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In the Nov. 3, 2010, New England Journal of Medicine, researchers from the University of Pittsburgh, the Harvard School of Public Health and Harvard Medical School reported that doctors’ quality of drug prescribing for the elderly varied substantially among different geographic regions in the U.S. (The measure of quality was not being prescribed a high-risk drug.)
People age 65 and up are twice as likely to experience adverse events associated with medications than people under age 65,...
In the Nov. 3, 2010, New England Journal of Medicine, researchers from the University of Pittsburgh, the Harvard School of Public Health and Harvard Medical School reported that doctors’ quality of drug prescribing for the elderly varied substantially among different geographic regions in the U.S. (The measure of quality was not being prescribed a high-risk drug.)
People age 65 and up are twice as likely to experience adverse events associated with medications than people under age 65, and they are almost seven times more likely to be hospitalized as a result, according to the National Committee for Quality Assurance (the committee that accredits health care organizations).
The New England Journal of Medicine study utilized two quality measures from data collected by the National Committee for Quality Assurance: 1) the use of drugs that are considered to be high-risk for the elderly and 2) potentially harmful drug-disease interactions. (In this article we review just the first topic: the prescribing of high-risk drugs for the elderly.)
The researchers calculated, by U.S. geographic region, the proportion of Medicare beneficiaries who had received at least one high-risk drug in 2007. The median was 24.9 percent and the range was 11.4 percent to 44 percent. These percentages are too high; even one prescription being written for a high-risk drug is too many.
The results were consistent with an association between lower-quality prescribing and more adverse drug events that may cost more to treat.
High-risk drugs
In Table 1, we compare the list of medications that are considered high-risk for the elderly, as presented in the New England Journal of Medicine article, with our own recommendations for using (or not using) the drugs. Of the 77 drugs listed in the article, we had classified all 67 that we previously reviewed as “Do Not Use” or “Limited Use” on WorstPills.org. Of those 67, we listed 60 (90 percent) of them as “Do Not Use.”
Many of the drugs in the table are fixed combinations of drugs, in which at least one ingredient has not been proven to be effective or the second ingredient has not been proven to significantly add to the effectiveness of the first. In these cases, we list combination drugs as “Do Not Use.”
The antihistamine category in the table includes many drugs that contain oral decongestants, such as phenylephrine and pseudoephedrine, which are prescribed for the common cold. We do not recommend the use of any nasal decongestants that are taken by mouth for treatment of a cold because much smaller doses in the form of nose sprays or drops are safer and just as effective.
Ten of the drugs in the table have not been reviewed on WorstPills.org. These are listed as “not reviewed by WPBP.”
(Note: Worst Pills, Best Pills News and WorstPills.org cover drug use in all age groups, and in some cases when a drug is listed as “Limited Use,” this refers to younger age groups — not the elderly.)
