Beers Criteria - Criteria 4
Beers Criteria (Criteria 4)
NAV Top A B C D E F G H I L M N O P Q R S T V W Z

American Geriatrics Society 2023 updated AGS Beers Criteria®
for potentially inappropriate medication use in older adults. Reference Back to All Criteria View
Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5)
 A
Suggested Alt.Tx acetaminophen-codeine (Tylenol #3)
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
Suggested Alt.Tx acetaminophen-HYDROcodone (Lortab, Norco, Vicodin)
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
Suggested Alt.Tx acetaminophen-oxyCODONE (Percocet, Roxicet, Tylox)
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
Suggested Alt.Tx acetaminophen-traMADol (Ultracet)
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
Suggested Alt.Tx alfuzosin (Uroxatral)
Data are limited for selective peripheral alpha-1 blockers (e.g., tamsulosin, silodosin, and others) but may apply as well.
 
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)
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
Suggested Alt.Tx ALPRAZolam (Xanax)
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
 aMILoride (Midamor)
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
 aMILoride-hydroCHLOROthiazide (Moduretic)
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
Suggested Alt.Tx amitriptyline (Elavil)
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)
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
Suggested Alt.Tx ARIPiprazole (Abilify)
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.
 
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
Suggested Alt.Tx asenapine (Saphris)
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.
 
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
Suggested Alt.Tx atropine
excludes ophthalmic
 
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)
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
 azilsartan (Edarbi)
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
Suggested Alt.Tx baclofen (Lioresal)
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
 benazepril (Lotensin)
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
Suggested Alt.Tx benztropine (Cogentin)
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
Suggested Alt.Tx brexpiprazole (Rexulti)
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.
 
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
 brivaracetam (Briviact)
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
Suggested Alt.Tx brompheniramine (Dimetane, Dimetapp)
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
 C
 candesartan (Atacand)
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)
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
 captopril (Capoten)
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)
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)
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
Suggested Alt.Tx carbinoxamine (Clistin, Karbinal)
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
Suggested Alt.Tx cariprazine (Vraylar)
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.
 
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
Suggested Alt.Tx carisoprodol (Soma)
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
 cenobamate (Xcopri)
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
Suggested Alt.Tx chlordiazePOXIDE (Librium)
alone or in combination with amitriptyline or clidinium
 
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
Suggested Alt.Tx chlorpheniramine (Chlor-Trimeton)
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
Suggested Alt.Tx chlorproMAZINE (Thorazine)
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.
 
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
Suggested Alt.Tx chlorzoxazone (Parafon Forte DSC)
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
 citalopram (CeleXA)
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
Suggested Alt.Tx clidinium-chlordiazePOXIDE (Librax)
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
Suggested Alt.Tx cloBAZam (Onfi, Sympazan)
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
Suggested Alt.Tx clomiPRAMINE (Anafranil)
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
Suggested Alt.Tx clonazePAM (KlonoPIN)
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
Suggested Alt.Tx clorazepate (Tranxene)
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
Suggested Alt.Tx cloZAPine (Clozaril)
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.
 
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
Suggested Alt.Tx codeine
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
Suggested Alt.Tx cyclobenzaprine (Flexeril)
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
Suggested Alt.Tx cyproheptadine (Periactin)
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
Suggested Alt.Tx dantrolene (Dantrium)
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
 darifenacin (Enablex)
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
Suggested Alt.Tx desipramine (Norpramin)
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
 desvenlafaxine (Pristiq)
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
Suggested Alt.Tx diazePAM (Valium)
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
Suggested Alt.Tx dicyclomine (Bentyl)
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
Suggested Alt.Tx dimenhyDRINATE (Dramamine)
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
Suggested Alt.Tx diphenhydrAMINE (Benadryl)
diphenhydrAMINE (oral) Use of diphenhydrAMINE in situations such as acute treatment of severe allergic reactions may be appropriate.
 
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
Suggested Alt.Tx doxazosin (Cardura)
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
Suggested Alt.Tx doxepin (SINEquan)
>6 mg/day
 
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
Suggested Alt.Tx doxylamine (Unisom)
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
 droNABinol (Marinol)
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
Suggested Alt.Tx droperidol (Inapsine)
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.
 
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)
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
 E
 enalapril (Vasotec)
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
 eplerenone (Inspra, Espler)
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
 escitalopram (Lexapro)
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
 eslicarbazepine (Aptiom)
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
Suggested Alt.Tx estazolam (Prosom)
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
Suggested Alt.Tx eszopiclone (Lunesta)
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
 ethosuximide (Zarontin)
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
 everolimus (Afinitor, Zortress)
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
 F
 felbamate (Felbatol)
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
 fenfluramine (Fintepla)
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
Suggested Alt.Tx fentaNYL (Sublimaze)
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)
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
 finerenone (Kerendia)
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
 flavoxATE (Urispas)
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
 FLUoxetine (PROzac)
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
Suggested Alt.Tx fluPHENAZine (Prolixin)
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.
 
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
 fLuvoxaMINE (Luvox)
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
 fosinopril (Monopril)
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
 G
Suggested Alt.Tx gabapentin (Neurontin)
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
 ganaxolone (Ztalmy)
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
 H
Suggested Alt.Tx haloperidol (Haldol)
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.
 
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
Suggested Alt.Tx homatropine (Hycodan, Hydromet)
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
 hydroCHLOROthiazide-valsartan (Diovan HCT)
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
Suggested Alt.Tx HYDROmorphone (Dilaudid)
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
Suggested Alt.Tx hydrOXYzine (Atarax, Vistaril)
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
Suggested Alt.Tx hyoscyamine (Hyosyne, Levsin, Levsinex)
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
 I
Suggested Alt.Tx iloperidone (Fanapt)
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.
 
