CMS: High-Risk Medications

(Relevant for older people defined as greater than 65 years of age)

Drug High-risk agents to Avoid Non-high risk alternatives
Reason for Risk
classification (H) = considered Highest-risk¹ Drug
Amphetamines amphetamine & dextroamphetamine (H) CNS stimulation: agitation, insomnia; Consider discontinuing
(ADDERALL/XR ) hypertension, myocardial ischemia;
benzphetamine (H) (DIDREX ) dependence; appetite suppression
dexmethylphenidate (H) (FOCALIN/XR )
dextroamphetamine (H) (DEXADRINE,
DEXTROSTAT )
diethylpropion (H) (DURAD, TENUATE,
TEPANIL )
INTUNIV (H)
methamphetamine (H) (DESOXYN )
methylphenidate (H) (RITALIN/LA,
CONCERTA, DAYTRANA, METADATE CD )
phendimetrazine (H) (BONTRIL )
phentermine (H) (ADIPEX-P )
 Drug High-risk agents to Avoid Non-high risk alternatives
Reason for Risk
classification (H) = considered Highest-risk¹ Drug
Analgesics indomethacin (INDOCIN) Ketorolac: Gastrointestinal bleeding risk mild pain:
ketorolac (H) (TORADOL ) increased in elderly. APAP
ibuprofen
Indomethacin: GI bleeding/peptic ulcer in high- naproxen
risk patients.a Has more adverse effects than meloxicam
other NSAIDs. Edema may worsen heart
failure. moderate/severe pain:
tramadol
morphine sulfate (MS CONTIN)
hydrocodone/APAP(V ICODIN , etc)
oxycodone (OXYIR)
oxycodone/APAP (PERCOCET)
fentanyl patch (DURAGESIC)
OXYCONTIN
AVINZA

use lowest dose possible to avoid side

effects and reduce pain

Anti-adrenergics guanabenz Orthostatic hypotension, bradycardia, CNS HCTZ

 guanfacine (TENEX) adverse effects lisinopril
 methyldopa (ALDOMET) enalapril
 methyldopa/HCTZ (ALCOLOR, ALDORIL) losartan
metoprolol

Anti-anxiety meprobamate (H) (EQUINIL ) Dependence; sedation; depression; confusion; anxiety:

aspirin/meprobamate (H) (EQUAGESIC ) falls; fractures; respiratory depression buspirone (BUSPAR)
(especially in COPD)
sleep:
ROZEREM
 Drug High-risk agents to Avoid Non-high risk alternatives
Reason for Risk
classification (H) = considered Highest-risk¹ Drug
Anti-emetics trimethobenzamide (H) (TIGAN ) Anticholinergic side effects: worsened TRANSDERM-SCOP
promethazine (H) (PHENERGAN) cognition & behavioral problems (especially in ondansetron (ZOFRAN)
dementia); urinary retention OR incontinence; granisetron (KYTRIL)
questionable efficacy prochlorperazine (COMPAZINE)
metoclopramide (REGLAN)*

*avoid using long-term and/or in Parkinson’s

disease

Antihistamines APAP/dextromethorphan/diphenhydramine (H) Anticholinergic side effects: worsened Levocetirizine (XYZAL)

