Потенційно невідповідні ліки для літніх людей (на основі критеріїв Бірса Американського геріатричного товариства 2019 року^® Оновлення)

Anticholinergics (tricyclic antidepressants are excluded)

First-generation antihistamines (brompheniramine, carbinoxamine, chlorpheniramine, clemastine, cyproheptadine, dexbrompheniramine, dexchlorpheniramine, dimenhydrinate, diphenhydramine [oral], doxylamine, hydroxyzine, meclizine, promethazine, triprolidine)

Highly anticholinergic; risk of confusion, dry mouth, constipation, and other anticholinergic effects and toxicity

Clearance reduced with advanced age; tolerance develops when used as hypnotics

Avoid, except use of diphenhydramine in special situations (eg, severe allergic reaction) may be appropriate

Antiparkinson drugs (benztropine [oral], trihexyphenidyl)

Not recommended for prevention of extrapyramidal symptoms with antipsychotics; more effective agents available for treatment of Parkinson disease

Antispasmodics (atropine [excludes ophthalmic], belladonna alkaloids, clidinium-chlordiazepoxide, dicyclomine homatropine [excludes ophthalmic], hyoscyamine, methscopolamine, propantheline, scopolamine)

Highly anticholinergic, uncertain effectiveness; avoid

Anti-infectives

Nitrofurantoin

Potential for pulmonary toxicity, hepatotoxicity, and peripheral neuropathy, especially with long-term use; safer alternatives available

Avoid in patients with creatinine clearance < 30 mL/min (< 0.5 mL/sec) or for long-term suppression of bacteria

Antithrombotics

Dipyridamole, oral short-acting* (does not apply to extended-release combination with aspirin)

Possible orthostatic hypotension; more effective alternatives available; avoid, except

IV form acceptable for cardiac stress testing

Cardiovascular drugs

Alpha-1 blockers for treatment of hypertension (doxazosin, prazosin, terazosin)

High risk of orthostatic hypotension; alternative drugs have better risk/benefit ratio; avoid use as an antihypertensive

Central alpha agonists, clonidine for first-line treatment of hypertension, other central nervous system alpha-agonists (guanabenz*, guanfacine*, methyldopa*, reserpine [> 0.1 mg/day]*)

High risk of adverse CNS effects; may cause bradycardia and orthostatic hypotension

Not recommended as routine treatment for hypertension

Amiodarone

Effective for maintaining sinus rhythm but has greater toxicities than other antiarrhythmics used in atrial fibrillation; may be reasonable first-line therapy in patients with concomitant heart failure or substantial left ventricular hypertrophy if rhythm control is preferred over rate control

Avoid as first-line therapy for atrial fibrillation unless patient has heart failure or substantial left ventricular hypertrophy

Disopyramide*

Potent negative inotrope (may induce heart failure); strongly anticholinergic; avoid, other antiarrhythmic drugs preferred

Dronedarone

Worse outcomes in patients taking dronedarone who have permanent atrial fibrillation or severe or recently decompensated heart failure

Avoid in patients with permanent atrial fibrillation or severe or recently decompensated heart failure

Digoxin for first-line treatment of atrial fibrillation or heart failure

Use in atrial fibrillation: Should not be used as a first-line agent, because more effective alternatives exist; avoid as first-line therapy

Use in heart failure: Questionable effects on risk of hospitalization and may be associated with increased mortality in older adults with heart failure; in heart failure, higher dosages not associated with additional benefit and may increase risk of toxicity; avoid as first-line therapy

Decreased renal clearance of digoxin may lead to increased risk of toxic effects; further dose reduction may be necessary in patients with Stage 4 or 5 chronic kidney disease; if used for atrial fibrillation or heart failure, avoid doses > 0.125 mg/day

Nifedipine, immediate release*

Risk of hypotension and myocardial ischemia; avoid

Central nervous system

Antidepressants alone or in combination (amitriptyline, amoxapine, clomipramine, desipramine, doxepin [> 6 mg/day], imipramine, nortriptyline, paroxetine, protriptyline, trimipramine)

Highly anticholinergic and sedating and cause orthostatic hypotension; avoid

Safety profile of low-dose doxepin (≤ 6 mg/day) comparable with that of placebo

Antipsychotics, 1st (conventional) and 2nd (atypical) generations

Increased risk of stroke and greater rate of cognitive decline and mortality in patients with dementia

Avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and older adult is threatening substantial harm to self or others

Avoid, except for schizophrenia, bipolar disorder, or short-term use as antiemetic during chemotherapy

Barbiturates (amobarbital*, butabarbital*, butalbital, mephobarbital*, pentobarbital*, phenobarbital, secobarbital*)

High rate of physical dependence, tolerance to sleep benefits, greater risk of overdose at low dosages; avoid

Benzodiazepines, short- and intermediate-acting (alprazolam, estazolam, lorazepam, oxazepam, temazepam, triazolam)

