American Geriatrics Society 2023 updated AGS Beers Criteria®
for potentially inappropriate medication use in older adults. Reference |
| Alternate (filtered) views |
| Criteria 1 Potentially inappropriate medication use in older adults. (Table 2) |
| 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) - Drug View |
| 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) - Syndrome View |
| Criteria 3 Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Criteria 4 Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Criteria 5 For medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults. (Table 6) |
| Auxiliary Tables Various supporting detail tables |
| All Criteria view |
| A Beer's Criteria |
| Accupril - see quinapril |
| Aceon - see perindopril |
acetaminophen-codeine (Tylenol #3)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for pain management in the setting if severe acute pain. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
opioids ⇄ benzodiazepines |
| Risk Rationale |
Increased risk of overdose and adverse events. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ gabapentin, pregabalin |
| Risk Rationale |
Increased risk of severe sedation-related adverse events, including respiratory depression and death. |
| Recommendation |
Avoid; exceptions are when transitioning from opioid therapy to gabapentin or pregabalin, or when using gabapentinoids to reduce opioid dose, although caution should be used in all circumstances. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
acetaminophen-HYDROcodone (Lortab, Norco, Vicodin)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for pain management in the setting if severe acute pain. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
opioids ⇄ benzodiazepines |
| Risk Rationale |
Increased risk of overdose and adverse events. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ gabapentin, pregabalin |
| Risk Rationale |
Increased risk of severe sedation-related adverse events, including respiratory depression and death. |
| Recommendation |
Avoid; exceptions are when transitioning from opioid therapy to gabapentin or pregabalin, or when using gabapentinoids to reduce opioid dose, although caution should be used in all circumstances. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
acetaminophen-oxyCODONE (Percocet, Roxicet, Tylox)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for pain management in the setting if severe acute pain. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
opioids ⇄ benzodiazepines |
| Risk Rationale |
Increased risk of overdose and adverse events. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ gabapentin, pregabalin |
| Risk Rationale |
Increased risk of severe sedation-related adverse events, including respiratory depression and death. |
| Recommendation |
Avoid; exceptions are when transitioning from opioid therapy to gabapentin or pregabalin, or when using gabapentinoids to reduce opioid dose, although caution should be used in all circumstances. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
acetaminophen-traMADol (Ultracet)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for pain management in the setting if severe acute pain. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
opioids ⇄ benzodiazepines |
| Risk Rationale |
Increased risk of overdose and adverse events. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ gabapentin, pregabalin |
| Risk Rationale |
Increased risk of severe sedation-related adverse events, including respiratory depression and death. |
| Recommendation |
Avoid; exceptions are when transitioning from opioid therapy to gabapentin or pregabalin, or when using gabapentinoids to reduce opioid dose, although caution should be used in all circumstances. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
acetaZOLAMIDE (Diamox)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Aciphex - see RABEprazole |
| Actos - see pioglitazone |
| Adalat - see NIFEdipine |
| Afinitor - see everolimus |
| Aggrenox - see aspirin-dipyridamole |
| Aldactazide - see spironolactone-hydroCHLOROthiazide |
| Aldactone - see spironolactone |
| Aleve - see naproxen |
alfuzosin (Uroxatral)54321
| Data are limited for selective peripheral alpha-1 blockers (e.g., tamsulosin, silodosin, and others) but may apply as well. |
| |
| 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) |
| Drug(s) ⇆ disease or syndrome |
selective peripheral alpha-1 blockers ⇄ Urinary incontinence (all types) in women |
| Rationale |
Aggravation of incontinence. |
| Recommendation |
Avoid in women. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
selective peripheral alpha-1 blockers ⇄ Loop diuretics |
| Risk Rationale |
Increased risk of urinary incontinence in older women. |
| Recommendation |
Avoid in older women, unless conditions warrant both drugs. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
aliskiren (Tekturna)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Alora - see estradiol |
ALPRAZolam (Xanax)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
benzodiazepines |
| Rationale |
The use of benzodiazepines exposes users to risks of abuse, misuse, and addiction. Concomitant use of opioids may result in profound sedation, respiratory depression, coma, and death.
Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; the continued use of benzodiazepines may lead to clinically significant physical dependence. In general, all benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults.
May be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls.
Benzodiazepines: shorter-acting ones are not safer than long-acting ones.
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
benzodiazepines ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Altace - see ramipril |
| Amaryl - see glimepiride |
| Ambien - see zolpidem |
aMILoride (Midamor)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
potassium-sparing diuretics ⇄ RAS inhibitors (ACEIs, ARBs, ARNIs, aliskiren) |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| 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) |
| CrCl (mL/min) at which action is required |
<30 |
| Rationale |
Hyperkalemia and hyponatremia |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
aMILoride-hydroCHLOROthiazide (Moduretic)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
potassium-sparing diuretics ⇄ RAS inhibitors (ACEIs, ARBs, ARNIs, aliskiren) |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
amiodarone (Cordarone, Nexterone, Pacerone)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
amiodarone |
| Rationale |
Effective for maintaining sinus rhythm but has greater toxicities than other antiarrhythmics used in atrial fibrillation; may be reasonable first-line therapy in patients with concomitant heart failure or substantial left ventricular hypertrophy if rhythm control is preferred over rate control. |
| Recommendation |
Avoid as first-line therapy for atrial fibrillation unless the patient has heart failure or substantial left ventricular hypertrophy. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
amitriptyline (Elavil)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antidepressants with strong anticholinergic activity, alone or in combination |
| Rationale |
Highly anticholinergic, sedating, and cause orthostatic hypotension. |
| Recommendation |
Avoid |
| Quality of evidence: High, 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
tricyclic antidepressants (TCAs) ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
tertiary tricyclic antidepressants (TCAs) ⇄ Syncope |
| Rationale |
Tertiary TCAs increase the risk of orthostatic hypotension. |
| Recommendation |
Avoid |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antidepressants (selected: TCAs) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
antidepressants (TCAs, SSRIs, and SNRIs) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
amoxapine (Asendin)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antidepressants with strong anticholinergic activity, alone or in combination |
| Rationale |
Highly anticholinergic, sedating, and cause orthostatic hypotension. |
| Recommendation |
Avoid |
| Quality of evidence: High, 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Anafranil - see clomiPRAMINE |
| Anaprox - see naproxen |
| Androderm - see testosterone |
| AndroGel - see testosterone |
| Android - see methyltestosterone |
| Ansaid - see flurbiprofen |
| Antivert - see meclizine |
| Apidra - see insulin glulisine |
| Aptiom - see eslicarbazepine |
| Aricept - see donepezil |
ARIPiprazole (Abilify)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Arixtra - see fondaparinux |
| Armour Thyroid - see desiccated thyroid |
| Artane - see trihexyphenidyl |
asenapine (Saphris)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Asendin - see amoxapine |
aspirin54321
| 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 |
|
aspirin-dipyridamole (Aggrenox)54321
| aspirin > 325 mg/day |
| |
| 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 |
| |
| 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) |
| 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 |
| |
| 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) |
| 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 |
|
| Atacand - see candesartan |
| Atarax - see hydrOXYzine |
| Ativan - see LORazepam |
atropine54321
| excludes ophthalmic |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
GI antispasmodics with strong anticholinergic activity |
| Rationale |
Highly anticholinergic, uncertain effectiveness. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
atropine-diphenoxylate (Lomotil)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
GI antispasmodics with strong anticholinergic activity |
| Rationale |
Highly anticholinergic, uncertain effectiveness. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Avapro - see irbesartan |
| Aveed - see testosterone |
| Axid - see nizatidine |
azilsartan (Edarbi)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| B Beer's Criteria |
baclofen (Lioresal)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
skeletal muscle relaxants ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, 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) |
| CrCl (mL/min) at which action is required |
eGFR <60 |
| Rationale |
Increased risk of encephalopathy requiring hospitalization in older adults with eGFR <60 mL/min or who require chronic dialysis. |
| Recommendation |
Avoid baclofen in older adults with impaired kidney function (eGFR <60 mL/min). When baclofen cannot be avoided, use the lowest effective dose and monitor for signs of CNS toxicity, including altered mental status. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Bactrim - see trimethoprim-sulfamethoxazole |
| Banzel - see rufinamide |
| Benadryl - see diphenhydrAMINE |
benazepril (Lotensin)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Benemid - see probenecid |
| Benicar - see olmesartan |
| Bentyl - see dicyclomine |
benztropine (Cogentin)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Comments |
oral |
| Drug(s) |
antiParkinsonian agents with strong anticholinergic activity |
| Rationale |
Not recommended for prevention or treatment of extrapyramidal symptoms due to antipsychotics; more effective agents available for the treatment of Parkinson disease. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
brexpiprazole (Rexulti)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Brilinta - see ticagrelor |
brivaracetam (Briviact)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Briviact - see brivaracetam |
brompheniramine (Dimetane, Dimetapp)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
first-generation antihistamines |
| Rationale |
Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; risk of confusion, dry mouth, constipation, and other anticholinergic effects or toxicity. Cumulative exposure to anticholinergic drugs is associated with an increased risk of falls, delirium, and dementia, even in younger adults. Consider total anticholinergic burden during regular medication reviews and be cautious in "young-old" as well as "old-old" adults. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
bumetanide (Bumex)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
butalbital (Fioricet, Fiorinal)54321
| 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 |
|
| C Beer's Criteria |
| Calan - see verapamil |
| Caldolor - see ibuprofen |
| Cambia - see diclofenac |
canagliflozin (Invokana)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
sodium-glucose cotransporter-2 (SGLT2) inhibitors |
| Rationale |
Older adults may be at increased risk of urogenital infections, particularly women in the first month of treatment. An increased risk of euglycemic diabetic ketoacidosis has also been seen in older adults. |
| Recommendation |
Use with caution.
Monitor patients for urogenital infections and ketoacidosis. |
| Quality of evidence: Moderate, Strength of Recommendation: Weak |
|
candesartan (Atacand)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
cannabidiol (Epidiolex)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Caplyta - see lumateperone |
| Capozide - see captopril-hydroCHLOROthiazide |
captopril (Capoten)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
captopril-hydroCHLOROthiazide (Capozide)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
carBAMazepine (Carbatrol, TEGretol)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antiepileptics (selected) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
carbinoxamine (Clistin, Karbinal)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
first-generation antihistamines |
| Rationale |
Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; risk of confusion, dry mouth, constipation, and other anticholinergic effects or toxicity. Cumulative exposure to anticholinergic drugs is associated with an increased risk of falls, delirium, and dementia, even in younger adults. Consider total anticholinergic burden during regular medication reviews and be cautious in "young-old" as well as "old-old" adults. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Cardizem - see diltiaZEM |
| Cardura - see doxazosin |
cariprazine (Vraylar)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
carisoprodol (Soma)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
skeletal muscle relaxants |
| Rationale |
Muscle relaxants typically used to treat musculoskeletal complaints are poorly tolerated by older adults due to anticholinergic adverse effects, sedation, and increased risk of fractures; effectiveness at dosages tolerated by older adults is questionable.
This criterion does not apply to skeletal muscle relaxants typically used for the management of spasticity (i.e., baclofen and tiZANidine) although these drugs can also cause substantial adverse effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
skeletal muscle relaxants ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Carospir - see spironolactone |
| Cataflam - see diclofenac |
| Catapres - see cloNIDine |
celecoxib (CeleBREX)54321
| 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) |
| 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: Low, 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) |
| 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 |
|
| CeleXA - see citalopram |
| Cenestin - see estrogens, conjugated |
cenobamate (Xcopri)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
chlordiazePOXIDE (Librium)54321
| alone or in combination with amitriptyline or clidinium |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
benzodiazepines |
| Rationale |
The use of benzodiazepines exposes users to risks of abuse, misuse, and addiction. Concomitant use of opioids may result in profound sedation, respiratory depression, coma, and death.
Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; the continued use of benzodiazepines may lead to clinically significant physical dependence. In general, all benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults.
May be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls.
Benzodiazepines: shorter-acting ones are not safer than long-acting ones.
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
benzodiazepines ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
chlorothiazide (Diuril)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
chlorpheniramine (Chlor-Trimeton)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
first-generation antihistamines |
| Rationale |
Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; risk of confusion, dry mouth, constipation, and other anticholinergic effects or toxicity. Cumulative exposure to anticholinergic drugs is associated with an increased risk of falls, delirium, and dementia, even in younger adults. Consider total anticholinergic burden during regular medication reviews and be cautious in "young-old" as well as "old-old" adults. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
chlorproMAZINE (Thorazine)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (selected) ⇄ Syncope |
| Rationale |
Antipsychotic selected increases the risk of orthostatic hypotension. |
| Recommendation |
Avoid |
| Quality of evidence: High, Strength of Recommendation: Weak |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
chlorthalidone (Hygroton, Thalitone)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Chlor-Trimeton - see chlorpheniramine |
chlorzoxazone (Parafon Forte DSC)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
skeletal muscle relaxants |
| Rationale |
Muscle relaxants typically used to treat musculoskeletal complaints are poorly tolerated by older adults due to anticholinergic adverse effects, sedation, and increased risk of fractures; effectiveness at dosages tolerated by older adults is questionable.
