Geriatric emergency medication safety recommendations: Difference between revisions

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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>===
===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)
! Exclusions^
! Valid Exceptions^ (Use with Caution)
|-
|-
| Barbiturates
| [[Barbiturates]]
*Examples: [[phenobarbital]]
|  
|  
*Epilepsy: use other anticonvulsants (e.g., [[lamotrigine]], [[levetiracetam]]).
*[[Epilepsy]]
*Agitation: treat pain first with acetaminophen then low-dose opioid.
**Use other [[anticonvulsants]]
*Severe agitation: use low-dose second-generation antipsychotic (eg, olanzapine, risperidone, quetiapine [Lewy body dementia]).
**Examples: [[lamotrigine]], [[levetiracetam]])
|  
*[[Agitation]]
*Seizures disorders, benzodiazepine or ethanol withdrawal, barbiturates are acceptable to use.
**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
| [[Benzodiazepines]]
*Examples: [[diazepam]], [[lorazepam]], [[midazolam]]
|  
|  
*Epilepsy: use other anticonvulsants (eg, lamotrigine, levetiracetam).
*[[Epilepsy]]
*Agitation: treat pain first with acetaminophen then low-dose opioid.
**Use other [[anticonvulsants]]
**Severe agitation: use nonpharmacologic approach then low-dose second-generation antipsychotic (eg, olanzapine, risperidone, quetiapine [Lewy body dementia]).
**Examples: [[lamotrigine]], [[levetiracetam]]
|  
*[[Agitation]]
*Seizure disorders: benzodiazepine or ethanol withdrawal, severe generalized anxiety disorder, and end of life, benzodiazepines are acceptable to use.
**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]]
|-
|-
| First-Generation Antihistamines
| First-generation [[antihistamines]]
*Examples: [[diphenhydramine]] (Benadryl), [[doxylamine]], [[hydroxyzine]] (Vistaril), [[meclizine]]
|  
|  
*Allergies: use intranasal saline or steroid (eg, fluticasone, beclomethasone), topical antihistamines (eg, azelastine), or second-generation antihistamines (eg, fexofenadine, loratadine).
*[[Allergies]]
*Vertigo: use short-term steroids and canalith repositioning maneuvers.
**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.
|  
|  
*For allergic reactions, first-generation antihistamines are acceptable to use.
*[[Acute allergic reaction]]s
|-
|-
|Metoclopramide
|[[Metoclopramide]]
|
|
*For nausea, use ondansetron.
*[[Nausea]]
**Use [[ondansetron]]
|
|
*For gastroparesis, metoclopramide is acceptable to use.
*[[Gastroparesis]]
|-
|-
|First-Generation Antipsychotics
|First-generation [[antipsychotics]]
*Examples: [[haloperidol]], [[prochlorperazine]], [[promethazine]]
|
|
*Second-generation antipsychotics (eg, olanzapine, risperidone, quetiapine, aripiprazole, ziprasidone).
*Second-generation antipsychotics  
**Examples: [[olanzapine]], [[risperidone]], [[quetiapine]], [[aripiprazole]], [[ziprasidone]]
|
|
|-
|-
|Nonbenzodiazepine, Benzodiazepine Receptor Agonist Hypnotics (Z-drugs)
|[[Nonbenzodiazepine]]s (Z-drugs)
*Examples: [[zolpidem]] (Ambien), [[zaleplon]] (Sonata), [[eszopiclone]] (Lunesta)
|
|
*Insomnia: use melatonin, ramelteon, doxepin (<=3 mg).
*Insomnia
*Anxiety: use mirtazapine, buspirone, serotonin–norepinephrine reuptake inhibitor (serotonin and norepinephrine reuptake inhibitor, eg, duloxetine, venlafaxine, desvenlafaxine).
**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
|[[Skeletal muscle relaxants]]
*Examples: [[Baclofen]] (Lioresal), [[dantrolene]] (Dantrium), [[cyclobenzaprine]] (Amrix)
|
|
*Treat musculoskeletal pain first with nonpharmacologic agents (eg, heat, ice, massage) then with Tylenol, short-course NSAIDs, lidocaine patch, diclofenac gel.
*Treat musculoskeletal pain first with nonpharmacologic agents (e.g., heat, ice, massage) then with [[acetaminophen]], short-course [[NSAIDs]], [[lidocaine]] patch, [[diclofenac]] gel.
|
|
|-
|-
|Sulfonylureas
|[[Sulfonylureas]]
|Metformin, long-acting insulin (eg, glargine).
*Examples: [[Glipizide]], [[glyburide]]
|
*[[Metformin]], long-acting [[insulin]] (e.g., [[glargine]])
|
|
|}
|}
^Exclusion criteria: valid indications to prescribe potentially inappropriate medications at ED discharge for older adults.
^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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