Benzodiazepines, long-acting (chlordiazepoxide [alone or in combination with amitriptyline or clidinium], clonazepam, clorazepate, diazepam, flurazepam, quazepam)

Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting drugs; in general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults; avoid

May be appropriate for seizure disorders, rapid eye movement sleep disorders, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, periprocedural anesthesia

Meprobamate

High rate of physical dependence; sedating; avoid

Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics (eszopiclone, zolpidem, zaleplon)

Benzodiazepine-receptor agonists have adverse events similar to those of benzodiazepines in older adults (eg, delirium, falls, fractures); increased emergency department visits and hospitalizations; motor vehicle crashes; minimal improvement in sleep latency and duration; avoid

Ergot mesylates* (dehydrogenated ergot alkaloids)

Isoxsuprine*

Lack of efficacy; avoid

Endocrine therapy

Androgens (methyltestosterone*, testosterone)

Potential for cardiac problems; contraindicated in men with prostate cancer

Avoid except for confirmed hypogonadism with clinical symptoms

Desiccated thyroid

Possible cardiac effects; safer alternatives available; avoid

Estrogens with or without progestins

Evidence of carcinogenic potential (breast and endometrium); lack of cardioprotective effect and cognitive protection in older women

Evidence indicates that vaginal estrogens for the treatment of vaginal dryness are safe and effective; women with a history of breast cancer who do not respond to nonhormonal therapies are advised to discuss the risk and benefits of low-dose vaginal estrogen (dosages of estradiol < 25 mcg twice weekly) with their healthcare practitioner

Avoid topical patch and oral

Vaginal cream or tablets: Acceptable to use low-dose intravaginal estrogen for management of dyspareunia, recurrent lower urinary tract infections, and other vaginal symptoms

Growth hormone

Little effect on body composition; associated with edema, arthralgia, carpal tunnel syndrome, gynecomastia, impaired fasting glucose

Avoid except for patients diagnosed by evidence-based criteria with growth hormone deficiency due to an established etiology

Insulin, sliding scale (insulin regimens containing only short- or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin)

Higher risk of hypoglycemia without improvement in glucose control regardless of care setting

Avoid sole use of short- or rapid-acting insulins dosed according to blood glucose levels in absence of basal or long-acting insulin; does not apply to titration of basal insulin or use of additional short- or rapid-acting insulin in conjunction with scheduled insulin (ie, correction insulin)

Megestrol

Minimal effect on weight; increases risk of thrombotic events and possibly death; avoid

Sulfonylureas, long duration (chlorpropamide, glimepiride, glyburide [also known as glibenclamide])

Chlorpropamide: Prolonged half-life; can cause prolonged hypoglycemia; causes syndrome of inappropriate antidiuretic hormone secretion; avoid

Glyburide and glimepiride: Greater risk of severe prolonged hypoglycemia; avoid

Gastrointestinal therapy

Metoclopramide

Can cause extrapyramidal effects including tardive dyskinesia; risk may be greater in frail older adults; avoid unless for gastroparesis with duration of use not to exceed 12 weeks except in rare cases

Mineral oil, oral

Potential for aspiration; safer alternatives available; avoid

Proton-pump inhibitors

Risk of Clostridioides difficile infection and bone loss and fractures

Avoid scheduled use for > 8 weeks unless for high-risk patients (eg, oral corticosteroids or chronic NSAID use), erosive esophagitis, Barrett esophagitis, pathologic hypersecretory condition, or demonstrated need for maintenance treatment (eg, due to failure of drug discontinuation trial or H2 blockers)

Pain management

Meperidine

Not an effective oral analgesic in common dosages; may cause neurotoxicity; safer alternatives available; avoid

Non–COX-selective NSAIDs, oral (aspirin [> 325 mg/day], diclofenac, diflunisal, etodolac, fenoprofen, ibuprofen, ketoprofen, meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin)

Increased risk of gastrointestinal bleeding and peptic ulcer disease in high-risk groups, including those aged > 75 or taking oral or parenteral corticosteroids, anticoagulants, or antiplatelet agents

Upper gastrointestinal ulcers, gross bleeding, or perforation occur in about 1% of patients treated for 3 to 6 months and in about 2 to 4% of patients treated for 1 year; these trends continue with longer duration of use

Avoid chronic use unless other alternatives are ineffective and patients are able to take a proton pump inhibitor or misoprostol (which reduce but do not eliminate risk)

Indomethacin

Ketorolac, includes parenteral

Increased risk of gastrointestinal bleeding/peptic ulcer disease and acute kidney injury in older adults; avoid

Indomethacin: Increased risk of adverse CNS effects compared to other NSAIDs; avoid

Skeletal muscle relaxants (carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine)

Poorly tolerated because of anticholinergic effects; sedation; risk of fracture; effectiveness at dosages tolerated by older adults is questionable; avoid

Genitourinary

Desmopressin

High risk of hyponatremia; safer alternative treatments; avoid for treatment of nocturia or nocturnal polyuria