This criterion does not apply to skeletal muscle relaxants typically used for the management of spasticity (i.e., baclofen and tiZANidine) although these drugs can also cause substantial adverse effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
skeletal muscle relaxants ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
cilostazol (Pletal)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
cilostazol ⇄ Heart failure |
| Rationale |
Potential to increase mortality in older adults with heart failure |
| Recommendation |
Avoid |
| Quality of evidence: Low, Strength of Recommendation: Strong |
|
cimetidine (Tagamet)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
H2-receptor antagonists ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Low, 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) |
| CrCl (mL/min) at which action is required |
<50 |
| Rationale |
Mental status changes |
| Recommendation |
Reduce dose |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
ciprofloxacin (Cipro)54321
| Criteria 5: medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults. (Table 6) |
| CrCl (mL/min) at which action is required |
<30 |
| Rationale |
Increased risk of CNS effects (e.g., seizures, confusion) and tendon ruPture. |
| Recommendation |
Dosages used to treat common infections typically require reduction when CrCl <30 mL/min. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
citalopram (CeleXA)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antidepressants (selected classes: SSRIs) ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antidepressants (selected: SSRIs) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antidepressants (TCAs, SSRIs, and SNRIs) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
clidinium-chlordiazePOXIDE (Librax)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
benzodiazepines |
| Rationale |
The use of benzodiazepines exposes users to risks of abuse, misuse, and addiction. Concomitant use of opioids may result in profound sedation, respiratory depression, coma, and death.
Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; the continued use of benzodiazepines may lead to clinically significant physical dependence. In general, all benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults.
May be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) |
GI antispasmodics with strong anticholinergic activity |
| Rationale |
Highly anticholinergic, uncertain effectiveness. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls.
Benzodiazepines: shorter-acting ones are not safer than long-acting ones.
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
benzodiazepines ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Climara - see estradiol |
| Clinoril - see sulindac |
| Clistin - see carbinoxamine |
cloBAZam (Onfi, Sympazan)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
benzodiazepines |
| Rationale |
The use of benzodiazepines exposes users to risks of abuse, misuse, and addiction. Concomitant use of opioids may result in profound sedation, respiratory depression, coma, and death.
Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; the continued use of benzodiazepines may lead to clinically significant physical dependence. In general, all benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults.
May be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls.
Benzodiazepines: shorter-acting ones are not safer than long-acting ones.
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
benzodiazepines ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
clomiPRAMINE (Anafranil)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antidepressants with strong anticholinergic activity, alone or in combination |
| Rationale |
Highly anticholinergic, sedating, and cause orthostatic hypotension. |
| Recommendation |
Avoid |
| Quality of evidence: High, 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
tricyclic antidepressants (TCAs) ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
tertiary tricyclic antidepressants (TCAs) ⇄ Syncope |
| Rationale |
Tertiary TCAs increase the risk of orthostatic hypotension. |
| Recommendation |
Avoid |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antidepressants (selected: TCAs) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
antidepressants (TCAs, SSRIs, and SNRIs) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
clonazePAM (KlonoPIN)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
benzodiazepines |
| Rationale |
The use of benzodiazepines exposes users to risks of abuse, misuse, and addiction. Concomitant use of opioids may result in profound sedation, respiratory depression, coma, and death.
Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; the continued use of benzodiazepines may lead to clinically significant physical dependence. In general, all benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults.
May be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls.
Benzodiazepines: shorter-acting ones are not safer than long-acting ones.
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
benzodiazepines ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
cloNIDine (Catapres)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
central alpha-agonists for the treatment of hypertension |
| Rationale |
High risk of adverse CNS effects; may cause bradycardia and orthostatic hypotension; not recommended as routine treatment for hypertension. |
| Recommendation |
Avoid cloNIDine as first-line treatment for hypertension. |
| Quality of evidence: Low, Strength of Recommendation: Strong |
|
clorazepate (Tranxene)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
benzodiazepines |
| Rationale |
The use of benzodiazepines exposes users to risks of abuse, misuse, and addiction. Concomitant use of opioids may result in profound sedation, respiratory depression, coma, and death.
Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; the continued use of benzodiazepines may lead to clinically significant physical dependence. In general, all benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults.
May be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls.
Benzodiazepines: shorter-acting ones are not safer than long-acting ones.
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
benzodiazepines ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
cloZAPine (Clozaril)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
codeine54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for pain management in the setting if severe acute pain. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
opioids ⇄ benzodiazepines |
| Risk Rationale |
Increased risk of overdose and adverse events. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ gabapentin, pregabalin |
| Risk Rationale |
Increased risk of severe sedation-related adverse events, including respiratory depression and death. |
| Recommendation |
Avoid; exceptions are when transitioning from opioid therapy to gabapentin or pregabalin, or when using gabapentinoids to reduce opioid dose, although caution should be used in all circumstances. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Cogentin - see benztropine |
colchicine (Colcrys, Mitigare)54321
| Criteria 5: medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults. (Table 6) |
| CrCl (mL/min) at which action is required |
<30 |
| Rationale |
GI, neuromuscular, and bone marrow toxicity |
| Recommendation |
Reduce dose; monitor for adverse effects. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Compazine - see prochlorperazine |
| Cordarone - see amiodarone |
cortisone (Cortone)54321
| 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 |
corticosteroids (oral and parenteral) Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| Drug(s) ⇆ disease or syndrome |
corticosteroids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
If needed, use the lowest possible dose for the shortest duration and monitor for delirium. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Coumadin - see warfarin |
| Covera - see verapamil |
| Cozaar - see losartan |
cyclobenzaprine (Flexeril)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
skeletal muscle relaxants |
| Rationale |
Muscle relaxants typically used to treat musculoskeletal complaints are poorly tolerated by older adults due to anticholinergic adverse effects, sedation, and increased risk of fractures; effectiveness at dosages tolerated by older adults is questionable.
This criterion does not apply to skeletal muscle relaxants typically used for the management of spasticity (i.e., baclofen and tiZANidine) although these drugs can also cause substantial adverse effects. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
skeletal muscle relaxants ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Cymbalta - see DULoxetine |
cyproheptadine (Periactin)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
first-generation antihistamines |
| Rationale |
Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; risk of confusion, dry mouth, constipation, and other anticholinergic effects or toxicity. Cumulative exposure to anticholinergic drugs is associated with an increased risk of falls, delirium, and dementia, even in younger adults. Consider total anticholinergic burden during regular medication reviews and be cautious in "young-old" as well as "old-old" adults. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| D Beer's Criteria |
dabigatran (Pradaxa)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Comments |
for long-term treatment of nonvalvular atrial fibrillation or venous thromboembolism (VTE)
When selecting among DOACs and choosing a dosage, pay special consideration to kidney function (see Table 6), indication, and body weight. |
| Drug(s) |
dabigatran |
| Rationale |
Increased risk of GI bleeding compared with warfarin (based on head-to-head clinical trials) and of GI bleeding and major bleeding compared with apixaban (based on observational studies and meta-analyses) in older adults when used for long-term treatment of nonvalvular atrial fibrillation or VTE. |
| Recommendation |
Use caution in selecting dabigatran over other DOACs (e.g., apixaban) for long-term treatment of nonvalvular atrial fibrillation or VTE.
See also criteria on warfarin and rivaroxaban (Table 2) and comment above regarding choice among DOACs. |
| 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) |
| CrCl (mL/min) at which action is required |
<30 |
| Rationale |
Lack of evidence for efficacy and safety in individuals with a CrCl <30 mL/min. Label dose for patients with CrCl 15-30 mL/min based on pharmacokinetic data. |
| Recommendation |
Avoid when CrCl <30 mL/min; dose adjustment is advised when CrCl >30 mL/min in the presence of drug-drug interactions. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
dantrolene (Dantrium)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
skeletal muscle relaxants ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
dapagliflozin (Farxiga)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
sodium-glucose cotransporter-2 (SGLT2) inhibitors |
| Rationale |
Older adults may be at increased risk of urogenital infections, particularly women in the first month of treatment. An increased risk of euglycemic diabetic ketoacidosis has also been seen in older adults. |
| Recommendation |
Use with caution.
Monitor patients for urogenital infections and ketoacidosis. |
| Quality of evidence: Moderate, Strength of Recommendation: Weak |
|
darifenacin (Enablex)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Daypro - see oxaprozin |
| DDAVP - see desmopressin |
| Decadron - see dexamethasone |
deflazacort (Emflaza)54321
| 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 |
corticosteroids (oral and parenteral) Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| Drug(s) ⇆ disease or syndrome |
corticosteroids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
If needed, use the lowest possible dose for the shortest duration and monitor for delirium. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Deltasone - see predniSONE |
| Demadex - see torsemide |
| Demerol - see meperidine |
| Depacon - see valproic acid |
| DEPO-Medrol - see methylPREDNISolone |
| Depo-testosterone - see testosterone |
| DES - see diethylstilbestrol |
desiccated thyroid (Armour Thyroid)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
desiccated thyroid |
| Rationale |
Concerns about cardiac effects; safer alternatives available. |
| Recommendation |
Avoid |
| Quality of evidence: Low, Strength of Recommendation: Strong |
|
desipramine (Norpramin)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antidepressants with strong anticholinergic activity, alone or in combination |
| Rationale |
Highly anticholinergic, sedating, and cause orthostatic hypotension. |
| Recommendation |
Avoid |
| Quality of evidence: High, 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
tricyclic antidepressants (TCAs) ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antidepressants (selected: TCAs) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
antidepressants (TCAs, SSRIs, and SNRIs) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
desmopressin (DDAVP)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
desmopressin |
| Rationale |
High risk of hyponatremia; safer alternative treatments for nocturia (including nonpharmacologic). |
| Recommendation |
Avoid for treatment of nocturia or nocturnal polyuria. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
desvenlafaxine (Pristiq)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antidepressants (selected classes: SNRIs) ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antidepressants (selected: SNRIs) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antidepressants (TCAs, SSRIs, and SNRIs) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Detrol - see tolterodine |
dexamethasone (Decadron)54321
| 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 |
corticosteroids (oral and parenteral) Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| Drug(s) ⇆ disease or syndrome |
corticosteroids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
If needed, use the lowest possible dose for the shortest duration and monitor for delirium. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
dexlansoprazole (Kapidex)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
proton-pump inhibitors |
| Rationale |
Risk of C. difficile infection, pneumonia, GI malignancies, bone loss, and fractures. |
| Recommendation |
Avoid scheduled use for >8 weeks unless for high-risk patients (e.g., oral corticosteroids or chronic NSAID use), erosive esophagitis, Barrett's esophagitis, pathologic hypersecretory condition, or demonstrated need for maintenance treatment (e.g., because of failure of drug discontinuation trial or H2-receptor antagonists). |
Quality of evidence: C. difficile, bone loss, and fractures: High
Pneumonia and GI malignancies: Moderate, Strength of Recommendation: Strong |
|
dextromethorphan-quiNIDine (Nuedexta)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
dextromethorphan-quiNIDine ⇄ Heart failure |
| Rationale |
Concerns about QT prolongation. |
| Recommendation |
Avoid |
| Quality of evidence: Low, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
dextromethorphan-quiNIDine |
| Rationale |
Limited efficacy in patients with behavioral symptoms of dementia (does not apply to the treatment of pseudobulbar affect). May increase the risk of falls and concerns with clinically significant drug interactions and with use in those with heart failure (see Table 3). |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Diabeta - see glyBURIDE |
| Diacomit - see stiripentol |
| Diamox - see acetaZOLAMIDE |
diazePAM (Valium)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
benzodiazepines |
| Rationale |
The use of benzodiazepines exposes users to risks of abuse, misuse, and addiction. Concomitant use of opioids may result in profound sedation, respiratory depression, coma, and death.
Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; the continued use of benzodiazepines may lead to clinically significant physical dependence. In general, all benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults.
May be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls.
Benzodiazepines: shorter-acting ones are not safer than long-acting ones.
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
skeletal muscle relaxants ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
benzodiazepines ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
diclofenac (Cambia, Cataflam, Voltaren)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| 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) |
| 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 |
| |
| Drug(s) ⇆ disease or syndrome |
non-COX-2 selective NSAIDs ⇄ 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) |
| 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 |
|
dicyclomine (Bentyl)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
GI antispasmodics with strong anticholinergic activity |
| Rationale |
Highly anticholinergic, uncertain effectiveness. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
diethylstilbestrol (DES)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
estrogens with or without progestins (includes natural and synthetic estrogen preparations) |
| Rationale |
Evidence of carcinogenic potential (breast and endometrium); lack of cardioprotective effect and cognitive protection in older women.
For women who start HRT at age 60 and older, the risks of HRT are greater than the benefits, as HRT is linked to a higher risk of heart disease, stroke, blood clots, and dementia.
Evidence indicates that vaginal estrogens for the treatment of vaginal dryness are safe and effective; women with a history of breast cancer who do not respond to nonhormonal therapies are advised to discuss the risks and benefits of low-dose vaginal estrogen (e.g., dosages of estradiol <25 mcg twice weekly) with their healthcare provider. |
| Recommendation |
Do not initiate systemic estrogen (e.g., oral tablets or transdermal patches). Consider deprescribing among older women already using this medication.
