Geriatric emergency medication safety recommendations: Difference between revisions

(Created page with "{| class="wikitable" |- ! Therapeutic Class ! Alternatives ! Exclusoins ! ! |- | Barbiturates | For epilepsy, use other anticonvulsants (eg, lamotrigine,<br />levetiracetam).46-48 For agitation, treat pain first with<br />acetaminophen then low-dose opioid.49,74,75 For severe<br />agitation, use low-dose second-generation antipsychotic (eg,<br />olanzapine, risperidone, quetiapine [Lewy body dementia]).49-51 | For seizures disorders,<br />benzodiazepine or ethanol<br...")
 
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==Background==
*Consensus guidelines with alternative medications for geriatric medication use upon discharge from the ED.
===High-Risk Medications to Avoid for Geriatric Patients at ED Discharge<ref>Skains, et al. Geriatric Emergency Medication Safety Recommendations (GEMS-Rx). Annals of Emergency Medicine. September 2024. 84(3):274-284. https://doi.org/10.1016/j.annemergmed.2024.01.033</ref>===
{| class="wikitable"  
{| class="wikitable"  
|-
|-
! Therapeutic Class
! High-Risk Therapeutic Class (AVOID)
! Alternatives
! Alternative Options (Preferred)
! Exclusoins
! Valid Exceptions^ (Use with Caution)
!
!  
|-
|-
| Barbiturates
| [[Barbiturates]]
| For epilepsy, use other anticonvulsants (eg, lamotrigine,<br />levetiracetam).46-48 For agitation, treat pain first with<br />acetaminophen then low-dose opioid.49,74,75 For severe<br />agitation, use low-dose second-generation antipsychotic (eg,<br />olanzapine, risperidone, quetiapine [Lewy body dementia]).49-51
*Examples: [[phenobarbital]]
| For seizures disorders,<br />benzodiazepine or ethanol<br />withdrawal, barbiturates are<br />acceptable to use.52-56
|  
|  
*[[Epilepsy]]
**Use other [[anticonvulsants]]
**Examples: [[lamotrigine]], [[levetiracetam]])
*[[Agitation]]
**Treat pain first with [[acetaminophen]] then low-dose [[opioid]]
*Severe [[agitation]]
**Use low-dose second-generation antipsychotic
**Examples: [[olanzapine]], [[risperidone]], [[quetiapine]] (Lewy body dementia)
|
*[[Seizure disorders]]
**[[Benzodiazepine withdrawal]]
**[[Ethanol withdrawal]]
|-
| [[Benzodiazepines]]
*Examples: [[diazepam]], [[lorazepam]], [[midazolam]]
|  
|  
*[[Epilepsy]]
**Use other [[anticonvulsants]]
**Examples: [[lamotrigine]], [[levetiracetam]]
*[[Agitation]]
**Treat pain first with [[acetaminophen]] then low-dose [[opioid]]
*Severe [[agitation]]
**use nonpharmacologic approach then low-dose second-generation [[antipsychotic]]
**Examples: [[olanzapine]], [[risperidone]], [[quetiapine]] (Lewy body dementia)
|
*[[Seizure disorders]]
**[[Benzodiazepine withdrawal]]
**[[Ethanol withdrawal]]
**Severe generalized [[anxiety disorder]]
**[[Palliative care]]
|-
|-
| Benzodiazepines
| First-generation [[antihistamines]]
| For epilepsy, use other anticonvulsants (eg, lamotrigine,<br />levetiracetam).46-48 For agitation, treat pain first with<br />acetaminophen then low-dose opioid.49,74,75 For severe<br />agitation, use nonpharmacologic approach then low-dose<br />second-generation antipsychotic (eg, olanzapine, risperidone,<br />quetiapine [Lewy body dementia]).49
*Examples: [[diphenhydramine]] (Benadryl), [[doxylamine]], [[hydroxyzine]] (Vistaril), [[meclizine]]
| For seizure disorders,<br />benzodiazepine or ethanol<br />withdrawal, severe generalized<br />anxiety disorder, and end of life,<br />benzodiazepines are acceptable<br />to use.52-54,57,58
|  
|  
*[[Allergies]]
**Use intranasal saline or steroid (e.g., [[fluticasone]], [[beclomethasone]]), topical antihistamines (e.g., [[azelastine]]), or second-generation antihistamines (e.g., [[fexofenadine]], [[loratadine]]).
*[[Vertigo]]
**Use short-term steroids and canalith repositioning maneuvers.
|  
|  
*[[Acute allergic reaction]]s
|-
|[[Metoclopramide]]
|
*[[Nausea]]
**Use [[ondansetron]]
|
*[[Gastroparesis]]
|-
|-
|  
|First-generation [[antipsychotics]]
|  
*Examples: [[haloperidol]], [[prochlorperazine]], [[promethazine]]
|  
|
|  
*Second-generation antipsychotics
|  
**Examples: [[olanzapine]], [[risperidone]], [[quetiapine]], [[aripiprazole]], [[ziprasidone]]
|
|-
|[[Nonbenzodiazepine]]s (Z-drugs)
*Examples: [[zolpidem]] (Ambien), [[zaleplon]] (Sonata), [[eszopiclone]] (Lunesta)
|
*Insomnia
**Use [[melatonin]], [[ramelteon]], [[doxepin]] (<=3 mg)
*Anxiety
**Use [[mirtazapine]], [[buspirone]], serotonin–norepinephrine reuptake inhibitor (serotonin and norepinephrine reuptake inhibitor, eg, [[duloxetine]], [[venlafaxine]], [[desvenlafaxine]])
|
|-
|[[Skeletal muscle relaxants]]
*Examples: [[Baclofen]] (Lioresal), [[dantrolene]] (Dantrium), [[cyclobenzaprine]] (Amrix)
|
*Treat musculoskeletal pain first with nonpharmacologic agents (e.g., heat, ice, massage) then with [[acetaminophen]], short-course [[NSAIDs]], [[lidocaine]] patch, [[diclofenac]] gel.
|
|-
|[[Sulfonylureas]]
*Examples: [[Glipizide]], [[glyburide]]
|
*[[Metformin]], long-acting [[insulin]] (e.g., [[glargine]])
|
|}
|}
 
^Indications for use where high-risk medication benefit may outweigh risks.
 
 
 
 
 
 
 
 
 
 
 
 
 
 


==See Also==
==See Also==
*[[Geriatrics (main)]]
*[[Geriatrics (main)]]
==References==

Latest revision as of 23:32, 20 May 2026

Background

  • Consensus guidelines with alternative medications for geriatric medication use upon discharge from the ED.

High-Risk Medications to Avoid for Geriatric Patients at ED Discharge[1]

High-Risk Therapeutic Class (AVOID) Alternative Options (Preferred) Valid Exceptions^ (Use with Caution)
Barbiturates
Benzodiazepines
First-generation antihistamines
Metoclopramide
First-generation antipsychotics
Nonbenzodiazepines (Z-drugs)
Skeletal muscle relaxants
Sulfonylureas

^Indications for use where high-risk medication benefit may outweigh risks.

See Also

References

  1. ↑ Skains, et al. Geriatric Emergency Medication Safety Recommendations (GEMS-Rx). Annals of Emergency Medicine. September 2024. 84(3):274-284. https://doi.org/10.1016/j.annemergmed.2024.01.033
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