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aspirin-butalbital-caffeine

aspirin-butalbital-caffeine
  • Restricted Medications Non-Formulary
Brand names: Fiorinal
No brands, forms, or strengths have been added for this generic.
Display Analgesics and Antipyretics, Miscellaneous Class: 280892
Medication comments:
Per policy, orders for these non-formulary agents will be changed to formulary equivalents.
Non-Formulary Agent Formulary Equivalent
ASA 325 mg-butalbital 50 mg-caffeine 40 mg (Fiorinal) APAP 325 mg-butalbital 50 mg-caffeine 40 mg (Fioricet)
2023 American Geriatrics Society Beers Criteria® for potentially inappropriate medication use in older adults.
Medication: butalbital (Fioricet, Fiorinal)
Criteria 1: Potentially inappropriate medication use in older adults. (Table 2)
Drug(s) barbiturates
Rationale High rate of physical dependence, tolerance to sleep benefits, greater risk of overdose at low dosages.
Recommendation Avoid
 Quality of evidence: High, Strength of Recommendation: Strong
Medication: aspirin
Criteria 1: Potentially inappropriate medication use in older adults. (Table 2)
Comments for primary prevention of cardiovascular disease
Drug(s) aspirin
Rationale Risk of major bleeding from aspirin increases markedly in older age. Studies suggest a lack of net benefit and potential for net harm when initiated for primary prevention in older adults. There is less evidence about stopping aspirin among long-term users, although similar principles for initiation may apply.
Note: aspirin is generally indicated for secondary prevention in older adults with established cardiovascular disease.
Recommendation Avoid initiating aspirin for primary prevention of cardiovascular disease.
Consider deprescribing aspirin in older adults already taking it for primary prevention.
 Quality of evidence: High, Strength of Recommendation: Strong
 
Comments > 325 mg/day
Drug(s) non-COX-2-selective NSAIDs, oral
Rationale Increased risk of GI bleeding or peptic ulcer disease in high-risk groups, including those >75 years old or taking oral or parenteral corticosteroids, anticoagulants, or antiplatelet agents; use of proton-pump inhibitor or miSOPROStol reduces but does not eliminate risk. Upper GI ulcers, gross bleeding or perforation caused by NSAIDs occur in ~1% of patients treated for 3-6 months and in ~2%-4% of patients treated for 1 year; these trends continue with longer duration of use. Also can increase blood pressure and induce kidney injury. Risks are dose-related.
Recommendation Avoid chronic use unless other alternatives are not effective and the patient can take a gastroprotective agent (proton-pump inhibitor or miSOPROStol).
Avoid short-term scheduled use in combination with oral or parenteral corticosteroids, anticoagulants or antiplatelet agents unless other alternatives are not effective and the patient can take a gastroprotective agent (proton-pump inhibitor or miSOPROStol).
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 
Criteria 2: Potentially inappropriate medication use in older adults due to drug–disease or drug–syndrome interactions that may exacerbate the disease or syndrome. (Table 3)
Comments > 325 mg/day
Drug(s) ⇆ disease or syndrome NSAIDs and COX-2 inhibitors ⇄ Heart failure
Rationale Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 
Comments > 325 mg/day
Drug(s) ⇆ disease or syndrome aspirin ⇄ History of gastric or duodenal ulcers
Rationale May exacerbate existing ulcers or cause new/additional ulcers
Recommendation Avoid unless other alternatives are not effective and the patient can take a gastroprotective agent (i.e., proton-pump inhibitor or miSOPROStol).
 Quality of evidence: Moderate, Strength of Recommendation: Strong
 
Criteria 5: medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults. (Table 6)
Comments > 325 mg/day
CrCl (mL/min) at which action is required <30
Rationale NSAIDs (oral and parenteral) may increase the risk of acute kidney injury and a further decline in kidney function.
Recommendation Avoid
 Quality of evidence: Moderate, Strength of Recommendation: Strong
Last updated: Nov. 2, 2025
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