Vaginal cream or vaginal tablets: acceptable to use low-dose intravaginal estrogen for the management of dyspareunia, recurrent lower urinary tract infections, and other vaginal symptoms. |
Quality of evidence: Oral and patch: high
Vaginal cream or vaginal tablets: moderate, Strength of Recommendation: Oral and patch: strong
Topical vaginal cream or tablets: weak |
| |
| 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) |
| Drug(s) ⇆ disease or syndrome |
estrogen, oral and transdermal (excludes intravaginal estrogen) ⇄ Urinary incontinence (all types) in women |
| Rationale |
Lack of efficacy. |
| Recommendation |
Avoid in women. See also recommendation on estrogen (Table 2) |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
diflunisal (Dolobid)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| 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) |
| 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 |
| |
| Drug(s) ⇆ disease or syndrome |
non-COX-2 selective NSAIDs ⇄ 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) |
| 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 |
|
digoxin (Lanoxin)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Comments |
for first-line treatment of atrial fibrillation or heart failure |
| Drug(s) |
digoxin |
| Rationale |
Use in atrial fibrillation: should not be used as a first-line agent because there are safer and more effective alternatives for rate control.
Use in heart failure: evidence for benefits and harms of digoxin is conflicting and of lower quality; most (but not all) evidence concerns use in HFrEF. There is strong evidence for other agents as firstline therapy to reduce hospitalizations and mortality in adults with HFrEF. In heart failure, higher dosages are not associated with additional benefits and may increase the risk of toxicity. Use caution in discontinuing digoxin among current users with HFrEF, given limited evidence suggesting worse clinical outcomes after discontinuation.
Decreased renal clearance of digoxin may lead to an increased risk of toxic effects; further dose reduction may be necessary for those with Stage 4 or 5 chronic kidney disease. |
| Recommendation |
Avoid this rate control agent as first-line therapy for atrial fibrillation.
Avoid as first-line therapy for heart failure. See rationale for caution about withdrawal in long-term users with HFrEF.
If used for atrial fibrillation or heart failure, avoid dosages >0.125 mg/day. |
Quality of evidence: Atrial fibrillation; heart failure: low
Dosage > 0.125 mg/day: moderate, Strength of Recommendation: Strong |
|
| Dilantin - see phenytoin |
| Dilaudid - see HYDROmorphone |
diltiaZEM (Cardizem, Dilacor)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
non-dihydropyridine calcium channel blockers (CCBs) ⇄ Heart failure |
| Rationale |
Potential to promote fluid retention and/or exacerbate heart failure. |
| Recommendation |
Avoid in heart failure with reduced ejection fraction. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
dimenhyDRINATE (Dramamine)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
first-generation antihistamines |
| Rationale |
Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; risk of confusion, dry mouth, constipation, and other anticholinergic effects or toxicity. Cumulative exposure to anticholinergic drugs is associated with an increased risk of falls, delirium, and dementia, even in younger adults. Consider total anticholinergic burden during regular medication reviews and be cautious in "young-old" as well as "old-old" adults. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Dimetane - see brompheniramine |
| Dimetapp - see brompheniramine |
| Diovan - see valsartan |
| Diovan HCT - see hydroCHLOROthiazide-valsartan |
diphenhydrAMINE (Benadryl)54321
| diphenhydrAMINE (oral) Use of diphenhydrAMINE in situations such as acute treatment of severe allergic reactions may be appropriate. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
first-generation antihistamines |
| Rationale |
Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; risk of confusion, dry mouth, constipation, and other anticholinergic effects or toxicity. Cumulative exposure to anticholinergic drugs is associated with an increased risk of falls, delirium, and dementia, even in younger adults. Consider total anticholinergic burden during regular medication reviews and be cautious in "young-old" as well as "old-old" adults. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
dipyridamole (Persantine)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Comments |
oral short-acting (does not apply to extended-release combination with aspirin) |
| Drug(s) |
dipyridamole |
| Rationale |
May cause orthostatic hypotension; more effective alternatives available; IV form acceptable for use in cardiac stress testing. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Ditropan - see oxybutynin |
| Diuril - see chlorothiazide |
| divalproex - see valproic acid |
| Doan's - see magnesium salicylate |
dofetilide (Tikosyn)54321
| Criteria 5: medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults. (Table 6) |
| CrCl (mL/min) at which action is required |
<60 |
| Rationale |
QTc prolongation and torsades de pointes. |
| Recommendation |
Reduce dose if CrCl is 20-59 mL/min.
Avoid if CrCl <20 mL/min. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Dolobid - see diflunisal |
| Dolophine - see methadone |
donepezil (Aricept)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
cholinesterase inhibitors (AChEIs) ⇄ Syncope |
| Rationale |
AChEIs cause bradycardia and should be avoided in older adults whose syncope may be due to bradycardia. |
| Recommendation |
Avoid |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
doxazosin (Cardura)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
non-selective peripheral alpha-1 blockers for the treatment of hypertension |
| Rationale |
High risk of orthostatic hypotension and associated harms, especially in older adults; not recommended as routine treatment for hypertension; alternative agents have superior risk/benefit profile. |
| Recommendation |
Avoid use as an antihypertensive. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
non-selective peripheral alpha-1 blockers ⇄ Syncope |
| Rationale |
Non-selective peripheral alpha-1 blockers cause orthostatic blood pressure changes and should be avoided in older adults whose syncope may be due to orthostatic hypotension. |
| Recommendation |
Avoid |
| Quality of evidence: High, Strength of Recommendation: Weak |
| |
| Drug(s) ⇆ disease or syndrome |
non-selective peripheral alpha-1 blockers ⇄ Urinary incontinence (all types) in women |
| Rationale |
Aggravation of incontinence. |
| Recommendation |
Avoid in women. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
non-selective peripheral alpha-1 blockers ⇄ Loop diuretics |
| Risk Rationale |
Increased risk of urinary incontinence in older women. |
| Recommendation |
Avoid in older women, unless conditions warrant both drugs. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
doxepin (SINEquan)54321
| >6 mg/day |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antidepressants with strong anticholinergic activity, alone or in combination |
| Rationale |
Highly anticholinergic, sedating, and cause orthostatic hypotension; the safety profile of low-dose doxepin (≤6 mg/day) is comparable to that of placebo. |
| Recommendation |
Avoid |
| Quality of evidence: High, 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
tricyclic antidepressants (TCAs) ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls.
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
tertiary tricyclic antidepressants (TCAs) ⇄ Syncope |
| Rationale |
Tertiary TCAs increase the risk of orthostatic hypotension. |
| Recommendation |
Avoid |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antidepressants (selected: TCAs) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
antidepressants (TCAs, SSRIs, and SNRIs) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
doxylamine (Unisom)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
first-generation antihistamines |
| Rationale |
Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; risk of confusion, dry mouth, constipation, and other anticholinergic effects or toxicity. Cumulative exposure to anticholinergic drugs is associated with an increased risk of falls, delirium, and dementia, even in younger adults. Consider total anticholinergic burden during regular medication reviews and be cautious in "young-old" as well as "old-old" adults. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Dramamine - see dimenhyDRINATE |
droNABinol (Marinol)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
dronedarone (Multaq)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
dronedarone |
| Rationale |
Worse outcomes in people who have permanent atrial fibrillation or severe or recently decompensated heart failure. In some circumstances, worse outcomes have also been reported in people with HFrEF (e.g., left ventricular ejection fraction ~35%) who have milder symptoms (NYHA class I or II). |
| Recommendation |
Avoid in individuals with permanent atrial fibrillation or severe or recently decompensated heart failure. Use caution in patients with HFrEF with less severe symptoms (NYHA class I or II). |
| Quality of evidence: High, 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) |
| Drug(s) ⇆ disease or syndrome |
dronedarone ⇄ Heart failure |
| Rationale |
Potential to increase mortality in older adults with heart failure. |
| Recommendation |
Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
droperidol (Inapsine)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
DULoxetine (Cymbalta)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antidepressants (selected classes: SNRIs) ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antidepressants (selected: SNRIs) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antidepressants (TCAs, SSRIs, and SNRIs) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, 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) |
| CrCl (mL/min) at which action is required |
<30 |
| Rationale |
Increased GI adverse effects (nausea, diarrhea) |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Weak |
|
| Dyazide - see triamterene-hydroCHLOROthiazide |
| Dyrenium - see triamterene |
| E Beer's Criteria |
| Edarbi - see azilsartan |
| Edecrin - see ethacrynic acid |
edoxaban (Savaysa)54321
| Criteria 5: medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults. (Table 6) |
| CrCl (mL/min) at which action is required |
15-50
<15 or > 95 |
| Rationale |
Lack of evidence of efficacy or safety in patients with CrCl <30 mL/min. |
| Recommendation |
Reduce dose if CrCl is 15-50 mL/min.
Avoid if CrCl <15 or > 95 mL/min. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Effexor - see venlafaxine |
| Effient - see prasugrel |
| Elavil - see amitriptyline |
| Emflaza - see deflazacort |
empagliflozin (Jardiance)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
sodium-glucose cotransporter-2 (SGLT2) inhibitors |
| Rationale |
Older adults may be at increased risk of urogenital infections, particularly women in the first month of treatment. An increased risk of euglycemic diabetic ketoacidosis has also been seen in older adults. |
| Recommendation |
Use with caution.
Monitor patients for urogenital infections and ketoacidosis. |
| Quality of evidence: Moderate, Strength of Recommendation: Weak |
|
| Enablex - see darifenacin |
enalapril (Vasotec)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
enoxaparin (Lovenox)54321
| Criteria 5: medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults. (Table 6) |
| CrCl (mL/min) at which action is required |
<30 |
| Rationale |
Increased risk of bleeding |
| Recommendation |
Reduce dose |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Entresto - see sacubitril-valsartan |
| Epidiolex - see cannabidiol |
eplerenone (Inspra, Espler)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
potassium-sparing diuretics ⇄ RAS inhibitors (ACEIs, ARBs, ARNIs, aliskiren) |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Equanil - see meprobamate |
ergoloid mesylate (Hydergine)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
ergoloid mesylates (dehydrogenated ergot alkaloids) |
| Rationale |
Lack of efficacy. |
| Recommendation |
Avoid |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
ertugliflozin (Steglatro)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
sodium-glucose cotransporter-2 (SGLT2) inhibitors |
| Rationale |
Older adults may be at increased risk of urogenital infections, particularly women in the first month of treatment. An increased risk of euglycemic diabetic ketoacidosis has also been seen in older adults. |
| Recommendation |
Use with caution.
Monitor patients for urogenital infections and ketoacidosis. |
| Quality of evidence: Moderate, Strength of Recommendation: Weak |
|
escitalopram (Lexapro)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antidepressants (selected classes: SSRIs) ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antidepressants (selected: SSRIs) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antidepressants (TCAs, SSRIs, and SNRIs) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Eskalith - see lithium |
eslicarbazepine (Aptiom)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
esomeprazole (NexIUM)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
proton-pump inhibitors |
| Rationale |
Risk of C. difficile infection, pneumonia, GI malignancies, bone loss, and fractures. |
| Recommendation |
Avoid scheduled use for >8 weeks unless for high-risk patients (e.g., oral corticosteroids or chronic NSAID use), erosive esophagitis, Barrett's esophagitis, pathologic hypersecretory condition, or demonstrated need for maintenance treatment (e.g., because of failure of drug discontinuation trial or H2-receptor antagonists). |
Quality of evidence: C. difficile, bone loss, and fractures: High
Pneumonia and GI malignancies: Moderate, Strength of Recommendation: Strong |
|
| Espler - see eplerenone |
estazolam (Prosom)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
benzodiazepines |
| Rationale |
The use of benzodiazepines exposes users to risks of abuse, misuse, and addiction. Concomitant use of opioids may result in profound sedation, respiratory depression, coma, and death.
Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; the continued use of benzodiazepines may lead to clinically significant physical dependence. In general, all benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults.
May be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls.
Benzodiazepines: shorter-acting ones are not safer than long-acting ones.
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
benzodiazepines ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
estradiol (Alora, Climara, Estrace, Vivelle-Dot)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
estrogens with or without progestins (includes natural and synthetic estrogen preparations) |
| Rationale |
Evidence of carcinogenic potential (breast and endometrium); lack of cardioprotective effect and cognitive protection in older women.
For women who start HRT at age 60 and older, the risks of HRT are greater than the benefits, as HRT is linked to a higher risk of heart disease, stroke, blood clots, and dementia.
Evidence indicates that vaginal estrogens for the treatment of vaginal dryness are safe and effective; women with a history of breast cancer who do not respond to nonhormonal therapies are advised to discuss the risks and benefits of low-dose vaginal estrogen (e.g., dosages of estradiol <25 mcg twice weekly) with their healthcare provider. |
| Recommendation |
Do not initiate systemic estrogen (e.g., oral tablets or transdermal patches). Consider deprescribing among older women already using this medication.