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
Suggested Alt.Tx imipramine (Tofranil)
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
 irbesartan (Avapro)
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
 L
 lacosamide (Vimpat)
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)
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
 levETIRAcetam (Keppra)
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
 levomilnacipran (Fetzima)
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
 lisinopril (Prinivil, Zestril)
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)
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
Suggested Alt.Tx LORazepam (Ativan)
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
 losartan (Cozaar)
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
Suggested Alt.Tx loxapine (Loxitane)
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.
 
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
Suggested Alt.Tx lumateperone (Caplyta)
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.
 
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
Suggested Alt.Tx lurasidone (Latuda)
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.
 
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
 M
Suggested Alt.Tx meclizine (Antivert)
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
Suggested Alt.Tx meperidine (Demerol)
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
Suggested Alt.Tx metaxalone (Skelaxin)
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
Suggested Alt.Tx methadone (Dolophine)
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
Suggested Alt.Tx methocarbamol (Robaxin)
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
Suggested Alt.Tx midazolam (Versed)
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)
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
 moexipril (Univasc)
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
Suggested Alt.Tx morphine (Oramorph SR, Roxanol)
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
 N
Suggested Alt.Tx nortriptyline (Pamelor)
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
 O
Suggested Alt.Tx OLANZapine (ZyPREXA)
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.
 
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)
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
Suggested Alt.Tx opium (Paragoric)
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
Suggested Alt.Tx orphenadrine (Norflex)
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
Suggested Alt.Tx oxazepam (Serax)
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)
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
 oxybutynin (Ditropan)
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
Suggested Alt.Tx oxyCODONE (Oxaydo, OxyCONTIN, Oxyfast, Oxy-IR, Percodan, Roxicodone, Roxybond, Xtampza)
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
Suggested Alt.Tx oxyMORphone (Numorphan, Opana)
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
Suggested Alt.Tx paliperidone (Invega)
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.
 
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
 PARoxetine (Paxil)
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
 perampanel (Fycompa)
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
 perindopril (Aceon)
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
Suggested Alt.Tx perphenazine (Trilafon)
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.
 
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
Suggested Alt.Tx PHENobarbital (Luminal)
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)
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
Suggested Alt.Tx pimavanserin (Nuplazid)
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.
 
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
Suggested Alt.Tx pimozide (Orap)
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.
 
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
Suggested Alt.Tx prazosin (Minipress)
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
Suggested Alt.Tx pregabalin (Lyrica)
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
Suggested Alt.Tx primidone (Mysoline)
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
Suggested Alt.Tx prochlorperazine (Compazine)
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.
 
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
Suggested Alt.Tx promethazine (Phenadoz, Phenergan)
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
 Q
Suggested Alt.Tx QUEtiapine (SEROquel)
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.
 
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)
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
 ramipril (Altace)
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
Suggested Alt.Tx risperiDONE (RisperDAL)
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.
 
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
 rufinamide (Banzel)
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
 sacubitril-valsartan (Entresto)
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
Suggested Alt.Tx scopolamine (Transderm Scop)
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
 sertraline (Zoloft)
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
Suggested Alt.Tx silodosin (Rapaflo)
Data are limited for selective peripheral alpha-1 blockers (e.g., tamsulosin, silodosin, and others) but may apply as well.
 
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
 solifenacin (Vesicare)
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
 spironolactone (Aldactone, Carospir)
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
 spironolactone-hydroCHLOROthiazide (Aldactazide)
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
 stiripentol (Diacomit)
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
Suggested Alt.Tx SUFentanil (Sufenta)
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
 T
Suggested Alt.Tx tamsulosin (Flomax)
Data are limited for selective peripheral alpha-1 blockers (e.g., tamsulosin, silodosin, and others) but may apply as well.
 
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
 telmisartan (Micardis)
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
Suggested Alt.Tx temazepam (Restoril)
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
Suggested Alt.Tx terazosin (Hytrin)
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
 theophylline
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
Suggested Alt.Tx thioridazine (Mellaril)
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.
 
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
Suggested Alt.Tx thiothixene (Navane)
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
 tiaGABine (Gabitril)
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
Suggested Alt.Tx tiZANidine (Zanaflex)
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
 tolterodine (Detrol)
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)
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
Suggested Alt.Tx traMADol (Ultram)
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
 trandolapril (Mavik)
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)
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
 triamterene (Dyrenium)
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
 triamterene-hydroCHLOROthiazide (Dyazide, Maxzide)
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
Suggested Alt.Tx triazolam (Halcion)
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
Suggested Alt.Tx trifluoperazine (Stelazine)
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.
 
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
Suggested Alt.Tx trihexyphenidyl (Artane)
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
Suggested Alt.Tx triprolidine (Histex, Zymine)
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)
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
 V
 valproic acid (Depacon, Stavzor)
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)
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
 venlafaxine (Effexor)
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
 vigabatrin (Sabril)
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
 W
Suggested Alt.Tx warfarin (Coumadin, Jantoven)
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
 Z
Suggested Alt.Tx zaleplon (Sonata)
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
Suggested Alt.Tx ziprasidone (Geodon)
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.
 
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
Suggested Alt.Tx zolpidem (Ambien)
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
 zonisamide (Zonegran)
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

Pharmacy Contact Info:

Main Inpatient Pharmacy: ext 4599, 3503
Fax: 704-878-7283

Director of Pharmacy - Randi Raynor, PharmD: ext 4501
Clinical Coordinator - Laura Rollings, PharmD: ext 4597
Pharmacy Informaticist - Stephen Pringle, PharmD: ext 7645
Pharmacy Technician Supervisor - Amy Wingler, CPhT: ext 7385
Pharmacy Automation Coordinator (Omnicell) - Melissa Fulford, CPhT: ext 3556



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