What You Can Do
Before you get a new prescription filled, you should always read about the drug in Worst Pills, Best Pills News or on WorstPills.org. If you have concerns after checking out your drug, talk with your prescriber about better, safer alternatives. This will improve the quality of drugs you receive and may prevent needless adverse drug reactions.
Table 1. New England Journal of Medicine List of High-Risk Medications, With WorstPills.org Classification
|
Category |
Drugs and Drug Combinations |
WorstPills.org Classification |
|---|---|---|
|
Antianxiety (includes combination drugs) |
||
|
|
aspirin–meprobamate (EQUAGESIC, MICRAININ) |
Do Not Use |
|
|
meprobamate (EQUANIL, MILTOWN) |
Do Not Use |
|
Antiemetics |
||
|
|
scopolamine (TRANSDERM-SCOP) |
not reviewed by WPBP |
|
|
trimethobenzamide (TIGAN) |
Do Not Use |
|
Analgesics (includes combination drugs) |
||
|
|
ketorolac (TORADOL) |
Do Not Use |
|
Antihistamines (includes combination drugs) |
||
|
|
APAP/dextromethorphan/diphenhydramine (DIABETIC TUSSIN NIGHT TIME FORMULA) |
Do Not Use |
|
|
APAP/diphenhydramine/phenylephrine (BENADRYL ALLERGY & COLD, BENADRYL ALLERGY & SINUS, SUDAFED PE SEVERE COLD, THERAFLU WARMING SEVERE COLD NIGHTTIME) |
Do Not Use |
|
|
APAP/diphenhydramine/pseudoephedrine (ACTIFED SINUS DAY AND NIGHT, BENADRYL ALLERGY COLD, BENADRYL ALLERGY/SINUS HEADACHE, BENADRYL COLD, BENADRYL SEVERE ALLERGY & SINUS HEADACHE, CHILDREN’S TYLENOL ALLERGY-D, CONTAC DAY AND NIGHT ALLERGY, SUDAFED SINUS NIGHTTIME PLUS PAIN, TYLENOL ALLERGY COMPLETE NIGHTTIME, TYLENOL ALLERGY SINUS NIGHTTIME, TYLENOL NIGHTIME FLU GELCAP MAXIMUM STRENGTH, TYLENOL NIGHTIME HOT LIQUID MAXIMUM STRENGTH |
Do Not Use |
|
|
acetaminophen-diphenhydramine (TYLENOL COLD RELIEF, TYLENOL SEVERE ALLERGY) |
Do Not Use |
|
|
carbetapentane/diphenhydramine/phenylephrine (DYTAN-CS) |
Do Not Use |
|
|
codeine/phenylephrine/promethazine |
Do Not Use |
|
|
codeine-promethazine (PHENERGAN with codeine) |
Do Not Use |
|
|
cyproheptadine (PERIACTIN) |
n/a |
|
|
dexchlorpheniramine (POLARAMINE) |
not reviewed by WPBP |
|
|
dexchlorpheniramine/dextromethorphan/PSE (BROMATAN PLUS, DURATAN FORTE, TANAFED DMX, TANDUR DM, TANNATE DMP-DEX, C-PHED DPD TANN, TANAFED-DMX, DUR-TANN FORTE, SUTAN-DM, TANNATE PD-DM) |
Do Not Use |
|
|
dexchlorpheniramine/guaifenesin/PSE (POLARAMINE EXPECTORANT) |
Do Not Use |
|
|
dexchlorpheniramine/hydrocodone/phenylephrine (HYDEX PD, ZOTEX HC) |
Do Not Use |
|
|
dexchlorpheniramine/methscopolamine/PSE (DURAHIST D) |
Do Not Use |
|
|
dexchlorpheniramine-pseudoephedrine (DUOTAN PD, TANAFED DP) |
Do Not Use |
|
|
dextromethorphan-promethazine (PHENERGAN with dextromethorphan) |
Do Not Use |
|
|
diphenhydramine (BENADRYL) |
n/a |
|
|
diphenhydramine-magnesium salicylate (DOAN’S PM) |
not reviewed by WPBP |
|
|
diphenhydramine-phenylephrine (ALAHIST LQ, ALDEX-CT, CHILDREN’S TRIACTING NIGHT TIME, D-TANN, DIMETAPP NIGHTTIME COLD & CONGESTION, DIPHENMAX D, DYTAN-D, PEDIACARE CHILDREN’S ALLERGY & COLD, ROBITUSSIN NIGHT TIME COUGH & COLD, ROBITUSSIN NIGHT TIME COUGH & COLD CHILDREN’S, ROBITUSSIN NIGHT TIME COUGH & COLD PEDIATRIC, TRIAMINIC NIGHT TIME COLD & COUGH, DIPHENTANN-D, UNI-TANN D |
Do Not Use |
|
|
diphenhydramine-pseudoephedrine (RESPA SA) |
Do Not Use |
|
|
hydroxyzine hydrochloride (ATARAX, VISTARIL) |
n/a |
|
|
hydroxyzine pamoate (VISTARIL) |
n/a |
|
|
phenylephrine-promethazine |
Do Not Use |
|
|