Vaginal cream or vaginal tablets: acceptable to use low-dose intravaginal estrogen for the management of dyspareunia, recurrent lower urinary tract infections, and other vaginal symptoms. |
Quality of evidence: Oral and patch: high
Vaginal cream or vaginal tablets: moderate, Strength of Recommendation: Oral and patch: strong
Topical vaginal cream or tablets: weak |
| |
| 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) |
| Drug(s) ⇆ disease or syndrome |
estrogen, oral and transdermal (excludes intravaginal estrogen) ⇄ Urinary incontinence (all types) in women |
| Rationale |
Lack of efficacy. |
| Recommendation |
Avoid in women. See also recommendation on estrogen (Table 2) |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
estrogen/progesterone combinations (Prempro, Premphase)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
estrogens with or without progestins (includes natural and synthetic estrogen preparations) |
| Rationale |
Evidence of carcinogenic potential (breast and endometrium); lack of cardioprotective effect and cognitive protection in older women.
For women who start HRT at age 60 and older, the risks of HRT are greater than the benefits, as HRT is linked to a higher risk of heart disease, stroke, blood clots, and dementia.
Evidence indicates that vaginal estrogens for the treatment of vaginal dryness are safe and effective; women with a history of breast cancer who do not respond to nonhormonal therapies are advised to discuss the risks and benefits of low-dose vaginal estrogen (e.g., dosages of estradiol <25 mcg twice weekly) with their healthcare provider. |
| Recommendation |
Do not initiate systemic estrogen (e.g., oral tablets or transdermal patches). Consider deprescribing among older women already using this medication.
Vaginal cream or vaginal tablets: acceptable to use low-dose intravaginal estrogen for the management of dyspareunia, recurrent lower urinary tract infections, and other vaginal symptoms. |
Quality of evidence: Oral and patch: high
Vaginal cream or vaginal tablets: moderate, Strength of Recommendation: Oral and patch: strong
Topical vaginal cream or tablets: weak |
| |
| 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) |
| Drug(s) ⇆ disease or syndrome |
estrogen, oral and transdermal (excludes intravaginal estrogen) ⇄ Urinary incontinence (all types) in women |
| Rationale |
Lack of efficacy. |
| Recommendation |
Avoid in women. See also recommendation on estrogen (Table 2) |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
estrogens, conjugated (Cenestin)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
estrogens with or without progestins (includes natural and synthetic estrogen preparations) |
| Rationale |
Evidence of carcinogenic potential (breast and endometrium); lack of cardioprotective effect and cognitive protection in older women.
For women who start HRT at age 60 and older, the risks of HRT are greater than the benefits, as HRT is linked to a higher risk of heart disease, stroke, blood clots, and dementia.
Evidence indicates that vaginal estrogens for the treatment of vaginal dryness are safe and effective; women with a history of breast cancer who do not respond to nonhormonal therapies are advised to discuss the risks and benefits of low-dose vaginal estrogen (e.g., dosages of estradiol <25 mcg twice weekly) with their healthcare provider. |
| Recommendation |
Do not initiate systemic estrogen (e.g., oral tablets or transdermal patches). Consider deprescribing among older women already using this medication.
Vaginal cream or vaginal tablets: acceptable to use low-dose intravaginal estrogen for the management of dyspareunia, recurrent lower urinary tract infections, and other vaginal symptoms. |
Quality of evidence: Oral and patch: high
Vaginal cream or vaginal tablets: moderate, Strength of Recommendation: Oral and patch: strong
Topical vaginal cream or tablets: weak |
| |
| 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) |
| Drug(s) ⇆ disease or syndrome |
estrogen, oral and transdermal (excludes intravaginal estrogen) ⇄ Urinary incontinence (all types) in women |
| Rationale |
Lack of efficacy. |
| Recommendation |
Avoid in women. See also recommendation on estrogen (Table 2) |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
estrogens, esterified (Menest)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
estrogens with or without progestins (includes natural and synthetic estrogen preparations) |
| Rationale |
Evidence of carcinogenic potential (breast and endometrium); lack of cardioprotective effect and cognitive protection in older women.
For women who start HRT at age 60 and older, the risks of HRT are greater than the benefits, as HRT is linked to a higher risk of heart disease, stroke, blood clots, and dementia.
Evidence indicates that vaginal estrogens for the treatment of vaginal dryness are safe and effective; women with a history of breast cancer who do not respond to nonhormonal therapies are advised to discuss the risks and benefits of low-dose vaginal estrogen (e.g., dosages of estradiol <25 mcg twice weekly) with their healthcare provider. |
| Recommendation |
Do not initiate systemic estrogen (e.g., oral tablets or transdermal patches). Consider deprescribing among older women already using this medication.
Vaginal cream or vaginal tablets: acceptable to use low-dose intravaginal estrogen for the management of dyspareunia, recurrent lower urinary tract infections, and other vaginal symptoms. |
Quality of evidence: Oral and patch: high
Vaginal cream or vaginal tablets: moderate, Strength of Recommendation: Oral and patch: strong
Topical vaginal cream or tablets: weak |
| |
| 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) |
| Drug(s) ⇆ disease or syndrome |
estrogen, oral and transdermal (excludes intravaginal estrogen) ⇄ Urinary incontinence (all types) in women |
| Rationale |
Lack of efficacy. |
| Recommendation |
Avoid in women. See also recommendation on estrogen (Table 2) |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
estropipate (Ogen, Ortho-Est)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
estrogens with or without progestins (includes natural and synthetic estrogen preparations) |
| Rationale |
Evidence of carcinogenic potential (breast and endometrium); lack of cardioprotective effect and cognitive protection in older women.
For women who start HRT at age 60 and older, the risks of HRT are greater than the benefits, as HRT is linked to a higher risk of heart disease, stroke, blood clots, and dementia.
Evidence indicates that vaginal estrogens for the treatment of vaginal dryness are safe and effective; women with a history of breast cancer who do not respond to nonhormonal therapies are advised to discuss the risks and benefits of low-dose vaginal estrogen (e.g., dosages of estradiol <25 mcg twice weekly) with their healthcare provider. |
| Recommendation |
Do not initiate systemic estrogen (e.g., oral tablets or transdermal patches). Consider deprescribing among older women already using this medication.
Vaginal cream or vaginal tablets: acceptable to use low-dose intravaginal estrogen for the management of dyspareunia, recurrent lower urinary tract infections, and other vaginal symptoms. |
Quality of evidence: Oral and patch: high
Vaginal cream or vaginal tablets: moderate, Strength of Recommendation: Oral and patch: strong
Topical vaginal cream or tablets: weak |
| |
| 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) |
| Drug(s) ⇆ disease or syndrome |
estrogen, oral and transdermal (excludes intravaginal estrogen) ⇄ Urinary incontinence (all types) in women |
| Rationale |
Lack of efficacy. |
| Recommendation |
Avoid in women. See also recommendation on estrogen (Table 2) |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
eszopiclone (Lunesta)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
nonbenzodiazepine benzodiazepine receptor agonist hypnotics (“Z-drugs”) |
| Rationale |
Nonbenzodiazepine benzodiazepine receptor agonist hypnotics ("Z-drugs") 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. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
nonbenzodiazepine benzodiazepine receptor agonist hypnotics (“Z-drugs”) ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
nonbenzodiazepine benzodiazepine receptor agonist hypnotics (“Z-drugs”) ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
nonbenzodiazepine benzodiazepine receptor agonist hypnotics ("Z-drugs") ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
nonbenzodiazepine benzodiazepine-receptor agonist hypnotics (i.e., "Z-drugs") ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
ethacrynic acid (edecrin)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
ethinyl estradiol-norethindrone (Femhrt)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
estrogens with or without progestins (includes natural and synthetic estrogen preparations) |
| Rationale |
Evidence of carcinogenic potential (breast and endometrium); lack of cardioprotective effect and cognitive protection in older women.
For women who start HRT at age 60 and older, the risks of HRT are greater than the benefits, as HRT is linked to a higher risk of heart disease, stroke, blood clots, and dementia.
Evidence indicates that vaginal estrogens for the treatment of vaginal dryness are safe and effective; women with a history of breast cancer who do not respond to nonhormonal therapies are advised to discuss the risks and benefits of low-dose vaginal estrogen (e.g., dosages of estradiol <25 mcg twice weekly) with their healthcare provider. |
| Recommendation |
Do not initiate systemic estrogen (e.g., oral tablets or transdermal patches). Consider deprescribing among older women already using this medication.
Vaginal cream or vaginal tablets: acceptable to use low-dose intravaginal estrogen for the management of dyspareunia, recurrent lower urinary tract infections, and other vaginal symptoms. |
Quality of evidence: Oral and patch: high
Vaginal cream or vaginal tablets: moderate, Strength of Recommendation: Oral and patch: strong
Topical vaginal cream or tablets: weak |
| |
| 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) |
| Drug(s) ⇆ disease or syndrome |
estrogen, oral and transdermal (excludes intravaginal estrogen) ⇄ Urinary incontinence (all types) in women |
| Rationale |
Lack of efficacy. |
| Recommendation |
Avoid in women. See also recommendation on estrogen (Table 2) |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
ethosuximide (Zarontin)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
etodolac (Lodine)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| 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) |
| 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 |
| |
| Drug(s) ⇆ disease or syndrome |
non-COX-2 selective NSAIDs ⇄ 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) |
| 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 |
|
everolimus (Afinitor, Zortress)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Exelon - see rivastigmine |
| F Beer's Criteria |
famotidine (Pepcid)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
H2-receptor antagonists ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Low, 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) |
| CrCl (mL/min) at which action is required |
<50 |
| Rationale |
Mental status changes |
| Recommendation |
Reduce dose |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Fanapt - see iloperidone |
| Farxiga - see dapagliflozin |
felbamate (Felbatol)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Felbatol - see felbamate |
| Feldene - see piroxicam |
| Femhrt - see ethinyl estradiol-norethindrone |
fenfluramine (Fintepla)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
fentaNYL (Sublimaze)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for pain management in the setting if severe acute pain. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
opioids ⇄ benzodiazepines |
| Risk Rationale |
Increased risk of overdose and adverse events. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ gabapentin, pregabalin |
| Risk Rationale |
Increased risk of severe sedation-related adverse events, including respiratory depression and death. |
| Recommendation |
Avoid; exceptions are when transitioning from opioid therapy to gabapentin or pregabalin, or when using gabapentinoids to reduce opioid dose, although caution should be used in all circumstances. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
fesoterodine (Toviaz)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Fetzima - see levomilnacipran |
finerenone (Kerendia)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
potassium-sparing diuretics ⇄ RAS inhibitors (ACEIs, ARBs, ARNIs, aliskiren) |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Fintepla - see fenfluramine |
| Fioricet - see butalbital |
| Fiorinal - see butalbital |
flavoxATE (Urispas)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Flexeril - see cyclobenzaprine |
| Flomax - see tamsulosin |
| Florinef - see fludrocortisone |
fludrocortisone (Florinef)54321
| 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 |
corticosteroids (oral and parenteral) Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| Drug(s) ⇆ disease or syndrome |
corticosteroids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
If needed, use the lowest possible dose for the shortest duration and monitor for delirium. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
FLUoxetine (PROzac)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antidepressants (selected classes: SSRIs) ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antidepressants (selected: SSRIs) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antidepressants (TCAs, SSRIs, and SNRIs) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
fluPHENAZine (Prolixin)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
flurbiprofen (Ansaid, Ocufen)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| 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) |
| 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 |
| |
| Drug(s) ⇆ disease or syndrome |
non-COX-2 selective NSAIDs ⇄ 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) |
| 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 |
|
fLuvoxaMINE (Luvox)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antidepressants (selected classes: SSRIs) ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antidepressants (selected: SSRIs) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antidepressants (TCAs, SSRIs, and SNRIs) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
fondaparinux (Arixtra)54321
| Criteria 5: medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults. (Table 6) |
| CrCl (mL/min) at which action is required |
<30 |
| Rationale |
Increased risk of bleeding |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Fortesta - see testosterone |
fosinopril (Monopril)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Furadantin - see nitrofurantoin |
furosemide (Lasix)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Fycompa - see perampanel |
| G Beer's Criteria |
gabapentin (Neurontin)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, 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) |
| CrCl (mL/min) at which action is required |
<60 |
| Rationale |
CNS adverse effects |
| Recommendation |
Reduce dose |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Gabitril - see tiaGABine |
galantamine (Razadyne)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
cholinesterase inhibitors (AChEIs) ⇄ Syncope |
| Rationale |
AChEIs cause bradycardia and should be avoided in older adults whose syncope may be due to bradycardia. |
| Recommendation |
Avoid |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
ganaxolone (Ztalmy)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Genotropin - see growth hormone |
| Geodon - see ziprasidone |
glimepiride (Amaryl)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
sulfonylureas (all, including short- and longer-acting) |
| Rationale |
Sulfonylureas have a higher risk of cardiovascular events, all-cause mortality, and hypoglycemia than alternative agents. Sulfonylureas may increase the risk of cardiovascular death and ischemic stroke.
Among sulfonylureas, long-acting agents (e.g., glyBURIDE, glimepiride) confer a higher risk of prolonged hypoglycemia than short-acting agents (e.g., glipiZIDE). |
| Recommendation |
Avoid sulfonylureas as first- or second-line monotherapy or add-on therapy unless there are substantial barriers to the use of safer and more effective agents.
