# Medications That Are Jive When You're Over 65



## SifuPhil (Mar 22, 2013)

The STOPP (Screening Tool of Older People’s potentially inappropriate  Prescriptions) and START (Screening Tool to Alert doctors to the Right  Treatment) criteria have been attracting interest among geriatric  clinicians because they are more recent than the Beers criteria and they  address undertreatment among older adults along with use of medications  that are potentially inappropriate.





*Medications: Avoid in age >65 - Short List*
Beer's List most common items
Sedating Antihistamines (e.g. Diphenhydramine)
Long acting Benzodiazepines (e.g. Diazepam)
Tricyclic Antidepressants (e.g. Amitriptyline)
Antispasmodics (e.g. Oxybutynin, dicyclomine)
Fick (2003) Arch Intern Med 163:2716

STOPP List most common items (in addition to those on short Beer's List)
Non-selective Beta Blockers
Proton Pump Inhibitors
Ryan (2009) Br J Clin Pharmacol 68(6): 936-47


*Medications: Neuropsychiatric Agents to avoid in age >65*
Anticholinergic Agents (see Antihistamines, Antidepressants, Benzodiazepines below)
Selective Serotonin Reuptake Inhibitors (SSRI)
Associated with increased fall risk more than TCA agents
Boyle (2010) Clin Geriatr Med 26(4): 583-605

Prozac is no longer contraindicated in the elderly despite long half-life (as safe as other SSRIs)
Avoid SSRIs if non-iatrogenic Hyponatremia with Serum Sodium <130 mmol/L in last 2 months (STOPP)

Tricyclic Antidepressants (TCA)
Indications to avoid TCA agents (STOPP)
Dementia due to cognitive Impairment
Glaucoma due to exacerbation risk
Cardiac conduction abnormalities due to pro-arrhythmic effect
Constipation or in combination with Opioids or Calcium Channel Blockers due to exacerbation risk
Benign Prostatic Hyperplasia due to urinary obstruction risk

Avoid TCA Agents in general due to anticholinergic and sedating effects
Most anticholinergic and sedating agents: Amitriptyline, Doxepin, Imipramine
Nortriptyline may be slightly less anticholinergic
Consider less sedating alternatives for pain management: Neurontin, Lyrica


First-Generation Sedating Antihistamines (Benadryl, Periactin, Atarax, Tylenol PM)
Avoid use longer than one week (STOPP)
Use second generation Antihistamines instead
Avoid Antihistamines for Insomnia management
Avoid if at least one fall in the last 3 months (STOPP)

Barbiturates (e.g. Fiorinal, Nembutal, Seconal)
Benzodiazepines (Librium, Valium, Dalmane, Halcion)
Use Benzodiazepines only with caution
Avoid longer acting agents (e.g. Clonazepam) or those with long acting metabolites (e.g. Diazepam)
Use shorter acting agents (e.g. Ativan, Restoril)

Use lower doses (<1 mg Ativan, <15 mg Restoril)
Avoid use longer than 1 month (STOPP)
Avoid if at least one fall in the last 3 months (STOPP)

Increased risk of physical performance decline, confusion, Sedation, falls
Gray (2003) J Am Geriatr Soc 51:1563-70

Neuroleptics (Antipsychotics)
Avoid Haloperidol (Haldol) due to two fold increase in mortality in older Nursing Home residents
Consider Quetiapine (Seroquel) as alternative
Huybrechts (2012) BMJ 344:e977

Avoid longterm use >1 month, especially in Parkinsonism (STOPP)
Avoid Anticholinergic Medications to treat Extrapyramidal Side Effects of Antipsychotic agents (STOPP)
Avoid if at least one fall in the last 3 months (STOPP)

Meprobamate (addictive and sedating)
Stimulants: Amphetamines and Methylphenidate (Ritalin)
Skeletal Muscle Relaxants (e.g. Flexeril, Soma, Robaxin, Norflex)
Thioridazine (Mellaril)
Cholinesterase inhibitors (e.g. Aricept) in patients with Syncope

