Makindo Medical Notes.com |
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Class | Drug | Prescribing Concern |
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first generation (sedating) antihistamines | diphenhydramine
chlorpheniramine promethazine cyproheptadine clemastine hydroxyzine doxylamine (and others) |
sedating and strongly anticholinergic; promote delirium, falls, urinary retention, dry mouth, constipation; use of diphenhydramine may be appropriate for acute treatment of severe allergic reactions |
antispasmodic | dicyclomine
hyocyamine propantheline oxybutynin (immediate release) scopolamine belladonna alkaloids clinidinium |
sedating and strong anticholinergic properties; promote delirium, falls, urinary retention, dry mouth, constipation; use of hyoscyamine, scopolamine, and belladonna alkaloids to dry secretions in palliative medical care may be appropriate |
Tricyclic antidepressants | amitriptyline
doxepin imipramine nortriptyline (and others) |
avoid in the elderly; sedating and strong anticholinergic properties promote delirium, falls, urinary retention, constipation, and orthostatic hypotension |
Anti-cholinergic anti Parkinson agent | benztropine
trihexyphenidyl |
avoid due to sedation, anti-cholinergic properties; not recommended for prevention of antipyramidal side effects from antipsychotic medications and better medications available for Parkinson |
muscle relaxants | cyclobenzaprine
methocarbamol carisoprodol metaxalone (and others) |
avoid in the elderly due to sedation and anti-cholinergic properties; questionable effectiveness in tolerable doses, and promotes delirium, sedation, and falls |
benzodiazepines | alprazolam
lorazepam diazepam chlordiazepoxide chlorazepate (and others) |
avoid in the elderly for control of delirium, sleep disorders, or agitation; elders are more sensitive to the delirium promoting and fall promoting side effects of these medications; may be appropriate for some conditions such as alcohol withdrawal, or benzodiazepine withdrawal |
Non-benzodiazepine hypnotics | Zolpidem (and others) | Avoid due to sedation; promotes delirium, falls, and fractures in the elderly like the benzodiazepines do |
Antipsychotic agents (atypical and conventional) | Haloperidol
Thioridazine Chlorpromazine Olanzapine Quetiapine Risperidone (and others) |
Because of increased risk of stroke and death, avoid for behavioral problems in the elderly unless non-pharmacologic measures have failed and the patient is a risk to themselves or others |
Alpha 1 blockers | doxazosin
prazosin terazosin |
avoid use as antihypertensive due to high risk of orthostatic hypotension and better agents are available |
CNS acting alpha agonist hypotensive agents | clonidine
methyldopa |
associated with bradycardia, orthostatic hypotension, sedation, delirium, depression; avoid methyldopa and clonidine should not be first-line for hypertension |
cardiac glycoside | Digoxin over 0.125mg daily | Higher doses used in heart failure increases risk of toxicity without adding benefit; reduced renal function may increase risk of toxicity |
antiarrhythmic drugs | amiodarone
flecainide procainamide sotalol quinidine disopyramide (and others) |
risk - benefit analysis favours rate control over rhythm control in most older adults; amiodarone associated with thyroid problems, pulmonary problems and QT prolongation; disopyramide may have a negative inotropic effect and may precipitate heart failure, it is also anticholinergic |
Non-COX selective NSAIDS | Aspirin > 325mg/day
Ibuprofen Naproxen Piroxicam Indomethacin (and others) |
Avoid chronic use unless other measures fail and can use PPI with it; risk of GI bleeding, reduced renal function, exacerbation of heart failure |
Long acting sulfonylureas | Chlorpropamide
glyburide |
Avoid in the elderly because of increased risk of prolonged hypoglycemia |
a urinary anti-infective agent | nitrofurantoin | contraindicated in those with creatinine clearances below 60ml/min because of failure to reach therapeutic concentrations in the urine and increased risk of nerve and liver toxicity |