If a sulfonylurea is used, choose short-acting agents (e.g., glipiZIDE) over long-acting agents (e.g., glyBURIDE, glimepiride). |
Quality of evidence: Hypoglycemia: High
CV events and all-cause mortality: Moderate
CV death and ischemic stroke: Low, Strength of Recommendation: Strong |
|
glipiZIDE (Glucotrol)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
sulfonylureas (all, including short- and longer-acting) |
| Rationale |
Sulfonylureas have a higher risk of cardiovascular events, all-cause mortality, and hypoglycemia than alternative agents. Sulfonylureas may increase the risk of cardiovascular death and ischemic stroke.
Among sulfonylureas, long-acting agents (e.g., glyBURIDE, glimepiride) confer a higher risk of prolonged hypoglycemia than short-acting agents (e.g., glipiZIDE). |
| Recommendation |
Avoid sulfonylureas as first- or second-line monotherapy or add-on therapy unless there are substantial barriers to the use of safer and more effective agents.
If a sulfonylurea is used, choose short-acting agents (e.g., glipiZIDE) over long-acting agents (e.g., glyBURIDE, glimepiride). |
Quality of evidence: Hypoglycemia: High
CV events and all-cause mortality: Moderate
CV death and ischemic stroke: Low, Strength of Recommendation: Strong |
|
glyBURIDE (Diabeta, Glynase, Micronase)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Comments |
aka glibenclamide |
| Drug(s) |
sulfonylureas (all, including short- and longer-acting) |
| Rationale |
Sulfonylureas have a higher risk of cardiovascular events, all-cause mortality, and hypoglycemia than alternative agents. Sulfonylureas may increase the risk of cardiovascular death and ischemic stroke.
Among sulfonylureas, long-acting agents (e.g., glyBURIDE, glimepiride) confer a higher risk of prolonged hypoglycemia than short-acting agents (e.g., glipiZIDE). |
| Recommendation |
Avoid sulfonylureas as first- or second-line monotherapy or add-on therapy unless there are substantial barriers to the use of safer and more effective agents.
If a sulfonylurea is used, choose short-acting agents (e.g., glipiZIDE) over long-acting agents (e.g., glyBURIDE, glimepiride). |
Quality of evidence: Hypoglycemia: High
CV events and all-cause mortality: Moderate
CV death and ischemic stroke: Low, Strength of Recommendation: Strong |
|
growth hormone (Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Skytrofa, Zomacton, Zorbtive )54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
growth hormone |
| Rationale |
Impact on body composition is small and associated with edema, arthralgia, carpal tunnel syndrome, gynecomastia, and impaired fasting glucose. |
| Recommendation |
Avoid, except for patients rigorously diagnosed by evidence-based criteria with growth hormone deficiency due to an established etiology. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
guanFACINE (Intuniv, Tenex)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
central alpha-agonists for the treatment of hypertension |
| Rationale |
High risk of adverse CNS effects; may cause bradycardia and orthostatic hypotension; not recommended as routine treatment for hypertension. |
| Recommendation |
Avoid central alpha-agonists for the treatment of hypertension. |
| Quality of evidence: Low, Strength of Recommendation: Strong |
|
| H Beer's Criteria |
| Halcion - see triazolam |
haloperidol (Haldol)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| HCTZ - see hydroCHLOROthiazide |
| Histex - see triprolidine |
homatropine (Hycodan, Hydromet)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| HumaLOG - see insulin lispro |
| Humatrope - see growth hormone |
| HumuLIN R - see insulin regular |
| Hycodan - see homatropine |
| Hydergine - see ergoloid mesylate |
hydroCHLOROthiazide (HydroDiuril, Microzide, HCTZ)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
hydroCHLOROthiazide-valsartan (Diovan HCT)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
hydrocortisone (Solu-CORTEF, Cortef)54321
| 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 |
corticosteroids (oral and parenteral) Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| Drug(s) ⇆ disease or syndrome |
corticosteroids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
If needed, use the lowest possible dose for the shortest duration and monitor for delirium. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| HydroDiuril - see hydroCHLOROthiazide |
| Hydromet - see homatropine |
HYDROmorphone (Dilaudid)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for pain management in the setting if severe acute pain. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
opioids ⇄ benzodiazepines |
| Risk Rationale |
Increased risk of overdose and adverse events. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ gabapentin, pregabalin |
| Risk Rationale |
Increased risk of severe sedation-related adverse events, including respiratory depression and death. |
| Recommendation |
Avoid; exceptions are when transitioning from opioid therapy to gabapentin or pregabalin, or when using gabapentinoids to reduce opioid dose, although caution should be used in all circumstances. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
hydrOXYzine (Atarax, Vistaril)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
first-generation antihistamines |
| Rationale |
Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; risk of confusion, dry mouth, constipation, and other anticholinergic effects or toxicity. Cumulative exposure to anticholinergic drugs is associated with an increased risk of falls, delirium, and dementia, even in younger adults. Consider total anticholinergic burden during regular medication reviews and be cautious in "young-old" as well as "old-old" adults. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Hygroton - see chlorthalidone |
hyoscyamine (Hyosyne, Levsin, Levsinex)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
GI antispasmodics with strong anticholinergic activity |
| Rationale |
Highly anticholinergic, uncertain effectiveness. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Hytrin - see terazosin |
| I Beer's Criteria |
ibuprofen (Caldolor, Motrin)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| 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) |
| 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 |
| |
| Drug(s) ⇆ disease or syndrome |
non-COX-2 selective NSAIDs ⇄ 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) |
| 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 |
|
iloperidone (Fanapt)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
imipramine (Tofranil)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antidepressants with strong anticholinergic activity, alone or in combination |
| Rationale |
Highly anticholinergic, sedating, and cause orthostatic hypotension. |
| Recommendation |
Avoid |
| Quality of evidence: High, 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
tricyclic antidepressants (TCAs) ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls.
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
tertiary tricyclic antidepressants (TCAs) ⇄ Syncope |
| Rationale |
Tertiary TCAs increase the risk of orthostatic hypotension. |
| Recommendation |
Avoid |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antidepressants (selected: TCAs) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
antidepressants (TCAs, SSRIs, and SNRIs) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Inapsine - see droperidol |
indapamide (Lozol)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
indomethacin (Indocin)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
indomethacin |
| Rationale |
Inreased risk of GI bleeding/peptic ulcer disease and acute kidney injury in older adults. Of all the NSAIDs, indomethacin has the most adverse effects, including a higher risk of adverse CNS effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| 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) |
| 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 |
| |
| Drug(s) ⇆ disease or syndrome |
non-COX-2 selective NSAIDs ⇄ 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) |
| 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 |
|
| Inspra - see eplerenone |
insulin aspart (NovoLOG)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
insulin, sliding scale (insulin regimens containing only short- or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin) |
| Rationale |
Higher risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting. Avoid insulin regimens that include only short- or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin. This recommendation does not apply to regimens that contain basal insulin or long-acting insulin. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
insulin glulisine (Apidra)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
insulin, sliding scale (insulin regimens containing only short- or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin) |
| Rationale |
Higher risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting. Avoid insulin regimens that include only short- or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin. This recommendation does not apply to regimens that contain basal insulin or long-acting insulin. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
insulin human in Normal Saline (Myxredlin)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
insulin, sliding scale (insulin regimens containing only short- or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin) |
| Rationale |
Higher risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting. Avoid insulin regimens that include only short- or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin. This recommendation does not apply to regimens that contain basal insulin or long-acting insulin. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
insulin lispro (HumaLOG)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
insulin, sliding scale (insulin regimens containing only short- or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin) |
| Rationale |
Higher risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting. Avoid insulin regimens that include only short- or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin. This recommendation does not apply to regimens that contain basal insulin or long-acting insulin. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
insulin regular (HumuLIN R)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
insulin, sliding scale (insulin regimens containing only short- or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin) |
| Rationale |
Higher risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting. Avoid insulin regimens that include only short- or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin. This recommendation does not apply to regimens that contain basal insulin or long-acting insulin. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Intuniv - see guanFACINE |
| Invega - see paliperidone |
| Invokana - see canagliflozin |
irbesartan (Avapro)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Isoptin - see verapamil |
| J Beer's Criteria |
| Jantoven - see warfarin |
| Jardiance - see empagliflozin |
| K Beer's Criteria |
| Kapidex - see dexlansoprazole |
| Karbinal - see carbinoxamine |
| Keppra - see levETIRAcetam |
| Kerendia - see finerenone |
ketorolac (Toradol)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Comments |
oral and parenteral |
| Drug(s) |
ketorolac |
| Rationale |
Inreased risk of GI bleeding/peptic ulcer disease and acute kidney injury in older adults. Of all the NSAIDs, indomethacin has the most adverse effects, including a higher risk of adverse CNS effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| 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) |
| 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 |
| |
| Drug(s) ⇆ disease or syndrome |
non-COX-2 selective NSAIDs ⇄ 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) |
| 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 |
|
| KlonoPIN - see clonazePAM |
| L Beer's Criteria |
lacosamide (Vimpat)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
lamoTRIgine (LaMICtal)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Lanoxin - see digoxin |
lansoprazole (Prevacid)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
proton-pump inhibitors |
| Rationale |
Risk of C. difficile infection, pneumonia, GI malignancies, bone loss, and fractures. |
| Recommendation |
Avoid scheduled use for >8 weeks unless for high-risk patients (e.g., oral corticosteroids or chronic NSAID use), erosive esophagitis, Barrett's esophagitis, pathologic hypersecretory condition, or demonstrated need for maintenance treatment (e.g., because of failure of drug discontinuation trial or H2-receptor antagonists). |
Quality of evidence: C. difficile, bone loss, and fractures: High
Pneumonia and GI malignancies: Moderate, Strength of Recommendation: Strong |
|
| Lasix - see furosemide |
| Latuda - see lurasidone |
levETIRAcetam (Keppra)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, 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) |
| CrCl (mL/min) at which action is required |
≤80 |
| Rationale |
CNS adverse effects |
| Recommendation |
Reduce dose |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
levomilnacipran (Fetzima)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antidepressants (selected classes: SNRIs) ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antidepressants (selected: SNRIs) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antidepressants (TCAs, SSRIs, and SNRIs) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Levsin - see hyoscyamine |
| Levsinex - see hyoscyamine |
| Lexapro - see escitalopram |
| Librax - see clidinium-chlordiazePOXIDE |
| Librium - see chlordiazePOXIDE |
| Lioresal - see baclofen |
lisinopril (Prinivil, Zestril)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
lithium (Eskalith, Lithobid)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
lithium ⇄ ACEIs, ARBs, ARNIs |
| Risk Rationale |
Increased risk of lithium toxicity. |
| Recommendation |
Avoid; monitor lithium concentrations. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
lithium ⇄ Loop diuretics |
| Risk Rationale |
Increased risk of lithium toxicity. |
| Recommendation |
Avoid; monitor lithium concentrations. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Lodine - see etodolac |
| Lomotil - see atropine-diphenoxylate |
LORazepam (Ativan)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
benzodiazepines |
| Rationale |
The use of benzodiazepines exposes users to risks of abuse, misuse, and addiction. Concomitant use of opioids may result in profound sedation, respiratory depression, coma, and death.
Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; the continued use of benzodiazepines may lead to clinically significant physical dependence. In general, all benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults.
May be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls.
Benzodiazepines: shorter-acting ones are not safer than long-acting ones.
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
benzodiazepines ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Lortab - see acetaminophen-HYDROcodone |
losartan (Cozaar)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Lotensin - see benazepril |
| Lovenox - see enoxaparin |
loxapine (Loxitane)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Lozol - see indapamide |
lumateperone (Caplyta)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (selected) ⇄ Syncope |
| Rationale |
Antipsychotic selected increases the risk of orthostatic hypotension. |
| Recommendation |
Avoid |
| Quality of evidence: High, Strength of Recommendation: Weak |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Luminal - see PHENobarbital |
| Lunesta - see eszopiclone |
lurasidone (Latuda)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Luvox - see fLuvoxaMINE |
| Lyrica - see pregabalin |
| M Beer's Criteria |
| Macrobid - see nitrofurantoin |
| Macrodantin - see nitrofurantoin |
magnesium salicylate (Doan's)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| 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) |
| Drug(s) ⇆ disease or syndrome |
nonacetylated salicylates ⇄ 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 |
| |
| Drug(s) ⇆ disease or syndrome |
non-COX-2 selective NSAIDs ⇄ 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) |
| 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 |
|
mannitol54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Marinol - see droNABinol |
| Mavik - see trandolapril |
| Maxzide - see triamterene-hydroCHLOROthiazide |
meclizine (Antivert)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
first-generation antihistamines |
| Rationale |
Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; risk of confusion, dry mouth, constipation, and other anticholinergic effects or toxicity. Cumulative exposure to anticholinergic drugs is associated with an increased risk of falls, delirium, and dementia, even in younger adults. Consider total anticholinergic burden during regular medication reviews and be cautious in "young-old" as well as "old-old" adults. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Medrol - see methylPREDNISolone |
megestrol (Megace)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
megestrol |
| Rationale |
Minimal effect on weight; increases the risk of thrombotic events and possibly death in older adults. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Mellaril - see thioridazine |
meloxicam (Mobic)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| 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) |
| 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 |
| |
| Drug(s) ⇆ disease or syndrome |
non-COX-2 selective NSAIDs ⇄ 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) |
| 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 |
|
| Menest - see estrogens, esterified |
meperidine (Demerol)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
meperidine |
| Rationale |
Oral analgesic not effective in dosages commonly used; may have a higher risk of neurotoxicity, including delirium, than other opioids; safer alternatives available. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for pain management in the setting if severe acute pain. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
opioids ⇄ benzodiazepines |
| Risk Rationale |
Increased risk of overdose and adverse events. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ gabapentin, pregabalin |
| Risk Rationale |
Increased risk of severe sedation-related adverse events, including respiratory depression and death. |
| Recommendation |
Avoid; exceptions are when transitioning from opioid therapy to gabapentin or pregabalin, or when using gabapentinoids to reduce opioid dose, although caution should be used in all circumstances. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
meprobamate (Equanil, Miltown)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
meprobamate |
| Rationale |
High rate of physical dependence; very sedating. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
metaxalone (Skelaxin)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
skeletal muscle relaxants |
| Rationale |
Muscle relaxants typically used to treat musculoskeletal complaints are poorly tolerated by older adults due to anticholinergic adverse effects, sedation, and increased risk of fractures; effectiveness at dosages tolerated by older adults is questionable.
