High Risk Medications in the Elderly Form
High Risk Medications in the Elderly
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High-risk medications are those identified by American Geriatrics Society (AGS) Beers Criteria and by the Pharmacy Quality Alliance as having the potential to cause adverse drug events in older adults due to their pharmacologic properties and the physiologic changes of aging.
The Centers for Medicare and Medicaid Services (CMS) considers the use of high-risk drugs in the elderly an actionable quality concern. Both CMS and the Healthcare Effectiveness Data and Information Set (HEDIS) have quality measures that focus on decreasing the use of high-risk medications in the elderly. The CMS measure is defined as the percentage of members age 65 or older who receive more than two prescription fills of a high-risk medication.
Buckeye Health Plan would like to work with providers to avoid prescribing drugs that may be inappropriate for our members over the age of 65 and work to utilize safer alternatives where possible. The following table displays a list of commonly prescribed high-risk medications and their safer alternatives. A complete list of high-risk medications and their impact on CMS stars ratings can be found on the Pharmacy Quality Alliance website at http://pqaalliance.org/measures/cms.asp.
Buckeye Health Plan is committed to the safety of our Medicare members, which includes providing the most appropriate medications available. Please carefully evaluate whether any of the medications on this list are appropriate for your elderly patients and consider safer alternatives when prescribing.
| Description | High Risk Medications | Reason for Risk | Alternatives* |
|---|---|---|---|
| ANTICHOLINERGICS (EXCLUDES TCAS) | |||
| First-generation antihistamines (as single agent or combination product) | Brompheniramine<br>Carbinoxamine<br>Chlorpheniramine<br>Clemastine<br>Cyproheptadine<br>Diphenhydramine (Oral)<br>Diphenhydramine<br>Doxylamine<br>Hydroxyzine<br>Meclizine<br>Promethazine<br>Triprolidine<br>Debrompheniramine<br>Dexchlorpheniramine<br>Pyrilamine | Highly anticholinergic; clearance reduced with advanced age and tolerance develops when used as hypnotic; greater risk of confusion, dry mouth, constipation, and other anticholinergic effects and toxicity.<br><br>Use of diphenhydramine in situations such as acute treatment of severe allergic reaction may be appropriate. | Anxiety:<br>SSRI<br>Citalopram (Celexa)<br>Escitalopram (Lexapro)<br>Fluoxetine (Prozac)<br>Sertraline (Zoloft)<br><br>SNRI<br>Desvenlafaxine ER (Pristiq)<br>Duloxetine (Cymbalta)<br>Venlafaxine<br>Venlafaxine ER (Effexor XR)<br><br>BUSPIRONE<br><br>Second Generation Antihistamines:<br>Azelastine (Astelin)<br>Cetirizine (Zyrtec)<br>Fexofenadine (Allegra)<br>Levocetirizine (Xyzal)<br>Loratadine (Claritin)<br><br>Intranasal Steroids:<br>Budesonide (Rhinocort)<br>Flunisolide nasal spray<br>Fluticasone (Flonase)<br>Mometasone (Nasonex)<br>Triamcinolone (Nasacort)<br><br>Nausea/vomiting:<br>Ondansetron (Zofran)<br><br>Cough<br>Guaifenesin<br>Dextromethorphan<br>Dextromethorphan/guaifenesin |
| Antiparkinson agents | Benztropine<br>Trihexyphenidyl | Not recommended for prevention of extrapyramidal symptoms with antipsychotics; more effective agents available for treatment of Parkinson’s disease | Drug-induced extrapyramidal symptoms:<br>Amantadine<br><br>Parkinson’s Disease:<br>Amantadine<br>Carbidopa/Levodopa (Sinemet)<br>Carbidopa/Levodopa ER (Sinemet CR)<br>Carbidopa/Levodopa ODT (Parcopa) |