*Medications: Cardiovascular Agents to avoid in age >65*
Amiodarone: Risk of QT Prolongation and Torsade de Pointes
Disopyramide (Norpace): Anticholinergic, risk of Congestive Heart Failure
Methyldopa
Reserpine
Ticlopidine
Digoxin >125 mcg daily
Avoid longterm use at >125 mcg if GFR <50 ml/min (STOPP)

Loop Diuretic
Avoid use for lower extremity edema only (e.g. no history of Heart Failure, STOPP)
Avoid use as first-line monotherapy for Hypertension (STOPP)

Thiazide Diuretic
Avoid use in Gouty Arthritis (STOPP)

Beta Blockers
Avoid Non-selective Beta Blockers such as Propranolol in COPD (STOPP)
Avoid Beta Blocker in combination with Verapamil due to AV Nodal block risk (STOPP)
Avoid in Diabetes Mellitus with more than 1 hypoglycemic episode monthly due to risk of masking symptoms (STOPP)

Calcium Channel Blockers
Avoid Diltiazem or Verapamil in NYHA Class III or Class IV Heart Failure due to exacerbation risk (STOPP)

Vasodilators
Avoid in persistent Postural Hypotension with SBP drop on standing >20 mmHg if at least one fall in the last 3 months (STOPP)


*Medications: Endocrine Agents to avoid in age >65*
Chlorpropamide (Diabinese)
Risk of prolonged Hypoglycemia (STOPP)

Glyburide
Risk of Hypoglycemia
Use Glipizide or Glimepiride instead

Pioglitazone (Actos)
Avoid in Heart Failure

Sliding Scale Insulin
Risk of Hypoglycemia

Desiccated Thyroid (Armour Thyroid)
Methyltestosterone (Provokes BPH)
Megestrol
Low efficacy for stimulation of appetite
Risk of thrombosis

Estrogens
Avoid Estrogen if history of VTE or Breast Cancer (STOPP)
Avoid Unopposed Estrogen without Progesterone with intact Uterus (STOPP)


*Medications: Analgesic Agents to avoid in age >65*
Opioids
Avoid longterm Opioids if at least one fall in the last 3 months (STOPP)
Avoid longterm high potency Opioids such as morphine or Fentanyl as first-line management of mild to moderate pain (STOPP)
Avoid regular Opioids for more than 2 weeks if Chronic Constipation and no without prophylactic Laxative (STOPP)
See Constipation Prophylaxis in Chronic Opioid Use

Avoid longterm Opioids in Dementia patients outside of Palliative Care or moderate-severe Chronic Pain (STOPP)
Avoid Meperidine (Demerol) completely
Avoid Propoxyphene (Darvon) completely

Pentazocine (Talwin)
Corticosteroids
Avoid use longer than 3 months as monotherapy for Rheumatoid Arthritis, gout or Osteoarthritis (STOPP)

NSAIDs
Limit to low dose, short duration, short half-life
Avoid use longer than 3 months for mild osteoarthritic pain (STOPP)
Avoid prolonged use for gout prevention in place of Allopurinol when not contraindicated (STOPP)
Use alternative management (e.g. Acetaminophen, Contrast Bath)

NSAIDs to avoid completely
Indomethacin (CNS and gastrointestinal effects)
Ketorlac (Toradol)
Long-acting NSAIDs (Feldene, Naprosyn, Daypro)

Avoid use completely in high risk patients
Over age 75 years
GFR <50 ml/min (STOPP)
Concurrent Corticosteroid use
Concurrent anticoagulant use such as Warfarin or Pradaxa (STOPP)
History of PUD or GI Bleeding and no GI prophylaxis with H2 Blocker, PPI, or Misoprostol (STOPP)
Moderate to Severe Hypertension with BP >160/100 mmHg due to exacerbation risk (STOPP)
Congestive Heart Failure history due to exacerbation risk (STOPP)



