alprazolam doses >2mg (XANAX®)

Benzodiazepines, Short-Acting

Due to sensitivity in the elderly, total daily doses should not exceed the suggested maximum dose of 2mg

(Algorithm A) Anxiety: taper off benzodiazepine and add buspirone, lorazepam <3mg/day, oxazepam <60mg/day⁵ (Algorithm I) Insomnia: sleep hygiene, trazodone, temazepam, zolpidem, zaleplon, eszopiclone, ramelteon^5,6,7

amiodarone (CORDARONE®)

Anti-Arrhythmic Agents, Class III

QT interval prolongation, Torsades de pointes, uncertain effectiveness, Boxed Warning: pulmonary toxicity, hepatotoxicity, pro-arrhythmic events

(Algorithm A/F) Atrial Fibrillation, Rate Control; Left Ventricular Ejection Fraction (LVEF) <40%: metoprolol (extended release), carvedilol, bisoprolol + digoxin, (amiodarone may be used if alternative suggestions have failed)^8,22
Atrial Fibrillation, Rate Control; LVEF ≥ 40%: atenolol, metoprolol, propranolol, non-dihydropyridine CCB (diltiazem, verapamil), digoxin (no more than 125mcg/day)^8,22; Atrial Fibrillation, Rhythm Control (no or minimal heart disease): propafenone, flecainide, sotalol (amiodarone may be used if alternative suggestions have failed)^8,22; Atrial Fibrillation, Rhythm Control (heart disease present): propafenone, flecainide, dofetilide, sotalol^8,22

amitriptyline (ELAVIL®)

Antidepressants, Tricyclic

Anticholinergic effects, sedative effects

(Algorithm P) Pain, Neuropathic: topical (capsaicin, menthol), lidocaine patch, tricyclic antidepressant without active metabolites (nortriptyline), gabapentin, pregabalin⁹; Depression: psychotherapy, SSRI, SNRI, bupropion, mirtazapine¹⁰; (Algorithm I) Insomnia: sleep hygiene, trazodone, temazepam, zolpidem, zaleplon, eszopiclone, ramelteon^5,6,7

amphetamines

Amphetamines

Hypertension, angina, myocardial infarction, Boxed Warning: High abuse potential, dependency

Depression: psychotherapy, SSRI, SNRI, bupropion, mirtazapine¹¹; Weight Control: diet and lifestyle modifications

anorexic agents

Anorexic Agents

Dependency, hypertension, angina, myocardial infarction

Weight Control: diet and lifestyle modifications

barbiturates

Sedatives, Barbiturate

Dependency, sedative effects

(Algorithm I) Insomnia: sleep hygiene, trazodone, temazepam, zolpidem, zaleplon, eszopiclone, ramelteon^5,6,7 (phenobarbital may be used if controlling seizures)

belladonna alkaloids (DONNATAL® and others)

Antispasmodic Agents, Gastrointestinal

Anticholinergic effects, uncertain effectiveness

Pain, IBS/GI: APAP, fiber (psyllium), simethicone, (belladonna may be used in IBS due to chronic opioid therapy)^9,12; (Algorithm C) Constipation: increase fluids and fiber intake, psyllium, polyethylene glycol, stool softener (docusate), glycerin suppository¹²; Diarrhea: loperamide, cholestyramine¹²

bisacodyl (DULCOLAX®)

Laxatives, Stimulant

Bowel dysfunction

(Algorithm C) Constipation: increase fluids and fiber intake, psyllium, polyethylene glycol, stool softener (docusate), glycerin suppository, (biscodyl may be used in elderly or hospice patients taking medications that may cause constipation and have failed alternative suggestions)¹²

carisoprodol (SOMA®)

Musculoskeletal Agents, Skeletal Muscle Relaxant

Anticholinergic effects, sedative effects, weakness, uncertain effectiveness

Spasticity: treat underlying problem, correct seating/footwear, APAP, NSAID+PPI, baclofen, tizanidine¹³

chlorazepate (TRANXENE®)

Benzodiazepines, Long-Acting

Long half-life, anticholinergic effects, sedative effects

(Algorithm A) Anxiety: taper off benzodiazepine and add buspirone, lorazepam <3mg/day, oxazepam <60mg/day⁵; (Algorithm I) Insomnia: sleep hygiene, trazodone, temazepam, zolpidem, zaleplon, eszopiclone, ramelteon^5,6,7

chlordiazepoxide (LIBRIUM®), chlordiazepoxide-amitriptyline (LIMBITROL®)

Benzodiazepines, Long-Acting Antidepressant Agents, Tricyclic

Long half-life, anticholinergic effects, sedative effects, increased risk of falls

(Algorithm A) Anxiety: taper off benzodiazepine and add buspirone, lorazepam <3mg/day, oxazepam <60mg/day⁵; (Algorithm I) Insomnia: sleep hygiene, trazodone, temazepam, zolpidem, zaleplon, eszopiclone, ramelteon^5,6,7

chlorpheniramine (CHLORTRIMETON®)

Antihistamines, H1 Receptor Antagonist

Anticholinergic effects

(Algorithm A/R) Allergic Rhinitis: nasal corticosteroid, opthalmic antihistamine, fexofenadine, loratadine, desloratadine, cetirizine, levocetirizine^5,14,28

chlorpromazine (THORAZINE®)

Antipsychotic
Agents, Typical

Increased risk of falls, extrapyramidal symptoms, Boxed Warning: increased mortality risk in elderly dementia related patients on typical or atypical antipsychotics

(Algorithm N/V) Chemotherapy Induced/Post-Operative Nausea and Vomiting: ondansetron, granisetron, dolasetron, palonosetron, + dexamethasone (chlorpromazine may be used in hospice or schizophrenia patients)¹⁵

chlorpropamide (DIABINESE®)

Antidiabetic Agents, Sulfonylurea

Long half-life, hypoglycemia, SIADH

(Algorithm D) Diabetes Mellitus, Type II: glimepiride, glipizide, glyburide, tolbutamide, (sulfonylureas may be used as add on therapy to metformin and TZDs when appropriate)^16,25,27

chlorzoxazone (PARAFLEX®)

Musculoskeletal Agents, Skeletal Muscle Relaxant

Anticholinergic effects, sedative effects, weakness, hepatotoxicity, uncertain effectiveness

Spasticity: treat underlying problem, correct seating/footwear, APAP, NSAID+PPI, baclofen, tizanidine¹³

cimetidine (TAGAMET®)

Antiulcer Agents, Histamine 2 Receptor Antagonist

CNS adverse effects

GI Indications: ranitidine, famotidine, nizatidine, proton pump inhibitor (PPI), (cimetidine may be used in the Emergency Department for allergies)