This criterion does not apply to skeletal muscle relaxants typically used for the management of spasticity (i.e., baclofen and tiZANidine) although these drugs can also cause substantial adverse effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
skeletal muscle relaxants ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
methadone (Dolophine)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for pain management in the setting if severe acute pain. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
opioids ⇄ benzodiazepines |
| Risk Rationale |
Increased risk of overdose and adverse events. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ gabapentin, pregabalin |
| Risk Rationale |
Increased risk of severe sedation-related adverse events, including respiratory depression and death. |
| Recommendation |
Avoid; exceptions are when transitioning from opioid therapy to gabapentin or pregabalin, or when using gabapentinoids to reduce opioid dose, although caution should be used in all circumstances. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
methazolAMIDE (Neptazane)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Methitest - see methyltestosterone |
methocarbamol (Robaxin)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
skeletal muscle relaxants |
| Rationale |
Muscle relaxants typically used to treat musculoskeletal complaints are poorly tolerated by older adults due to anticholinergic adverse effects, sedation, and increased risk of fractures; effectiveness at dosages tolerated by older adults is questionable.
This criterion does not apply to skeletal muscle relaxants typically used for the management of spasticity (i.e., baclofen and tiZANidine) although these drugs can also cause substantial adverse effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
skeletal muscle relaxants ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
methylPREDNISolone (DEPO-Medrol, Medrol, Solu-MEDROL)54321
| 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 |
corticosteroids (oral and parenteral) Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| Drug(s) ⇆ disease or syndrome |
corticosteroids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
If needed, use the lowest possible dose for the shortest duration and monitor for delirium. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
methyltestosterone (Android, Methitest, Testred)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
androgens |
| Rationale |
Potential for cardiac problems; potential risks in men with prostate cancer. |
| Recommendation |
Avoid unless indicated for confirmed hypogonadism with clinical symptoms. |
| Quality of evidence: Moderate, Strength of Recommendation: Weak |
|
metoclopramide (Reglan)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
metoclopramide |
| Rationale |
Can cause extrapyramidal effects, including tardive dyskinesia; the risk may be greater in frail older adults and with prolonged exposure. |
| Recommendation |
Avoid, unless for gastroparesis with a duration of use not to exceed 12 weeks except in rare cases. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiemetics ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
metOLazone (Zaroxolyn)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Micardis - see telmisartan |
| Micronase - see glyBURIDE |
| Microzide - see hydroCHLOROthiazide |
| Midamor - see aMILoride |
midazolam (Versed)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
benzodiazepines |
| Rationale |
The use of benzodiazepines exposes users to risks of abuse, misuse, and addiction. Concomitant use of opioids may result in profound sedation, respiratory depression, coma, and death.
Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; the continued use of benzodiazepines may lead to clinically significant physical dependence. In general, all benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults.
May be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls.
Benzodiazepines: shorter-acting ones are not safer than long-acting ones.
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
benzodiazepines ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
milnacipran (Savella)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antidepressants (selected classes: SNRIs) ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antidepressants (selected: SNRIs) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antidepressants (TCAs, SSRIs, and SNRIs) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Miltown - see meprobamate |
mineral oil54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Comments |
given orally |
| Drug(s) |
mineral oil |
| Rationale |
Potential for aspiration and adverse effects; safer alternatives available. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Minipress - see prazosin |
mirtazapine (Remeron)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antidepressants (selected) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Mitigare - see colchicine |
| Mobic - see meloxicam |
| Moduretic - see aMILoride-hydroCHLOROthiazide |
moexipril (Univasc)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Monopril - see fosinopril |
morphine (Oramorph SR, Roxanol)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for pain management in the setting if severe acute pain. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
opioids ⇄ benzodiazepines |
| Risk Rationale |
Increased risk of overdose and adverse events. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ gabapentin, pregabalin |
| Risk Rationale |
Increased risk of severe sedation-related adverse events, including respiratory depression and death. |
| Recommendation |
Avoid; exceptions are when transitioning from opioid therapy to gabapentin or pregabalin, or when using gabapentinoids to reduce opioid dose, although caution should be used in all circumstances. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Motrin - see ibuprofen |
| Multaq - see dronedarone |
| Mysoline - see primidone |
| Myxredlin - see insulin human in Normal Saline |
| N Beer's Criteria |
nabumetone (Relafen)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| 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) |
| 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 |
| |
| Drug(s) ⇆ disease or syndrome |
non-COX-2 selective NSAIDs ⇄ 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) |
| 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 |
|
naproxen (Aleve, Anaprox, Naprelan, Naprosyn)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| 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) |
| 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 |
| |
| Drug(s) ⇆ disease or syndrome |
non-COX-2 selective NSAIDs ⇄ 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) |
| 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 |
|
| Navane - see thiothixene |
| Neptazane - see methazolAMIDE |
| Neurontin - see gabapentin |
| NexIUM - see esomeprazole |
| Nexterone - see amiodarone |
NIFEdipine (Adalat, Procardia)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Comments |
immediate release |
| Drug(s) |
NIFEdipine |
| Rationale |
Potential for hypotension; risk of precipitating myocardial ischemia. |
| Recommendation |
Avoid |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
nitrofurantoin (Furadantin, Macrobid, Macrodantin)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
nitrofurantoin |
| Rationale |
Potential for pulmonary toxicity, hepatoxicity, and peripheral neuropathy, especially with long-term use; safer alternatives available. |
| Recommendation |
Avoid in individuals with CrCl <30 mL/min or for long-term suppression. |
| Quality of evidence: Low, 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) |
| CrCl (mL/min) at which action is required |
<30 |
| Rationale |
Potential for pulmonary toxicity, hepatoxicity, and peripheral neuropathy, especially with long-term use. (See also Table 2). |
| Recommendation |
Avoid if CrCl <30 mL/min |
| Quality of evidence: Low, Strength of Recommendation: Strong |
|
nizatidine (Axid)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
H2-receptor antagonists ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Low, 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) |
| CrCl (mL/min) at which action is required |
<50 |
| Rationale |
Mental status changes |
| Recommendation |
Reduce dose |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Norco - see acetaminophen-HYDROcodone |
| Norditropin - see growth hormone |
| Norflex - see orphenadrine |
| Norpramin - see desipramine |
nortriptyline (Pamelor)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antidepressants with strong anticholinergic activity, alone or in combination |
| Rationale |
Highly anticholinergic, sedating, and cause orthostatic hypotension. |
| Recommendation |
Avoid |
| Quality of evidence: High, 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
tricyclic antidepressants (TCAs) ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls.
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antidepressants (selected: TCAs) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
antidepressants (TCAs, SSRIs, and SNRIs) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| NovoLOG - see insulin aspart |
| Nuedexta - see dextromethorphan-quiNIDine |
| Numorphan - see oxyMORphone |
| Nuplazid - see pimavanserin |
| Nutropin AQ - see growth hormone |
| O Beer's Criteria |
| Ocufen - see flurbiprofen |
| Ogen - see estropipate |
OLANZapine (ZyPREXA)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (selected) ⇄ Syncope |
| Rationale |
Antipsychotic selected increases the risk of orthostatic hypotension. |
| Recommendation |
Avoid |
| Quality of evidence: High, Strength of Recommendation: Weak |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
olmesartan (Benicar)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
omeprazole (PriLOSEC)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
proton-pump inhibitors |
| Rationale |
Risk of C. difficile infection, pneumonia, GI malignancies, bone loss, and fractures. |
| Recommendation |
Avoid scheduled use for >8 weeks unless for high-risk patients (e.g., oral corticosteroids or chronic NSAID use), erosive esophagitis, Barrett's esophagitis, pathologic hypersecretory condition, or demonstrated need for maintenance treatment (e.g., because of failure of drug discontinuation trial or H2-receptor antagonists). |
Quality of evidence: C. difficile, bone loss, and fractures: High
Pneumonia and GI malignancies: Moderate, Strength of Recommendation: Strong |
|
| Omnitrope - see growth hormone |
| Onfi - see cloBAZam |
| Opana - see oxyMORphone |
opium (Paragoric)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for pain management in the setting if severe acute pain. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
opioids ⇄ benzodiazepines |
| Risk Rationale |
Increased risk of overdose and adverse events. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ gabapentin, pregabalin |
| Risk Rationale |
Increased risk of severe sedation-related adverse events, including respiratory depression and death. |
| Recommendation |
Avoid; exceptions are when transitioning from opioid therapy to gabapentin or pregabalin, or when using gabapentinoids to reduce opioid dose, although caution should be used in all circumstances. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Oramorph SR - see morphine |
| Orap - see pimozide |
| Orapred - see prednisoLONE |
orphenadrine (Norflex)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
skeletal muscle relaxants |
| Rationale |
Muscle relaxants typically used to treat musculoskeletal complaints are poorly tolerated by older adults due to anticholinergic adverse effects, sedation, and increased risk of fractures; effectiveness at dosages tolerated by older adults is questionable.
This criterion does not apply to skeletal muscle relaxants typically used for the management of spasticity (i.e., baclofen and tiZANidine) although these drugs can also cause substantial adverse effects. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
skeletal muscle relaxants ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Ortho-Est - see estropipate |
oxaprozin (Daypro)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| 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) |
| 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 |
| |
| Drug(s) ⇆ disease or syndrome |
non-COX-2 selective NSAIDs ⇄ 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) |
| 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 |
|
| Oxaydo - see oxyCODONE |
oxazepam (Serax)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
benzodiazepines |
| Rationale |
The use of benzodiazepines exposes users to risks of abuse, misuse, and addiction. Concomitant use of opioids may result in profound sedation, respiratory depression, coma, and death.
Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; the continued use of benzodiazepines may lead to clinically significant physical dependence. In general, all benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults.
May be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls.
Benzodiazepines: shorter-acting ones are not safer than long-acting ones.
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
benzodiazepines ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
OXcarbazepine (Oxtellar XR)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antiepileptics (selected) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Oxtellar XR - see OXcarbazepine |
oxybutynin (Ditropan)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
oxyCODONE (Oxaydo, OxyCONTIN, Oxyfast, Oxy-IR, Percodan, Roxicodone, Roxybond, Xtampza)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for pain management in the setting if severe acute pain. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
opioids ⇄ benzodiazepines |
| Risk Rationale |
Increased risk of overdose and adverse events. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ gabapentin, pregabalin |
| Risk Rationale |
Increased risk of severe sedation-related adverse events, including respiratory depression and death. |
| Recommendation |
Avoid; exceptions are when transitioning from opioid therapy to gabapentin or pregabalin, or when using gabapentinoids to reduce opioid dose, although caution should be used in all circumstances. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
oxyMORphone (Numorphan, Opana)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for pain management in the setting if severe acute pain. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
opioids ⇄ benzodiazepines |
| Risk Rationale |
Increased risk of overdose and adverse events. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ gabapentin, pregabalin |
| Risk Rationale |
Increased risk of severe sedation-related adverse events, including respiratory depression and death. |
| Recommendation |
Avoid; exceptions are when transitioning from opioid therapy to gabapentin or pregabalin, or when using gabapentinoids to reduce opioid dose, although caution should be used in all circumstances. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| P Beer's Criteria |
| Pacerone - see amiodarone |
paliperidone (Invega)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Pamelor - see nortriptyline |
pantoprazole (ProtoNix)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
proton-pump inhibitors |
| Rationale |
Risk of C. difficile infection, pneumonia, GI malignancies, bone loss, and fractures. |
| Recommendation |
Avoid scheduled use for >8 weeks unless for high-risk patients (e.g., oral corticosteroids or chronic NSAID use), erosive esophagitis, Barrett's esophagitis, pathologic hypersecretory condition, or demonstrated need for maintenance treatment (e.g., because of failure of drug discontinuation trial or H2-receptor antagonists). |
Quality of evidence: C. difficile, bone loss, and fractures: High
Pneumonia and GI malignancies: Moderate, Strength of Recommendation: Strong |
|
| Parafon Forte DSC - see chlorzoxazone |
| Paragoric - see opium |
PARoxetine (Paxil)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antidepressants with strong anticholinergic activity, alone or in combination |
| Rationale |
Highly anticholinergic, sedating, and cause orthostatic hypotension. |
| Recommendation |
Avoid |
| Quality of evidence: High, 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antidepressants (selected classes: SSRIs) ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antidepressants (selected: SSRIs) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
antidepressants (TCAs, SSRIs, and SNRIs) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Paxil - see PARoxetine |
| PediaPred - see prednisoLONE |
| Pepcid - see famotidine |
perampanel (Fycompa)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Percocet - see acetaminophen-oxyCODONE |
| Percodan - see oxyCODONE |
| Periactin - see cyproheptadine |
perindopril (Aceon)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
perphenazine (Trilafon)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Persantine - see dipyridamole |
| Phenadoz - see promethazine |
| Phenergan - see promethazine |
PHENobarbital (Luminal)54321
| 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 |
| |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
phenytoin (Dilantin, Phenytek)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
phenytoin ⇄ trimethoprim-sulfamethoxazole |
| Risk Rationale |
Increased risk of phenytoin toxicity |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
pimavanserin (Nuplazid)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
pimozide (Orap)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
pioglitazone (Actos)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
thiazolidinediones ⇄ 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: High, Strength of Recommendation: Strong |
|
piroxicam (Feldene)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| 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) |
| 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 |
| |
| Drug(s) ⇆ disease or syndrome |
non-COX-2 selective NSAIDs ⇄ 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) |
| 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 |
|
| Pletal - see cilostazol |
| Pradaxa - see dabigatran |
prasugrel (Effient)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
prasugrel |
| Rationale |
Increases the risk of major bleeding in older adults compared with cLopidogrel, especially among those 75 years old and older. However, this risk may be offset by cardiovascular benefits in select patients. |
| Recommendation |
Use with caution, particularly in adults 75 years old and older.
