Antianxiety Analgesics Antihypertensive High-risk medications in older adults drug alternative(s) Guanabenz Guanfacine Methyldopa Reserpine (greater than 0.1 mg per day) High risk of adverse central nervous system (CNS) effects May cause bradycardia and orthostatic hypotension Not recommended as routine treatment for hypertension use as an antihypertensive Hypertension: Angiotensin converting enzyme inhibitor Angiotensin receptor blocker Thiazide Long acting dihydropyridine CCB Thiazide type diuretics or CCB for African Americans Mild pain: APAP (OTC) Ketorolac Indomethacin Increases risk of gastrointestinal bleeding and peptic ulcer disease in high-risk groups Moderate or severe pain: Morphine (G) Hydrocodone/APAP (Vicodin ) (G) Oxycodone/APAP (Percocet ) (G) chronic use. Meprobamate Dependence Sedation Anxiety: Buspirone (Buspar ) (G) SSRI (G) except paroxetine SNRI (G) * Formulary tiers vary by plan. Please check your patient s benefits for formulary status and coverage of Medication and Dosage Form. In some instances, when generics are available, the brand product may not be covered. Amerigroup STAR+PLUS MMP (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees. TXD-NL-0041-17-B 29264MUPENMUB April 2017
Antiparkinson agents Antiemetics Antidepressants Anticholinergics (includes combination products) Brompheniramine Chlorpheniramine Clemastine Dexbrompheniramine Dexchlorpheniramine Diphenhydramine Doxylamine Hydroxyzine Promethazine Paroxetine Highly anticholinergic (clearance reduced with age) Anticholinergic effects Sedation Orthostatic hypotension Delirium (use of diphenhydramine in situations such as acute severe allergic reactions may be appropriate) Allergic rhinitis: Intranasal normal saline Fexofenadine (Allegra ) (OTC) Cetirizine (Zyrtec ) (OTC) Intranasal steroid (G) (e.g., beclomethasone and fluticasone [OTC]) Pruritus: Topical agents: menthol and camphor, oatmeal baths, and calamine lotion (OTC) Antiemetic: See antiemetic section. Alternate SSRIs: Citalopram (20 mg per day) tier one Escitalopram (10 mg per day) tier two Sertraline (50 mg per day) tier one Alternate antidepressant: Mirtazapine (15-45 mg daily) tier two Trimethobenzamide Low efficacy Extrapyramidal adverse effects Ondansetron (Zofran ) (G) Benztropine (oral) Trihexyphenidyl Not recommended for prevention of extrapyramidal symptoms with antipsychotics More effective options are available for Parkinson s disease Parkinson s disease: Carbidopa/Levodopa (Sinemet, Sinemet CR) (G) Amantadine (G) tremor antipsychotics for behavioral problems of dementia unless nonpharmacologic options have failed and patient is a threat to themselves or others. Antipsychotics are associated with increased risk of cerebrovascular accident (stroke) and mortality in persons with dementia. Page 2 of 7
Antithrombotics Antispasmodics Antipsychotics typical Risperidone (Risperdal ) (G) Haloperidol (Haldol ) (G) Thioridazine Mesoridazine Atropine Dicyclomine Scopolamine Belladonna alkaloid Hyoscyamine Clidinium- Chlordiazepoxide Propantheline Ticlopidine Dipyridamole (oral and short acting) does not apply to the extended-release combination with aspirin Highly anticholinergic Risk of QT interval prolongation For atropine, gastric emptying is significantly slowed in elderly patients Scopolamine patch can cause increased confusion, memory deficits and dementia Anticholinergic effects increase the risk of delirium, urinary retention, agitation and blurred vision Drug class associated with memory deficits, confusion, dry mouth and worsening dementia Safer effective alternatives are available May cause orthostatic hypotension More effective alternatives are available antipsychotics for behavioral problems of dementia unless nonpharmacologic options have failed and patient is a threat to themselves or others. Antipsychotics are associated with increased risk of cerebrovascular accident (stroke) and mortality in persons with dementia. Antispasmodics: Baclofen (10 mg) tier two Antidiarrheal: Loperamide (2 mg) tier four Increase fiber Probiotics Motion sickness: Pressure band Ginger Stroke prevention: Low-dose Aspirin (OTC) Clopidogrel (Plavix ) (G) Aspirin/extended-release Dipyridamole (Aggrenox ) PCI: Clopidogrel (Plavix ) (G) Page 3 of 7