APAP/diphenhydramine/phenylephrine (H) cognition & behavioral problems (especially in CLARINEX
APAP= APAP/diphenhydramine/PSE (H) dementia); urinary retention OR incontinence;
acetaminophen APAP & diphenhydramine (H) confusion; enhanced sedation;
PSE= Brompheniramine / combination products (H)
pseudoephedrine carbetapentane/diphenhydramine/
phenylephrine (H)
carbinoxamine / combination products (H)
chlorpheniramine / combination products (H)
clemastine (H)
codeine/promethazine/phenylephrine (H)
codeine & promethazine (H)
cyproheptadine (H)
dexbrompheniramine-Pyrilamine (H)
dexchlorpheniramine
dexchlorpheniramine/dextromethorphan/PSE (H)
dexchlorpheniramine/guaifenesin/PSE (H)
dexchlorpheniramine/hydrocodone/
phenylephrine (H)
dexchlorpheniramine/methscopolamine/PSE (H)
dexchlorpheniramine & PSE (H)
 dextromethorphan & promethazine (H)
 diphenhydramine (H)
 diphenhydramine/hydrocodone/
phenylephrine (H)
 diphenhydramine & phenylephrine (H)
 diphenhydramine & PSE (H)
 diphenhydramine & magnesium salicylate (H)
 doxylamine
 hydroxyzine hydrochloride (H)
 hydroxyzine pamoate (H)
 phenylephrine & promethazine (H)
 promethazine (H)
 triprolidine
  diphenhydramine & PSE (H)
 diphenhydramine & magnesium salicylate (H)
 doxylamine
Drug  High-risk agents
(H) to Avoid Non-high risk alternatives
hydroxyzine hydrochloride Reason for Risk
classification  (H) =pamoate
hydroxyzine considered
(H) Highest-risk¹ Drug
 phenylephrine & promethazine (H)
 promethazine (H)
 triprolidine

Note: Various brand name drugs apply.

Antiparkinson/ benztropine (COGENTIN) Delirium, worsen cognitive impairment, worsen Consider discontinuing or using atypical
antipsychotics trihexyphenidyl constipation, worsen urinary retention; not antipsychotic
recommended to prevent
antipsychoticassociated extrapyramidal
effects; not very effective for Parkinson’s
disease

Antipsychotics thioridazine (H) (MELLARIL ) CNS side effects; seizure risk; extrapyramidal haloperidol (HALDOL)
effects: tremor, slurred speech, muscular risperidone (RISPERDAL)*
rigidity, dystonia (involuntary muscle ABILIFY*
contractions), bradykinesia (slowing of FANAPT*
movement), akathisia (inability to sit/stand still) GEODON*
INVEGA*
SEROQUEL*
ZYPREXA*

*atypical antipsychotics associated w/

increased mortality when used to treat
behavioral issues in elderly w/ dementia
 Drug High-risk agents to Avoid Non-high risk alternatives
Reason for Risk
classification (H) = considered Highest-risk¹ Drug
Barbiturates butabarbital (H) (BUTISOL ) Higher risk of side effects: falls; fractures; sleep:
butalbital / combinations (H) (FIORICET, confusion; cognitive impairment; dependence ROZEREM
FIORINAL, DOLGIC, ESGIC)
mephobarbital (H) (MEBARAL ) mild pain:
pentobarbital (H) (NEMBUTAL ) APAP
 phenobarbital (H) (LUMINAL) ibuprofen
naproxen
secobarbital (H) (SECONAl)
meloxicam

moderate/severe pain:
tramadol
morphine sulfate (MS CONTIN)
hydrocodone/APAP (VICODIN, etc)
oxycodone (OXYIR)
oxycodone/APAP (PERCOCET)
fentanyl patch (DURAGESIC)
OXYCONTIN
AVINZA

Belladona alkaloids atropine/hyoscyamine/phenobarbital/ Anticholinergic AEs: worsened cognition & constipation:

scopolamine (H) (BELLADONNA ALKALOIDS, behavioral problems (especially in dementia); psyllium fiber (METAMUCIL)
CPM= DONNATAL, ANTISPASMODIC ELIXIR) urine retention; agitation & delirium polyethylene glycol (MIRALAX)
chlorpheniramine atropine & edrophonium (ENLON) docusate
belladonna (H)
PE=phenylephrine belladonna/ergotamine/phenobarbital (H) diarrhea:
(BELLAMINE ) loperamide (IMODIUM)
butabarbital/hyoscyamine/phenazopyridine (H) aluminum hydroxide
(PHENAZOPYRIDEINE PLUS, atropine & difenoxin (MOTOFEN )
PHENAZOFORTE PLUS) atropine & diphenoxylate
digestive- enzymes/ hyoscyamine/ (LOMOTIL, LONOX, LOGEN,
phenyltoloxamine (H) (DIGEX NF) LOMANATE )