*Medications: Gastrointestinal and Genitourinary Agents to avoid in age >65*
Antiemetics
Avoid Phenergan, Tigan
Avoid Metoclopramide (Reglan) or Prochlorperazine (Compazine) in Parkinsonism due to exacerbation risk (STOPP)
Avoid Pheothiazines (e.g. Compazine) in Epilepsy due to exacerbation risk (STOPP)

Gastrointestinal antispasmodics (e.g. Donnatal, Bentyl, Levsin, Clidinium)
Avoid anticholinergic antispasmodic drugs in Chronic Constipation (STOPP)

Antidiarrheal agents (Lomotil, Imodium, Codeine)
Avoid antidiarrheals in Diarrhea of unknown cause due to risk of toxic Megacolon, exacerbation of overflow Diarrhea (STOPP)
Avoid antidiarrheals in dysentary (bloody Diarrhea, fever, toxicity) due to risk of exacerbation (STOPP)

Proton Pump Inhibitors (e.g. Omeprazole)
Avoid >8 weeks at high dose Peptic Ulcer Disease management doses (STOPP)
Stop or if continuation indicated (e.g. severe GERD), decrease to standard dosing

Nitrofurantoin (Macrobid)
May worsen renal insufficiency and risk interstitial fibrosis

Stimulant Laxatives (worsen bowel function in elderly)
Urinary antispasmodics (e.g. Ditropan)
Typically marginal benefit does not outweigh significant anticholinergic effects
Look for other causes of Urinary Incontinence (e.g. cholinesterase inhibitors such as Aricept)
Avoid use if contraindicating conditions (STOPP)
Dementia
Chronic Glaucoma
Chronic Constipation
Benign Prostatic Hyperplasia (BPH) with obstruction


Alpha-Blockers
Avoid alpha-blockers with one or more episodes of daily Incontinence due to exacerbation risk (STOPP)
Indwelling Urinary Catheter present >2 months due to lack of indication (STOPP)


*Medications: Respiratory Agents to avoid in age >65*
Inhaled anticholinergics (Atrovent, Spiriva)
Avoid in men with severe BPH
Avoid nebulized Ipratropium in Glaucoma due to exacerbation risk (STOPP)

Theophylline
Avoid as monotherapy for COPD due to safer alternatives with better efficacy (STOPP)

Systemic Corticosteroids
Avoid in place of Inhaled Corticosteroids as maintenance therapy in moderate to severe COPD (STOPP)


*Medications: Hematologic Agents to avoid in age >65*
Avoid antiplatelet agents such as Aspirin, Dipyridamole or Clopidogrel in concurrent Bleeding Disorder (STOPP)
Aspirin
Avoid for primary prevention in over age 80 years old
Avoid without cardiovascular indication such as CAD, PAD, CVA (STOPP)
Avoid as treatment for undifferentiated Dizziness
Avoid dose >150 mg daily due to increased bleeding risk without added efficacy (STOPP)
Avoid without the use of GI Protection (e.g. H2 Blocker or Proton Pump Inhibitor, STOPP)
Concurrent Warfain use
History of Peptic Ulcer Disease in the last year


Warfarin
Avoid >6 months for first uncomplicated DVT or >12 months for first uncomplicated PE (STOPP)

Pradaxa
Avoid in severe Chronic Kidney Disease

Dipyridamole
Avoid as monotherapy for cardiovascular secondary prevention due to lack of efficacy (STOPP)




All data from Family Practice Notebook


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## Pricklypear (Mar 22, 2013)

I've never heard of Family Practice Notebook until I skimmed through your post. Thanks.
I've bookmarked it to my health resource file.  Will take a longer look later. 

When I skimmed your post I noticed two STOP recommendations that support my decision to leave one medical group and get a new doctor.  New doctor got my medications down to my glaucoma drops and suggested an alternative to surgery.  The alternative works well for me.


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## SifuPhil (Mar 22, 2013)

Good! I'm glad you're able to safely cut-back on the meds. 

I know that ANY medication has possible side-effects, so I'm not out to condemn the entire pharmacopeia of the world. I just don't agree to the wholesale over-prescribing phenomenon, _especially_ for a population that can scarce afford it and shouldn't have to in the first place.


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