If prasugrel is used, consider a lower dose (5 mg) for those 75 years old and older. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
prazosin (Minipress)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
non-selective peripheral alpha-1 blockers for the treatment of hypertension |
| Rationale |
High risk of orthostatic hypotension and associated harms, especially in older adults; not recommended as routine treatment for hypertension; alternative agents have superior risk/benefit profile. |
| Recommendation |
Avoid use as an antihypertensive. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
non-selective peripheral alpha-1 blockers ⇄ Syncope |
| Rationale |
Non-selective peripheral alpha-1 blockers cause orthostatic blood pressure changes and should be avoided in older adults whose syncope may be due to orthostatic hypotension. |
| Recommendation |
Avoid |
| Quality of evidence: High, Strength of Recommendation: Weak |
| |
| Drug(s) ⇆ disease or syndrome |
non-selective peripheral alpha-1 blockers ⇄ Urinary incontinence (all types) in women |
| Rationale |
Aggravation of incontinence. |
| Recommendation |
Avoid in women. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
non-selective peripheral alpha-1 blockers ⇄ Loop diuretics |
| Risk Rationale |
Increased risk of urinary incontinence in older women. |
| Recommendation |
Avoid in older women, unless conditions warrant both drugs. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
prednisoLONE (Orapred, PediaPred, Pred Forte, Prelone)54321
| 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 |
corticosteroids (oral and parenteral) Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| Drug(s) ⇆ disease or syndrome |
corticosteroids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
If needed, use the lowest possible dose for the shortest duration and monitor for delirium. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
predniSONE (Deltasone, Sterapred)54321
| 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 |
corticosteroids (oral and parenteral) Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| Drug(s) ⇆ disease or syndrome |
corticosteroids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
If needed, use the lowest possible dose for the shortest duration and monitor for delirium. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
pregabalin (Lyrica)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, 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) |
| CrCl (mL/min) at which action is required |
<60 |
| Rationale |
CNS adverse effects |
| Recommendation |
Reduce dose |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Prelone - see prednisoLONE |
| Premphase - see estrogen/progesterone combinations |
| Prempro - see estrogen/progesterone combinations |
| Prevacid - see lansoprazole |
| PriLOSEC - see omeprazole |
primidone (Mysoline)54321
| 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 |
| |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Prinivil - see lisinopril |
| Pristiq - see desvenlafaxine |
probenecid (Benemid)54321
| Criteria 5: medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults. (Table 6) |
| CrCl (mL/min) at which action is required |
<30 |
| Rationale |
Loss of effectiveness |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Procardia - see NIFEdipine |
prochlorperazine (Compazine)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antiemetics ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Prolixin - see fluPHENAZine |
promethazine (Phenadoz, Phenergan)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
first-generation antihistamines |
| Rationale |
Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; risk of confusion, dry mouth, constipation, and other anticholinergic effects or toxicity. Cumulative exposure to anticholinergic drugs is associated with an increased risk of falls, delirium, and dementia, even in younger adults. Consider total anticholinergic burden during regular medication reviews and be cautious in "young-old" as well as "old-old" adults. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antiemetics ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Prosom - see estazolam |
| ProtoNix - see pantoprazole |
| PROzac - see FLUoxetine |
| Q Beer's Criteria |
| Qudexy XR - see topiramate |
QUEtiapine (SEROquel)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
quinapril (Accupril)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| R Beer's Criteria |
RABEprazole (Aciphex)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
proton-pump inhibitors |
| Rationale |
Risk of C. difficile infection, pneumonia, GI malignancies, bone loss, and fractures. |
| Recommendation |
Avoid scheduled use for >8 weeks unless for high-risk patients (e.g., oral corticosteroids or chronic NSAID use), erosive esophagitis, Barrett's esophagitis, pathologic hypersecretory condition, or demonstrated need for maintenance treatment (e.g., because of failure of drug discontinuation trial or H2-receptor antagonists). |
Quality of evidence: C. difficile, bone loss, and fractures: High
Pneumonia and GI malignancies: Moderate, Strength of Recommendation: Strong |
|
ramipril (Altace)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Rapaflo - see silodosin |
| Razadyne - see galantamine |
| Reglan - see metoclopramide |
| Relafen - see nabumetone |
| Remeron - see mirtazapine |
| Restoril - see temazepam |
| Rexulti - see brexpiprazole |
risperiDONE (RisperDAL)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
rivaroxaban (Xarelto)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Comments |
When selecting among DOACs and choosing a dose, pay special consideration to kidney function (see Table 6), indication, and body weight. |
| Drug(s) |
for long-term treatment of nonvalvular atrial fibrillation or venous thromboembolism (VTE) |
| Rationale |
At doses used for long-term treatment of VTE or nonvalvular atrial fibrillation, rivaroxaban appears to have a higher risk of major bleeding and GI bleeding in older adults than other DOACs, particularly apixaban.
rivaroxaban may be reasonable in special situations, for example when once-daily dosing is necessary to facilitate medication adherence. All DOACs confer a lower risk of intracranial hemorrhage than warfarin. |
| Recommendation |
Avoid for long-term treatment of atrial fibrillation or VTE in favor of safer anticoagulant alternatives.
See also criteria on warfarin (Table 2) and dabigatran (Table 4) and comment above regarding the choice between warfarin and DOACs and among DOACs. |
| 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) |
| CrCl (mL/min) at which action is required |
<50 |
| Rationale |
Lack of efficacy or safety evidence in people with CrCl <15 mL/min; limited evidence for CrCl 15-30 mL/min. |
| Recommendation |
Avoid if CrCl <15 mL/min.
Reduce the dose if CrCl is 15-50 mL/min following manufacturer dosing recommendations based on indication-specific dosing. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
rivastigmine (Exelon)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
cholinesterase inhibitors (AChEIs) ⇄ Syncope |
| Rationale |
AChEIs cause bradycardia and should be avoided in older adults whose syncope may be due to bradycardia. |
| Recommendation |
Avoid |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Robaxin - see methocarbamol |
| Roxanol - see morphine |
| Roxicet - see acetaminophen-oxyCODONE |
| Roxicodone - see oxyCODONE |
| Roxybond - see oxyCODONE |
rufinamide (Banzel)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| S Beer's Criteria |
| Sabril - see vigabatrin |
sacubitril-valsartan (Entresto)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Saizen - see growth hormone |
| Sanctura - see trospium |
| Saphris - see asenapine |
| Savaysa - see edoxaban |
| Savella - see milnacipran |
scopolamine (Transderm Scop)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
GI antispasmodics with strong anticholinergic activity |
| Rationale |
Highly anticholinergic, uncertain effectiveness. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Septra - see trimethoprim-sulfamethoxazole |
| Serax - see oxazepam |
| SEROquel - see QUEtiapine |
| Serostim - see growth hormone |
sertraline (Zoloft)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antidepressants (selected classes: SSRIs) ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antidepressants (selected: SSRIs) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antidepressants (TCAs, SSRIs, and SNRIs) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
silodosin (Rapaflo)54321
| Data are limited for selective peripheral alpha-1 blockers (e.g., tamsulosin, silodosin, and others) but may apply as well. |
| |
| 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) |
| Drug(s) ⇆ disease or syndrome |
selective peripheral alpha-1 blockers ⇄ Urinary incontinence (all types) in women |
| Rationale |
Aggravation of incontinence. |
| Recommendation |
Avoid in women. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
selective peripheral alpha-1 blockers ⇄ Loop diuretics |
| Risk Rationale |
Increased risk of urinary incontinence in older women. |
| Recommendation |
Avoid in older women, unless conditions warrant both drugs. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| SINEquan - see doxepin |
| Skelaxin - see metaxalone |
| Skytrofa - see growth hormone |
solifenacin (Vesicare)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Solu-CORTEF - see hydrocortisone |
| Solu-MEDROL - see methylPREDNISolone |
| Soma - see carisoprodol |
| Sonata - see zaleplon |
spironolactone (Aldactone, Carospir)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
potassium-sparing diuretics ⇄ RAS inhibitors (ACEIs, ARBs, ARNIs, aliskiren) |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| 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) |
| CrCl (mL/min) at which action is required |
<30 |
| Rationale |
Hyperkalemia |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
spironolactone-hydroCHLOROthiazide (Aldactazide)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
potassium-sparing diuretics ⇄ RAS inhibitors (ACEIs, ARBs, ARNIs, aliskiren) |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| 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) |
| CrCl (mL/min) at which action is required |
<30 |
| Rationale |
Hyperkalemia |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Stavzor - see valproic acid |
| Steglatro - see ertugliflozin |
| Stelazine - see trifluoperazine |
| Sterapred - see predniSONE |
stiripentol (Diacomit)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Sublimaze - see fentaNYL |
SUFentanil (Sufenta)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for pain management in the setting if severe acute pain. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
opioids ⇄ benzodiazepines |
| Risk Rationale |
Increased risk of overdose and adverse events. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ gabapentin, pregabalin |
| Risk Rationale |
Increased risk of severe sedation-related adverse events, including respiratory depression and death. |
| Recommendation |
Avoid; exceptions are when transitioning from opioid therapy to gabapentin or pregabalin, or when using gabapentinoids to reduce opioid dose, although caution should be used in all circumstances. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
sulindac (Clinoril)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| 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) |
| 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 |
| |
| Drug(s) ⇆ disease or syndrome |
non-COX-2 selective NSAIDs ⇄ 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) |
| 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 |
|
| Sympazan - see cloBAZam |
| T Beer's Criteria |
| Tagamet - see cimetidine |
tamsulosin (Flomax)54321
| Data are limited for selective peripheral alpha-1 blockers (e.g., tamsulosin, silodosin, and others) but may apply as well. |
| |
| 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) |
| Drug(s) ⇆ disease or syndrome |
selective peripheral alpha-1 blockers ⇄ Urinary incontinence (all types) in women |
| Rationale |
Aggravation of incontinence. |
| Recommendation |
Avoid in women. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
selective peripheral alpha-1 blockers ⇄ Loop diuretics |
| Risk Rationale |
Increased risk of urinary incontinence in older women. |
| Recommendation |
Avoid in older women, unless conditions warrant both drugs. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Tarka - see trandolapril-verapamil |
| TEGretol - see carBAMazepine |
| Tekturna - see aliskiren |
telmisartan (Micardis)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
temazepam (Restoril)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
benzodiazepines |
| Rationale |
The use of benzodiazepines exposes users to risks of abuse, misuse, and addiction. Concomitant use of opioids may result in profound sedation, respiratory depression, coma, and death.
Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; the continued use of benzodiazepines may lead to clinically significant physical dependence. In general, all benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults.
May be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls.
Benzodiazepines: shorter-acting ones are not safer than long-acting ones.