Benzodiazepines amitriptyline & chlordiazepoxide (H) (LIMBITROL Dependence; depression; prolonged sedation; buspirone (BUSPAR)
(long-acting) DS ) confusion; falls; fractures; respiratory chlordiazepoxide (H) (LIBRIUM )
depression (especially in COPD); accumulation diazepam (VALIUM )
of drug flurazepam (DALMANE )
 Drug High-risk agents to Avoid Non-high risk alternatives
Reason for Risk
classification (H) = considered Highest-risk¹ Drug
Calcium channel nifedipine (short-acting immediate release only) Hypotension; constipation nifedipine ER (PROCARDIAXL)
blockers (H) (ADALAT CC, PROCARDIA )

Cardiac glycosides digoxin (LANOXIN, DIGITEK, LANOXICAPS) No additional efficacy vs lower doses; toxicity Consider discontinuing or dose reduction
due to reduced renal clearance (e.g. 0.125mg) with monitoring
 Drug High-risk agents to Avoid Non-high risk alternatives
Reason for Risk
classification (H) = considered Highest-risk¹ Drug
Estrogens and Oral Increased risk of breast &/or endometrial Hot flashes*:
progestins ANGELIQ cancer; NOT cardioprotective venlafaxine (EFFEXOR)
conjugated estrogen (PREMARIN, ESTINYL) paroxetine (PAXIL)
conjugated estrogen & medroxyprogesterone fluoxetine (PROZAC)
(PREMPRO, PREMPHASE) sertraline (ZOLOFT)
 esterified estrogen (MENEST ) gabapentin
 esterified estrogen & methyltestosterone (H) * nondrug therapy should be emphasized
(COVARYX, ESTRATEST)
Bone density:
 estropipate (OGEN, ORTHO-EST)
Calcium vitamin D
 estradiol (H) (ESTRACE, GYNODIOL) (H)
alendronate (FOSAMAX)
 estradiol/norethindrone (H) (ACTIVELLA, ACTONEL
MIMVEY) Ibandronate (BONIVA)
 FEMHRT (H) EVISTA
 JEVANTIQUE (H)
 JINTELI (H) Genitourinary symptoms:
Megestrol (MEGACE/ES) (H) Femring
ORTHOPREFEST (H) Premarin vaginal cream
PREFEST (H) Vagifem

Transdermal
estradiol patch (H)
ALORA patch (H)
ESTRASORB (H)
ESCLIM patch (H)
CLIMARA PRO patch (H)
COMBIPATCH (H)
VIVELLE-DOT patch (H)
MENOSTAR patch (H)
DIVIGEL topical gel (H)
ELESTRIN topical gel (H)
EVAMIST topical spray (H)
 Drug High-risk agents to Avoid Non-high risk alternatives
Reason for Risk
classification (H) = considered Highest-risk¹ Drug
Narcotics ASA/caffeine/propoxyphene (DARVON Enhanced CNS effects: confusion, mild pain:
COMPOUND ) hallucinations; falls; fractures; seizure risk APAP
ASA=aspirin APAP & pentazocine (H) (TALACEN ) ibuprofen
APAP & propoxyphene (DARVOCET ) naproxen
APAP= meperidine (H) (DEMEROL ) meloxicam
acetaminophen meperidine & promethazine (H) (MEPROZINE )
moderate/severe pain:
naloxone & pentazocine (H) (TALWIN NX )
tramadol
pentazocine (H) (TALWIN )
morphine sulfate (MS CONTIN)
 propoxyphene hydrochloride (DARVON)
hydrocodone/APAP (VICODIN, etc)
 propoxyphene napsylate (DARVON)
oxycodone (OXYIR)
oxycodone/APAP (PERCOCET)
fentanyl patch (DURAGESIC)
OXYCONTIN
AVINZA

Oral hypoglycemics chlorpropamide (H) (DIABINESE, INSULASE ) Prolonged hypoglycemia; risk of SIADH glimepiride (AMARYL)
glyburide (DIABETA, MICRONASE, GLYCRON, glipizide (GLUCOTROL)
GLYNASE) (H)
glyburide/metformin (GLUCOVANCE) (H)