Cardiovascular agents other Calcium channel blockers Barbiturates Amobarbital Butabarbital Butalbital Mephobarbital Phenobarbital Pentobarbital High rate of physical dependence Tolerance to sleep benefits Risk of overdose at low dosages Sleep: Sleep hygiene caffeine and alcohol before bedtime Trazodone (Desyrel )(G) Ramelteon (Rozerem )(G) OTC melatonin (less than 15 mg total per day) Migraine: APAP (OTC) For epilepsy: Other anticonvulsants (e.g., lamotrigine and levetiracetam) Nifedipine (short acting only) Hypotension Risk of precipitating myocardial ischemia Nifedipine ER (long acting) (Procardia XL ) (G) Long acting dihydropyridine CCB (e.g., amlodipine) Disopyramide Digoxin (greater than 0.125 mg per day) in heart failure A potent negative inotrope may induce heart failure in older adults Strongly anticholinergic In heart failure, higher dosages associated with no additional benefit and may increase risk of toxicity Slow renal clearance Atrial fibrillation: Nondihydropyridine CCB betablocker (e.g., diltiazem) for rate control Dofetilide flecainide, propafenone for rhythm control Heart failure: Digoxin (average daily dose of less than or equal to 0.125 mg daily) dose reduction with monitoring Page 4 of 7
Narcotics (includes combination products) Hypnotics Hormones Estrogen (oral and topical patch) with or without progestin Carcinogenic potential Lack of cardioprotective effect and cognitive protection in older women Hot flashes: Cool environment, layered clothing and cool compress SSRI except paroxetine SNRI venlafaxine IR (Effexor ) (G) Gabapentin (Neurontin ) (G) Dyspareunia and vulvovaginitis: Vaginal estrogen formulations Nonbenzodiazepine hypnotics use of greater than 90 days: Eszopiclone Zaleplon Zolpidem Meperidine Adverse events similar to those of benzodiazepines in older adults (e.g., falls and delirium) Minimal improvement in sleep latency and duration Not an effective oral analgesic in dosages commonly used May cause neurotoxicity Safer alternatives are available chronic use (greater than 90 days) Bone density: Calcium/vitamin D (OTC) Bisphosphonates (G) Sleep: Sleep hygiene caffeine and alcohol before bedtime Trazodone (Desyrel ) (G) Ramelteon (Rozerem ) (G) Melatonin (less than 15 mg total per day) (OTC) For acute moderate to severe pain: Tramadol (Ultram ) (G) Morphine (G) Oxycodone/APAP (Percocet ) (G) Pentazocine Causes more adverse CNS effects than other narcotic drugs Mixed agonist and antagonist Safer alternatives available For chronic moderate to severe pain: Morphine (G) Hydrocodone/APAP (Vicodin ) (G) Oxycodone/APAP (Percocet ) (G) Tramadol (Ultram ) (G) long-duration, sustained-release dosage forms in opioid-naïve individuals. Page 5 of 7
Antidepressants (single agent or as part of a combination product) Skeletal muscle relaxants (as a single agent or in combination) Oral hypoglycemics Glyburide Prolonged hypoglycemia Glimepiride (Amaryl ) (G) Glipizide (Glucotrol ) (G) Metformin (Glucophage ) (G) Glipizide/metformin (Metaglip ) (G) Cyclobenzaprine Carisoprodol Chlorzoxazone Metaxalone Methocarbamol Orphenadrine Amoxapine Amitriptyline Clomipramine Desipramine Doxepin (greater than 6 mg per day) Imipramine Nortriptyline Paroxetine Trimipramine Protriptyline Poorly tolerated by older adults because of anticholinergic adverse effects, sedation and risk of fracture Questionable efficacy at doses tolerated by the elderly Anticholinergic effects Sedation Orthostatic hypotension Delirium Nondrug therapy: Physiotherapy Corrective seating and footwear Spasticity: Baclofen (Lioresal ) (G) Tizanidine (Zanaflex ) (G) Depression: Sertraline (Zoloft) (G) SNRI (G) Bupropion (Wellbutrin )(G) Neuropathic pain: Duloxetine (Cymbalta ) Venlafaxine (Effexor ) (G) Gabapentin (Neurontin ) (G) Capsaicin topical Sleep: Sleep hygiene caffeine and alcohol before bedtime Trazodone (Desyrel )(G) Ramelteon (Rozerem )(G) Melatonin (less than 15 mg total per day) (OTC) Page 6 of 7
Others (thyroid drugs, urinary anti-infectives) Desiccated thyroid Concerns about cardiac effects Safer alternatives are available Levothyroxine (Levoxyl, Synthroid ) (G) Nitrofurantoin (chronic use) Potential for pulmonary toxicity Safer alternatives available Lack of efficacy in CrCl less than 60 ml per minute due to inadequate drug concentrations in the urine for long-term suppression in patients with CrCl less than 60 ml per minute Confirmed UTI: TMP-SMX (Bactrim DS ) (G) Ciprofloxacin (Cipro ) (G) Cephalexin (Keflex ) (G) Trimethoprim (G) This is for informational purposes only and should not be construed as treatment protocols or required practice guidelines. Diagnosis, treatment s, and the provision of medical care services for customers and enrollees is the responsibility of physicians and providers. (Last updated April 5, 2017.) Page 7 of 7