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| Description | High Risk Medications | Reason for Risk | Alternatives* |
|---|---|---|---|
| Antispasmodics | Atropine (excludes ophthalmic)<br>Dicyclomine<br>Scopolamine<br>Belladonna alkaloids<br>Hyoscyamine<br>Cleidinium-chlordiazepoxide<br>Propantheline<br>Methscopolamine | Highly anticholinergic (e.g., confusion, cognitive impairment, delirium, dry mouth, constipation, urinary retention). Uncertain effectiveness. | Irritable bowel syndrome:<br>DIARRHEA:<br>Loperamide<br>Cholestyramine<br>Colestipol<br><br>CONSTIPATION<br>Fiber laxative<br>Metamucil<br>Polyethylene glycol<br><br>Nausea/vomiting:<br>Ondansetron (Zofran)<br><br>Reduction of secretions:<br>Glycopyrrolate |
| ANTITHROMBOTICS | |||
| Antithrombotics | Dipyridamole, oral short-acting (does not apply to the extended-release combination with aspirin) | May cause orthostatic hypotension; more-effective alternatives available; intravenous form acceptable for use in cardiac stress testing | Aspirin/Dipyridamole (Aggrenox)<br>Clopidogrel (Plavix)<br>Prasugrel (Effient)<br>Ticagrelor (Brilinta) |
| ANTI-INFECTIVE | |||
| Anti-infective | Nitrofurantoin (include when cumulative day supply >90 days) | Potential for pulmonary toxicity, hepatotoxicity, and peripheral neuropathy, especially with long-term use; safer alternatives available | Ciprofloxacin (Cipro)<br>Trimethoprim (Proloprim)<br>Trimethoprim/Sulfamethoxazole (Bactrim)<br>Trimethoprim/Sulfamethoxazole (Bactrim DS) |
| CARDIOVASCULAR | |||
| Central alpha blockers | Guanfacine<br>Methyldopa<br>Reserpine (>0.1mg/day)<br>Guanabenz | High risk of adverse CNS effects; may cause bradycardia and orthostatic hypotension; not recommended as routine treatment for hypertension | Thiazide-type diuretics:<br>Chlorthalidone (Thalitone)<br>Hydrochlorothiazide (Microzide)<br>Indapamide (Lozol)<br>Metolazone (Zaroxolyn)<br><br>ACE inhibitors:<br>Benazepril (Lotensin)<br>Captopril (Capoten)<br>Enalapril (Vasotec)<br>Fosinopril (Monopril)<br>Lisinopril (Prinivil, Zestril)<br>Quinapril (Accupril)<br>Ramipril (Altace)<br>Trandolapril (Mavik)<br><br>Angiotensin Receptor Blockers (ARBs):<br>Candesartan (Atacand)<br>Eprosartan (Teveten)<br>Irbesartan (Avapro)<br>Losartan (Cozaar)<br>Telmisartan (Micardis)<br>Valsartan (Diovan) |
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| Description | High Risk Medications | Reason for Risk | Alternatives* |
|---|---|---|---|
| Cardiovascular, other | Digoxin (>0.125 mg/day)<br>Disopyramide<br>Nifedipine, immediate release | Digoxin use in heart failure: Questionable effects on risk of hospitalization and may be associated with increased mortality in older adults with heart failure; higher dosages not associated with additional benefit and may increase risk of toxicity; decreased renal clearance may also lead to increased risk of toxic effects<br><br>Digoxin use in atrial fibrillation: Should not be used as first-line agent because more-effective alternatives exist and it may be associated with increased mortality<br><br>Disopyramide: Potent negative inotrope and therefore may induce heart failure in older adults; strongly anticholinergic; other antiarrhythmic drugs preferred<br><br>Nifedipine IR: Potential