathic pain: topicals (lidocaine [Lidoderm], capsaicin [Zostrix, etc]). Bupropion May cause seizure5 Tricyclic without active metabolites (Nortriptyline (Wellbutrin), seizure [Pamelor], desipramine [Norpramin])15. disorder (B) Trazodone (for insomnia)19. SSRI15. Mirtazapine (Remeron) (for insomnia or anorexia)19. Fluoxetine (Prozac) Long half-life; SSRI with shorter half-life ( , escitalopram used daily (B) agitation, insomnia, [Lexapro], sertraline [Zoloft]). anorexia5. Tricyclic for Fall risk; urinary SSRI, with blood pressure monitoring15. depression in patient retention; worsening with postural glaucoma, heart hypotension, BPH, block15.

4 Glaucoma, heart block (C). More.. Copyright 2007 by Therapeutic Research Center Pharmacist's Letter / Prescriber's Letter ~ Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249. ~ (Detail-Document #230907: Page 2 of 12). Drug Concern Alternative Treatment Antidepressants, cont. Tricyclic in patient Urinary retention or Antidepressant with little anticholinergic or alpha- with stress incontinence5 blocking effect ( , citalopram [Celexa]), bupropion incontinence or [Wellbutrin]). bladder outflow obstruction (B). SSRIs in patient with May cause or worsen Tricyclic without active metabolites (Nortriptyline SIADH (B) SIADH5 [Pamelor], desipramine [Norpramin])15.

5 Trazodone (for insomnia)19. Bupropion (Wellbutrin) (for cardiac patient)19. Mirtazapine (Remeron) (for insomnia or weight loss)19. SSRI in patient on Enhanced SSRI side Avoid combination. If switching from MAOI to MAOI (C) effects15 another antidepressant, ensure a 14-day washout. If switching from another antidepressant to an MAOI, minimum washout is 2 weeks for drug without long half-life and 5 weeks for drug with long half-life ( , fluoxetine).30. Antihistamines Antihistamines, anticholinergic Anticholinergic AE, Cetirizine (Zyrtec), fexofenadine (Allegra), (B): urine retention, loratadine (Claritin), desloratadine Chlorpheniramine (Chlor- confusion, sedation5 (Clarinex), levocetirizine (Xyzal), low-dose Trimeton, etc), diphenhydramine19,26.

6 Cyproheptadine (Periactin), Dexchlorpheniramine (Polaramine), Diphenhydramine (Benadryl, etc), Hydroxyzine (Vistaril, Atarax), Promethazine (Phenergan, etc). Antihypertensives Alpha-blockers Hypotension, dry mouth, Thiazide, ACE inhibitor, beta-blocker, (doxazosin [Cardura], incontinence5 calcium channel blocker22. prazosin [Minipress], terazosin [Hytrin])(B). Clonidine (Catapres) Orthostatic hypotension, CNS Thiazide, ACE inhibitor, beta-blocker, (B) AE5 calcium channel blocker22. Ethacrynic acid Hypotension; fluid, electrolyte Furosemide (Lasix), bumetanide (Bumex). (Edecrin) (B) imbalances5. Guanethidine (B) Orthostatic hypotension, Thiazide, ACE inhibitor, beta-blocker, depression5 calcium channel blocker22.

7 Methyldopa Bradycardia; depression5 Thiazide, ACE inhibitor, beta-blocker, (Aldomet) (B) calcium channel blocker22. Nifedipine, short- Hypotension, constipation5 Another calcium channel blocker or long- acting (Procardia, acting nifedipine Adalat) (B). More.. Copyright 2007 by Therapeutic Research Center Pharmacist's Letter / Prescriber's Letter ~ Box 8190, Stockton, CA 95208. Phone: 209-472-2240 ~ Fax: 209-472-2249. ~ (Detail-Document #230907: Page 3 of 12). Drug Concern Alternative Treatment Antihypertensives, cont. Reserpine > Depression, impotence, Thiazide, ACE inhibitor, beta-blocker, (B, C) sedation, orthostatic calcium channel blocker22.

8 Hypotension, extrapyramidal effects5,15. Thiazide in patient May precipitate gout attack15 ACE inhibitor, beta-blocker, calcium with gout (C) channel blocker22. Antiplatelet Drugs Dipyridamole, short- Ineffective for stroke For stroke prevention: low-dose aspirin, clopidogrel acting (Persantine) prevention & (Plavix), aspirin/dipyridamole (Aggrenox)19. (B); for dementia or dementia; orthostatic stroke (C) hypotension5,15. Ticlopidine (Ticlid) Not more effective Low dose aspirin, clopidogrel (Plavix), (B) than aspirin, but more aspirin/dipyridamole (Aggrenox)19. toxic5. Antipsychotics Mesoridazine CNS AE, seizures, Risperidone (Risperdal)*, haloperidol (Haldol)26.

9 (Serentil) (B), extrapyramidal effects5. Thioridazine *Atypicals associated with increased mortality when (Mellaril) (B) used to treat behavioral problems in elderly with dementia31. Chlorpromazine Fall risk15 Haloperidol, with blood pressure monitoring15. (Thorazine) in patient with history of postural hypotension (C). Clozapine (Clozaril) Lower seizure Risperidone (Risperdal)*, haloperidol (Haldol)26. in patient with threshold5. seizures (B) *Atypicals associated with increased mortality when used to treat behavioral problems in elderly with dementia31. Olanzapine (Zyprexa), Increased appetite, Risperidone (Risperdal)*, haloperidol (Haldol)26.

10 Obesity (B) weight gain *Atypicals associated with increased mortality when used to treat behavioral problems in elderly with dementia31. Thiothixene Lower seizure Risperidone (Risperdal)*, haloperidol (Haldol)26. (Navane), in patient threshold5. with seizure disorder *Atypicals associated with increased mortality when (B) used to treat behavioral problems in elderly with dementia31. More.. Copyright 2007 by Therapeutic Research Center Pharmacist's Letter / Prescriber's Letter ~ Box 8190, Stockton, CA 95208. Phone: 209-472-2240 ~ Fax: 209-472-2249. ~ (Detail-Document #230907: Page 4 of 12). Drug Concern Alternative Treatment Anxiolytics Long-acting Dependence, For anxiety: shorter acting benzodiazepines benzodiazepines (B, depression, prolonged (appropriately dosed) (alprazolam C): sedation, confusion, [Xanax],lorazepam [Ativan], oxazepam [Serax].)