Sedative hypnotics chloral hydrate (SOMNOTE) (H) Cognitive impairment, delirium, unsteady gait, Temazepam
LUNESTA (H) syncope, falls, accidents, Trazodone
zaleplon (SONATA) (H) fractures, tolerance, delirium, risk of overdose ROZEREM
zolpidem (AMBIEN/CR, INTERMEZZO, (narrow therapeutic window – chloral hydrate) Limit use of sedative hypnotic to short-term
EDLUAR, ZOLPIMIST) (H) use
 Drug High-risk agents to Avoid Non-high risk alternatives
Reason for Risk
classification (H) = considered Highest-risk¹ Drug
Skeletal muscle ASA/caffeine/orphenadrine (H) Anticholinergic side effects: worsened baclofen (LIORESAL)
relaxants ASA/carisoprodol/codeine (H) cognition & behavioral problems (especially in tizanidine (ZANAFLEX)
ASA & carisoprodol (H) dementia); urinary retention OR incontinence;
ASA=aspirin ASA & methocarbamol (H) confusion sedation; weakness; questionable
carisoprodol (H) (SOMA ) efficacy (at lower doses)
chlorzoxazone (H) (PARAFON FORTE )
cyclobenzaprine (H) (FLEXERIL, AMRIX,
FEXMID )
metaxalone (H) (SKELAXIN )
methocarbamol (H) (ROBAXIN )
orphenadrine (H) (NORFLEX )

Tricyclic amitriptyline/combinations (ELAVIL, Anticholinergic effects (e.g., confusion, dry nortriptyline

antidepressants VANATRIP) (H) mouth, constipation), cognitive impairment, desipramine
clomipramine (ANAFRANIL) (H) delirium, sedation, orthostatic hypotension trazodone (low dose)
doxepin (SINEQUAN, SILENOR) (H)
imipramine (TOFRANIL) (H)
Trimipramine (SURMONTIL) (H)

Vasodilators dipyridamole (short-acting only) (PERSANTINE ) Orthostatic hypotension; ineffective for stroke stroke prevention:
ergot mesyloid (ERGOMAR ) prevention; unproven &/or questionable aspirin
isoxsuprine (VASODILAN ) efficacy PLAVIX
AGGRENOX

Alzheimer’s/dementia:
galantamine
rivastigmine
ARICEPT
EXELON
 Drug High-risk agents to Avoid Non-high risk alternatives
Reason for Risk
classification (H) = considered Highest-risk¹ Drug
Other methyltestosterone (H) (ANDROID, TESTRED ) Methyltestosterone = cardiac side effects & NA
nitrofurantoin (H) (FURADANTIN ) prostatic enlargement in men
(androgen, anabolic nitrofurantoin macrocrystals (H) Nitrofurantoin = nephrotoxicity (kidney) Thyroid urinary tract infections
steroid; thyroid drug; (MACRODANTIN ) desiccated = cardiac AEs ciprofloxacin
urinary anti- infectives, nitrofurantoin macrocrystals-monohydrate (H) trimethoprim-sulfamethoxazole
psych, cardiac) (MACROBID ) (BACTRIM DS)
thyroid desiccated (H) (ARMOUR THYROID )
SERENTIL (H) thyroid:
levothyroxine (SYNTHROID)
ergoloid (HYDERDINE) (H)
levoxyl
reserpine/combinations (H)
ticlopidine (TICLID) (H)
anti-platelet
clopidogrel

References
1. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the beers criteria for potentially inappropriate medication use in older adults.
Arch Intern Med. 2003; 163(22): 2716-24.

2. Simon SR, Chan A, Soumerai SB, Wagner AK, Andrade SE, Feldstein AC, et al. Potentially inappropriate medication use by elderly persons in U.S. health
maintenance organizations, 2000-2001. J Am Geriatr Soc. 2005; 53(2): 227-32.

3. Chang CM, Liu PY, Yang YK, Yang YC, Wu C, Lu F. Use of the beers criteria to predict adverse drug reactions among first-visit elderly outpatients.
Pharmacotherapy. 2005; 25 (6): 831-38.

4. PL Detail-Document, Potentially Harmful Drugs in the Elderly: Beers List. Pharmacist’s Letter/Prescriber’s Letter. June 2012.