for hypotension; risk of precipitating myocardial ischemia | Heart failure: Optimize the following drug classes before using digoxin:<br>ACE inhibitors<br>Aldosterone antagonists<br>Beta blockers<br><br>Atrial fibrillation rate control:<br>Digoxin 0.125mg/day<brDiltiazem (Cardizem)<br>Diltiazem CD (Cardizem CD)<br>Diltiazem ER (Cardizem LA, Tiazac)<br>Diltiazem XT (Diltia XT)<br>Metoprolol tartrate<br>Verapamil (Calan, Isoptin)<br>Verapamil ER (Calan SR, Isoptin SR)<br>Verapamil SR (Verelan)<br><br>Atrial fibrillation rhythm control:<br>Dofetilide (Tikosyn)<br>Flecainide (Tambocor)<br>Propafenone (Rythmol)<br><br>Nifedipine IR alternatives:<br>Amlodipine (Norvasc)<br>Felodipine (Plendil)<br>Nifedipine ER (Procardia XL) |
| CENTRAL NERVOUS SYSTEM | |||
| Antidepressants (alone or in combination) | Amitriptyline<br>Nortriptyline<br>Protriptyline<br>Doxepin (> 6mg/day)<br>Amoxapine<br>Trimipramine<br>Imipramine<br>Desipramine<br>Clomipramine<br>Paroxetine | TCAs: Highly anticholinergic, sedating, and cause orthostatic hypotension; safety profile of low-dose doxepin (6mg/day) is comparable with that of placebo<br><br>Paroxetine: Highly anticholinergic; sedating and can cause orthostatic hypotension | Depression:<br>BUPROPION<br>Bupropion (Wellbutrin)<br>Bupropion SR (Wellbutrin SR)<br>Bupropion XL (Wellbutrin XL)<br><br>SSRI<br>Citalopram (Celexa)<br>Escitalopram (Lexapro)<br>Fluoxetine (Prozac)<br>Sertraline (Zoloft)<br><br>SNRI<br>Desvenlafaxine ER (Pristiq)<br>Duloxetine (Cymbalta)<br>Venlafaxine<br>Venlafaxine ER (Effexor XR)<br><br>Neuropathic pain or pain:<br>Capsaicin topical<br>Gabapentin (Neurontin)<br>Lidocaine<br>Pregabalin (Lyrica)<br><br>SNRI<br>Desvenlafaxine ER (Pristiq)<br>Duloxetine (Cymbalta)<br>Venlafaxine<br>Venlafaxine ER (Effexor XR) |
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| Description | High Risk Medications | Reason for Risk | Alternatives* |
|---|---|---|---|
| Barbiturates | Amobarbital<br>Pentobarbital<br>Phenobarbital<br>Butabarbital<br>Secobarbital<br>Butalbital<br>Mephobarbital | High rate of physical dependence; tolerance to sleep benefits; risk of overdose at low dosages | Headache/migraines:<br>Acetaminophen (Tylenol)<br>Ibuprofen (Advil, Motrin)<br>Naproxen (Aleve)<br>Sumatriptan<br><br>Epilepsy:<br>Lamotrigine (Lamictal)<br>Levetiracetam (Keppra) |
| Nonbenzodiazepine hypnotics (include when day supply is >90 days) | Zopiclone<br>Zolpidem<br>Zaleplon | Benzodiazepine-receptor agonists have adverse events similar to those of benzodiazepines in older adults (e.g., delirium, falls, fractures); increased emergency room visits/hospitalizations, motor vehicle crashes, minimal improvement in sleep latency and duration | Trazodone<br>Rozarem (Ramelteon) |
| Vasodilators for CNS disorders | Ergoloid mesylates<br>Isoxsuprine | Lack of efficacy | Donepezil (Aricept)<br>Galantamine (Razadyne)<br>Rivastigmine (Exelon)<br>Memantine (Namenda)<br>Memantine XR (Namenda XR) |
| Central Nervous System, other | Meprobamate | Meprobamate: High rate of physical dependence; very sedating | Anxiety:<br>SSRI<br>Citalopram (Celexa)<br>Escitalopram (Lexapro)<br>Fluoxetine (Prozac)<br>Sertraline (Zoloft)<br><br>SNRI<br>Desvenlafaxine ER (Pristiq)<br>Duloxetine (Cymbalta)<br>Venlafaxine<br>Venlafaxine ER (Effexor XR)<br><br>BUSPIRONE |
| ENDOCRINE | |||