promethazine (PHENERGAN, PROMETHEGAN, ROMERGAN, FARGAN, FARGANESSE, PROTHIAZINE, AVOMINE, ATOSIL, RECEPTOZINE, LERGIGAN) |
Do Not Use |
|
Antipsychotic, typical |
||
|
|
thioridazine (MELLARIL) |
Do Not Use |
|
Amphetamines |
||
|
|
amphetamine dextroamphetamine (ADDERALL) |
Limited Use |
|
|
benzphetamine (DIDREX) |
Do Not Use |
|
|
dexmethylphenidate (FOCALIN) |
Limited Use |
|
|
dextroamphetamine (DEXEDRINE, DEXTROSTAT) |
Limited Use |
|
|
diethylpropion (DURAD, TENUATE, TEPANIL) |
Do Not Use |
|
|
methamphetamine (DESOXYN) |
not reviewed by WPBP |
|
|
methylphenidate (CONCERTA, METADATE, METHYLIN, METHYLIN ER, RITALIN) |
Limited Use |
|
|
phendimetrazine (PLEGINE) |
n/a |
|
|
phentermine (ADIPEX-P, ATTI PLEX P, IONAMIN, KRAFTOBESE, PANSHAPE M, PHENTERCOT, PHENTRIDE, PRO-FAST, RAPHTRE, SUPRAMINE, TARA-8, TERAMINE, TERMENE) |
Do Not Use |
|
Barbiturates |
||
|
|
butabarbital (BUTISOL SODIUM) |
Do Not Use |
|
|
mephobarbital (MEBARAL) |
not reviewed by WPBP |
|
|
pentobarbital (NEMBUTOL) |
not reviewed by WPBP |
|
|
phenobarbital (LUMINAL SODIUM) |
Limited Use |
|
|
secobarbital (SECONAL SODIUM) |
not reviewed by WPBP |
|
Long-acting benzodiazepines (includes combination drugs) |
||
|
|
amitriptyline-chlordiazepoxide (LIMBITROL) |
Do Not Use |
|
|
chlordiazepoxide (H-TRAN, LIBRITABS, LIBRIUM, MITRAN, POXI) |
Do Not Use |
|
|
chlordiazepoxide-clidinium (LIBRAX) |
Do Not Use |
|
|
diazepam (VALIUM) |
Do Not Use |
|
|
flurazepam (DALMANE) |
Do Not Use |
|
Calcium channel blockers |
||
|
|
nifedipine—short-acting only (ADALAT, PROCARDIA) |
Do Not Use |
|
Belladonna alkaloids (includes combination drugs) |
||
|
|
atropine (ATREZA, ATROPEN, SAL-TROPINE) |
Do Not Use |
|
|
atropine/CPM/hyoscyamine/PE/scopolamine (ACCUHIST LA, BELLAHIST-D LA) |
Do Not Use |
|
|
atropine/hyoscyamine/PB/scopolamine (DONNATAL) |
Do Not Use |
|
|
atropine-difenoxin (MOTOFEN) |
Do Not Use |
|
|
atropine-diphenoxylate (LOMOTIL, LONOX) |
Do Not Use |
|
|
atropine-edrophonium (ENLON-PLUS) |
Do Not Use |
|
|
belladonna (BELLADONNA TINCTURE, BELLADONNA LEAF) |
Do Not Use |
|
|
belladonna/ergotamine/phenobarbital (BELLAMINE S, BELLASPAS) |
Do Not Use |
|
|
butabarbital/hyoscyamine/phenazopyridine (PHENAZOFORTE PLUS, URELIEF PLUS) |
Do Not Use |
|
|
digestive enzymes/hyoscyamine/phenyltoloxamine (DIGEX) |
Do Not Use |
|
|
hyoscyamine (LEVBID, LEVSIN) |
Do Not Use |
|
|
atropine, hyoscyamine, methenamine, methylene blue, phenyl salicylate and benzoic acid (PROSED/DS, URITACT DS) |
Do Not Use |
|
Skeletal muscle relaxants (includes combination drugs) |
||
|
|
ASA/caffeine/orphenadrine (NORGESIC, NORGESIC FORTE, ORPHENGESIC, ORPHENGESIC FORTE) |
Do Not Use |
|
|
ASA/carisoprodol/codeine (SOMA COMPOUND with codeine) |
Do Not Use |
|
|
aspirin-carisoprodol (SOMA COMPOUND) |
Do Not Use |
|
|
aspirin-methocarbamol (ROBAXISAL) |
Do Not Use |
|
|
carisoprodol (SOMA) |
Do Not Use |
|
|
chlorzoxazone (PARAFON FORTE DSC) |
Do Not Use |
|
|
cyclobenzaprine (FLEXERIL) |
Do Not Use |
|
|
metaxalone (SKELAXIN) |
not reviewed by WPBP |
|
|
methocarbamol (ROBAXIN) |
Do Not Use |
|
|
orphenadrine (NORFLEX) |
Do Not Use |
|
Oral estrogens (includes combination drugs) |
||
|
|
conjugated estrogen (PREMARIN) |
Limited Use |
|
|
conjugated estrogen medroxyprogesterone (PREMPRO, PREMPHASE) |
Limited Use |
|
|
esterified estrogen (ESTRATAB, MENEST) |
not reviewed by WPBP |
|
|
esterified estrogen methyltestosterone (ESTRATEST, ESTRATEST HS) |
Do Not Use |
|
|
estropipate (OGEN, ORTHO-EST) |
not reviewed by WPBP |