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
benzodiazepines ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Tenex - see guanFACINE |
terazosin (Hytrin)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
non-selective peripheral alpha-1 blockers for the treatment of hypertension |
| Rationale |
High risk of orthostatic hypotension and associated harms, especially in older adults; not recommended as routine treatment for hypertension; alternative agents have superior risk/benefit profile. |
| Recommendation |
Avoid use as an antihypertensive. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
non-selective peripheral alpha-1 blockers ⇄ Syncope |
| Rationale |
Non-selective peripheral alpha-1 blockers cause orthostatic blood pressure changes and should be avoided in older adults whose syncope may be due to orthostatic hypotension. |
| Recommendation |
Avoid |
| Quality of evidence: High, Strength of Recommendation: Weak |
| |
| Drug(s) ⇆ disease or syndrome |
non-selective peripheral alpha-1 blockers ⇄ Urinary incontinence (all types) in women |
| Rationale |
Aggravation of incontinence. |
| Recommendation |
Avoid in women. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
non-selective peripheral alpha-1 blockers ⇄ Loop diuretics |
| Risk Rationale |
Increased risk of urinary incontinence in older women. |
| Recommendation |
Avoid in older women, unless conditions warrant both drugs. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
testosterone (Androderm, AndroGel, Aveed, Depo-testosterone, Fortesta, Testim, Vogelxo)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
androgens |
| Rationale |
Potential for cardiac problems; potential risks in men with prostate cancer. |
| Recommendation |
Avoid unless indicated for confirmed hypogonadism with clinical symptoms. |
| Quality of evidence: Moderate, Strength of Recommendation: Weak |
|
| Testred - see methyltestosterone |
| Thalitone - see chlorthalidone |
theophylline54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
theophylline ⇄ cimetidine |
| Risk Rationale |
Increased risk of theophylline toxicity |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
theophylline ⇄ ciprofloxacin |
| Risk Rationale |
Increased risk of theophylline toxicity |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
thioridazine (Mellaril)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
thiothixene (Mellaril)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Thorazine - see chlorproMAZINE |
tiaGABine (Gabitril)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
ticagrelor (Brilinta)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
ticagrelor |
| Rationale |
Increases the risk of major bleeding in older adults compared with cLopidogrel, especially among those 75 years old and older. However, this risk may be offset by cardiovascular benefits in select patients. |
| Recommendation |
Use with caution, particularly in adults 75 years old and older. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Tikosyn - see dofetilide |
tiZANidine (Zanaflex)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
skeletal muscle relaxants ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Tofranil - see imipramine |
tolterodine (Detrol)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
topiramate (Qudexy XR, Topamax)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Toradol - see ketorolac |
torsemide (Demadex)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Toviaz - see fesoterodine |
traMADol (Ultram)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
opioids ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for pain management in the setting if severe acute pain. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
traMADol |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
opioids ⇄ benzodiazepines |
| Risk Rationale |
Increased risk of overdose and adverse events. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Interacting drug(s) or class(es) |
opioids ⇄ gabapentin, pregabalin |
| Risk Rationale |
Increased risk of severe sedation-related adverse events, including respiratory depression and death. |
| Recommendation |
Avoid; exceptions are when transitioning from opioid therapy to gabapentin or pregabalin, or when using gabapentinoids to reduce opioid dose, although caution should be used in all circumstances. |
| 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) |
| CrCl (mL/min) at which action is required |
<30 |
| Rationale |
CNS adverse effects |
| Recommendation |
Immediate release: reduce dose
Extended-release: avoid |
| Quality of evidence: Low, Strength of Recommendation: Weak |
|
trandolapril (Mavik)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
trandolapril-verapamil (Tarka)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
non-dihydropyridine calcium channel blockers (CCBs) ⇄ Heart failure |
| Rationale |
Potential to promote fluid retention and/or exacerbate heart failure. |
| Recommendation |
Avoid in heart failure with reduced ejection fraction. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Transderm Scop - see scopolamine |
| Tranxene - see clorazepate |
triamterene (Dyrenium)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
potassium-sparing diuretics ⇄ RAS inhibitors (ACEIs, ARBs, ARNIs, aliskiren) |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| 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) |
| CrCl (mL/min) at which action is required |
<30 |
| Rationale |
Hyperkalemia and hyponatremia |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
triamterene-hydroCHLOROthiazide (Dyazide, Maxzide)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
diuretics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
potassium-sparing diuretics ⇄ RAS inhibitors (ACEIs, ARBs, ARNIs, aliskiren) |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| 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) |
| CrCl (mL/min) at which action is required |
<30 |
| Rationale |
Hyperkalemia and hyponatremia |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
triazolam (Halcion)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
benzodiazepines |
| Rationale |
The use of benzodiazepines exposes users to risks of abuse, misuse, and addiction. Concomitant use of opioids may result in profound sedation, respiratory depression, coma, and death.
Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; the continued use of benzodiazepines may lead to clinically significant physical dependence. In general, all benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults.
May be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
benzodiazepines ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls.
Benzodiazepines: shorter-acting ones are not safer than long-acting ones.
If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
benzodiazepines ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
trifluoperazine (Stelazine)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
trihexyphenidyl (Artane)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antiParkinsonian agents with strong anticholinergic activity |
| Rationale |
Not recommended for prevention or treatment of extrapyramidal symptoms due to antipsychotics; more effective agents available for the treatment of Parkinson disease. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Trilafon - see perphenazine |
trimethoprim-sulfamethoxazole (Bactrim, Septra)54321
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
trimethoprim-sulfamethoxazole |
| Rationale |
Increased risk of hyperkalemia when used concurrently with an ACEI, ARB, or ARNI in presence of decreased CrCl. |
| Recommendation |
Use with caution in patients on ACEI, ARB, or ARNI and decreased CrCl. |
| Quality of evidence: Low, 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) |
| CrCl (mL/min) at which action is required |
<30 |
| Rationale |
Increased risk of worsening of kidney function and hyperkalemia; risk of hyperkalemia especially prominent with concurrent use of an ACE, ARB, or ARNI. |
| Recommendation |
Reduce dosage if CrCl is 15-29 mL/min.
Avoid if CrCl <15 mL/min. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
triprolidine (Histex, Zymine)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
first-generation antihistamines |
| Rationale |
Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; risk of confusion, dry mouth, constipation, and other anticholinergic effects or toxicity. Cumulative exposure to anticholinergic drugs is associated with an increased risk of falls, delirium, and dementia, even in younger adults. Consider total anticholinergic burden during regular medication reviews and be cautious in "young-old" as well as "old-old" adults.
Use of diphenhydrAMINE in situations such as acute treatment of severe allergic reactions may be appropriate. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia |
| Rationale |
May decrease urinary flow and cause urinary retention |
| Recommendation |
Avoid in men |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
trospium (Sanctura)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
anticholinergics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
anticholinergics ⇄ anticholinergics |
| Risk Rationale |
Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures. |
| Recommendation |
Avoid; minimize the number of anticholinergic drugs Click for list. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Tylenol #3 - see acetaminophen-codeine |
| Tylox - see acetaminophen-oxyCODONE |
| U Beer's Criteria |
| Ultracet - see acetaminophen-traMADol |
| Ultram - see traMADol |
| Unisom - see doxylamine |
| Univasc - see moexipril |
| Urispas - see flavoxATE |
| Uroxatral - see alfuzosin |
| V Beer's Criteria |
| Valium - see diazePAM |
valproic acid (Depacon, Stavzor)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
valsartan (Diovan)54321
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
RAS inhibitors (ACEIs ARBs, ARNIs, aliskiren) ⇄ Another RAS inhibitor or a potassium-sparing diuretic |
| Risk Rationale |
Increased risk of hyperkalemia. |
| Recommendation |
Avoid routinely using 2 or more RAS inhibitors, or a RAS inhibitor and potassium-sparing diuretic, concurrently in those with chronic kidney disease Stage 3a or higher. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Vasotec - see enalapril |
venlafaxine (Effexor)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antidepressants (selected classes: SNRIs) ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antidepressants (selected: SNRIs) |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antidepressants (TCAs, SSRIs, and SNRIs) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
verapamil (Calan, Covera, Isoptin)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
non-dihydropyridine calcium channel blockers (CCBs) ⇄ Heart failure |
| Rationale |
Potential to promote fluid retention and/or exacerbate heart failure. |
| Recommendation |
Avoid in heart failure with reduced ejection fraction. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| Versed - see midazolam |
| Vesicare - see solifenacin |
| Vicodin - see acetaminophen-HYDROcodone |
vigabatrin (Sabril)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Vimpat - see lacosamide |
| Vistaril - see hydrOXYzine |
| Vivelle-Dot - see estradiol |
| Vogelxo - see testosterone |
| Voltaren - see diclofenac |
| Vraylar - see cariprazine |
| W Beer's Criteria |
warfarin (Coumadin, Jantoven)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
for the treatment of nonvalvular atrial fibrillation or venous thromboembolism (VTE) |
| Rationale |
Compared with DOACs, warfarin has higher risks of major bleeding (particularly intracranial bleeding) and similar or lower effectiveness for the treatment of nonvalvular atrial fibrillation and VTE. DOACs are thus the preferred choice for anticoagulation for most people with these conditions. |
| Recommendation |
Avoid starting warfarin as initial therapy for the treatment of nonvalvular atrial fibrillation or VTE unless alternative options (i.e., DOACs) are contraindicated or there are substantial barriers to their use.
For older adults who have been using warfarin long-term, it may be reasonable to continue this medication, particularly among those with well-controlled INRs (i.e., >70% time in the therapeutic range) and no adverse effects.
See also criteria on rivaroxaban (Table 2) and dabigatran (Table 4) and footnote regarding choice among DOACs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
warfarin ⇄ amiodarone, ciprofloxacin, macrolides (excluding azithromycin), trimethoprim-sulfamethoxazole, SSRIs |
| Risk Rationale |
Increased risk of bleeding. |
| Recommendation |
Avoid when possible; if used together, monitor INR closely. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
|
| X Beer's Criteria |
| Xanax - see ALPRAZolam |
| Xarelto - see rivaroxaban |
| Xcopri - see cenobamate |
| Xtampza - see oxyCODONE |
| Z Beer's Criteria |
zaleplon (Sonata)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
nonbenzodiazepine benzodiazepine receptor agonist hypnotics (“Z-drugs”) |
| Rationale |
Nonbenzodiazepine benzodiazepine receptor agonist hypnotics ("Z-drugs") 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. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
nonbenzodiazepine benzodiazepine receptor agonist hypnotics (“Z-drugs”) ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
nonbenzodiazepine benzodiazepine receptor agonist hypnotics (“Z-drugs”) ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
nonbenzodiazepine benzodiazepine receptor agonist hypnotics ("Z-drugs") ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
nonbenzodiazepine benzodiazepine-receptor agonist hypnotics (i.e., "Z-drugs") ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Zanaflex - see tiZANidine |
| Zarontin - see ethosuximide |
| Zaroxolyn - see metOLazone |
| Zestril - see lisinopril |
ziprasidone (Geodon)54321
| May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration. |
| |
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
antipsychotics, first- (typical) and second- (atypical) generation |
| Rationale |
Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Additional evidence suggests an association of increased risk between antipsychotic medication and mortality independent of dementia.
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in FDA-approved indications such as schizophrenia, bipolar disorder, Parkinson disease psychosis (see Table 3), adjunctive treatment of major depressive disorder, or for short-term use as an antiemetic. |
| 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) |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid, except in situations listed under the rationale statement. |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease |
| Rationale |
DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 3: Potentially inappropriate medications: drugs to be used with caution in older adults. (Table 4) |
| Drug(s) |
antipsychotics |
| Rationale |
May exacerbate or cause SIADH or hyponatremia; monitor sodium levels closely when starting or changing dosages in older adults. |
| Recommendation |
Use with caution |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antipsychotics ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Zoloft - see sertraline |
zolpidem (Ambien)54321
| Criteria 1: Potentially inappropriate medication use in older adults. (Table 2) |
| Drug(s) |
nonbenzodiazepine benzodiazepine receptor agonist hypnotics (“Z-drugs”) |
| Rationale |
Nonbenzodiazepine benzodiazepine receptor agonist hypnotics ("Z-drugs") 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. |
| Recommendation |
Avoid |
| 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) |
| Drug(s) ⇆ disease or syndrome |
nonbenzodiazepine benzodiazepine receptor agonist hypnotics (“Z-drugs”) ⇄ Delirium |
| Rationale |
Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
nonbenzodiazepine benzodiazepine receptor agonist hypnotics (“Z-drugs”) ⇄ Dementia or cognitive impairment |
| Rationale |
Avoid because of adverse CNS effects. |
| Recommendation |
Avoid |
| Quality of evidence: Moderate, Strength of Recommendation: Strong |
| |
| Drug(s) ⇆ disease or syndrome |
nonbenzodiazepine benzodiazepine receptor agonist hypnotics ("Z-drugs") ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid unless safer alternatives are not available. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
nonbenzodiazepine benzodiazepine-receptor agonist hypnotics (i.e., "Z-drugs") ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Zomacton - see growth hormone |
zonisamide (Zonegran)54321
| 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) |
| Drug(s) ⇆ disease or syndrome |
antiepileptics ⇄ History of falls or fractures |
| Rationale |
May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk. |
| Recommendation |
Avoid except for seizures and mood disorders. |
| Quality of evidence: High, Strength of Recommendation: Strong |
| |
| Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5) |
| Interacting drug(s) or class(es) |
antiepileptics (including gabapentinoids) ⇄ CNS-active agents |
| Risk Rationale |
Increased risk of falls and of fracture with the concurrent use of ≥3 CNS-active agents (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids, and skeletal muscle relaxants). |
| Recommendation |
Avoid concurrent use of ≥3 CNS-active drugs Click for list; minimize the number of CNS-active drugs. |
| Quality of evidence: High, Strength of Recommendation: Strong |
|
| Zorbtive - see growth hormone |
| Zortress - see everolimus |
| Ztalmy - see ganaxolone |
| Zymine - see triprolidine |
| ZyPREXA - see OLANZapine |
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