| Endocrine | Desiccated thyroid/PA (Armour Thyroid)<br>Megestrol<br>Estrogens (with or without progesterone)<br>Climara Pro<br>Alora<br>Oral Estradiol<br>Estropipate<br>Premarin tablets<br>Premphase<br>Prempro<br>Vivelle-Dot<br>*Oral and topical patch products only | Desiccated thyroid: Risk of adverse cardiac effects; safer alternatives available<br><br>Megestrol: Minimal effect on weight; increases risk of thrombotic events and possibly death in older adults<br><br>Estrogens: Evidence of carcinogenic potential (breast and endometrium); lack of cardioprotective effect and cognitive protection in older women | Genitourinary symptoms:<br>Estrace Vaginal Cream<br>Premarin Vaginal Cream<br><br>Vasomotor symptoms:<br>SSRIs<br>Citalopram (Celexa)<br>Escitalopram (Lexapro)<br>Fluoxetine (Prozac)<br>Sertraline (Zoloft)<br><br>SNRIs<br>Desvenlafaxine ER (Pristiq)<br>Duloxetine (Cymbalta)<br>Venlafaxine<br>Venlafaxine ER (Effexor XR)<br><br>Thyroid:<br>Levothyroxine (Synthroid)<br>Liothyronine (Cytomel)<br>Thyrolar<br><br>Anorexia:<br>Dronabinol |
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| Description | High Risk Medications | Reason for Risk | Alternatives* |
|---|---|---|---|
| Sulfonylureas, long-duration | Chlorpropamide<br>Glyburide (as a single agent or in combination product)<br>Glimepiride | Chlorpropamide: Prolonged half-life in older adults; can cause prolonged hypoglycemia; causes syndrome of inappropriate antidiuretic hormone secretion<br><br>Glyburide and Glimepiride: Greater risk of severe prolonged hypoglycemia in older adults | Glipizide (Glucotrol)<br>Glipizide ER (Glucotrol XL)<br>Metformin (Glucophage) |
| ANALGESICS | |||
| NSAIDS | Indomethacin<br>Ketorolac (Oral & parenteral) | Indomethacin: More likely than other NSAIDs to have adverse CNS effects. Of all NSAIDs, indomethacin has the most adverse effects<br><br>Ketorolac: Increases risk of GI bleeding, peptic ulcer disease, and acute kidney injury in older adults | Acetaminophen (Tylenol)<br>Diclofenac<br>Ibuprofen (Advil, Motrin)<br>Naproxen (Aleve) |
| SKELETAL MUSCLE RELAXANTS | |||
| Skeletal Muscle Relaxants (as a single agent or in combination product) | Carisoprodol<br>Cyclobenzaprine<br>Methocarbamol<br>Chlorzoxazone<br>Metaxalone<br>Orphenadrine | Most muscle relaxants are poorly tolerated by older adults because some have anticholinergic adverse effects, sedation, increased risk of fractures; effectiveness at dosages tolerated by older adults questionable | Baclofen (Lioresal)<br>Tizanidine (Zanaflex) |
Abbreviations: TCAs – Tricyclic Antidepressants; ODT – Orally dissolving tablet; ER – Extended-release; CR – Controlled-release; CD – Controlled-delivery; XT – Extended-release; LA – Long-acting; SR – Sustained-release; XL – Extended-release; XR – Extended-release; SSRI–Selective Serotonin Reuptake Inhibitor; SNRI–Serotonin Norepinephrine Reuptake Inhibitors; PA – Prior authorization required for coverage consideration; NSAIDS – Non-steroidal anti-inflammatory drugs
- Listed alternatives covered on formulary without prior authorization; other available alternatives not listed. For most up to date formulary, refer to website https://mmp.buckeyehealthplan.com/content/dam/centene/Buckeye/mmp/pdfs/2018_OH_MMP_Formulary.pdf
** Use only if GFR>30 ml/min and no heart failure; administer with a proton pump inhibitor (PPI) for gastroprotection
*** Avoid in men due to urinary retention
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