ATRIO s Top Ten most prescribed High Risk Medications (HRM) with Formulary Alternatives:

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1 ATRIO s Top Ten most prescribed High Risk Medications (HRM) with Formulary Alternatives: High Risk Medication to Avoid: Generic (Brand) Alternatives for Consideration Reason to Avoid Prescribing Parameters and Tips Digoxin 0.25mg (Lanoxin) Digoxin 0.125mg/day No additional efficacy for higher dose vs lower doses: increased toxicity due to reduced renal clearance recommendation of dose reduction, with monitoring. In heart failure, higher dosages associated with no additional benefit and may increase risk of toxicity; decreased renal clearance may lead to increased risk of toxic effects. Digoxin 0.125mg is on formulary with PA required and quantity edit of 30 for 30 days. Heart Failure: Optimize ACEI, beta blocker, aldosterone antagonist before using digoxin. Goal digoxin level 0.8ng/ml (ideally ng/ml). Atrial Fibrillation: Digoxin 0.125mg, Metoprolol Tartrate (Lopressor), Verapamil SR Zolpidem (Ambien) Insomnia: Non pharmacologic treatment (sleep hygiene, cognitive behavior therapy), Melatonin (OTC), Low dose Doxepin (Silenor 6mg or less), Mirtazapine (Remeron), Low dose Trazodone, Ramelteon (Rozerem). Benzodiazepine receptor agonists that have adverse events similar to those of benzodiazepines in older adults (e.g., delirium, falls, fractures); minimal improvement in sleep latency and duration. Silenor is on formulary with quantity edit of 30 for 30 days. Temazepam (Restoril) Insomnia: Non pharmacologic treatment (sleep hygiene, cognitive behavior therapy), Melatonin (OTC), Low dose Doxepin (Silenor 6mg or less), Mirtazapine (Remeron), Low dose Trazodone, Ramelteon (Rozerem). Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long acting agents. In general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults. Silenor is on formulary with quantity edit of 30 for 30 days. 1

2 High Risk Medication to Avoid: Generic (Brand) Alternatives for Consideration Reason to Avoid Prescribing Parameters and Tips Amitriptyline (Elavil) Depression: Fluoxetine (Prozac), Sertraline (Zoloft), Citalopram (Celexa). Pain: Nortriptyline, Desipramine, Lidocaine Patch. Highly anticholinergic, sedating, and cause orthostatic hypotension; the rational of using low dose doxepin ( 6 mg/day) is that the safety profile is comparable to that of placebo. Silenor is on formulary with quantity edit of 30 for 30 days. Sleep: Non pharmacologic treatment (sleep hygiene, cognitive behavior therapy), Melatonin (OTC), Low dose Doxepin (Silenor 6mg or less), Mirtazapine (Remeron), Low dose Trazodone, Ramelteon (Rozerem). Nitrofurantoin (Macrobid) Alternatives: Trimethoprim/sulfamethoxazole DS (Bactrim DS), Ciprofloxacin (Cipro), Trimethoprim. Potentially less effective with compromised renal function. Increased risk of pulmonary toxicity or peripheral neuropathy. Increase risk when used long term (90 days/year). May be drug of choice due to allergies, drug interactions or resistance. Increase risk when used long term (90 days/year). May be drug of choice due to allergies, drug interactions or resistance. Cyclobenzaprine (Flexeril) Alternatives: Treat underlying problem, physiotherapy, application of heat or cold; correct seating and footwear. For Spasticity: Baclofen, Tizanidine, Nerve Blocks Most muscle relaxants poorly tolerated by older adults, because of anticholinergic adverse effects, sedation, increased risk of fractures. Effectiveness at dosages tolerated by older adults is questionable. 2

3 High Risk Medication to Avoid: Generic (Brand) Alternatives for Consideration Reason to Avoid Prescribing Parameters and Tips Glyburide (DiaBeta) Alternative Sulfonylureas: Glimepiride (Amaryl), Glipizide (Glucotrol) Higher risk of severe prolonged hypoglycemia in older adults. Glimepiride and glipizide are on formulary with quantity limits. Avoid Glucotrol XL due to hypoglycemia risk. Benztropine (Cogentin) Parkinson: Pramipexole (Mirapex), Ropinirole (Requip), Selegiline (Eldepryl) Not recommended for prevention of extrapyramidal symptoms with antipsychotics. More effective agents available for treatment of Parkinson disease. Estrogens with or without progestins Hot Flashes: Nondrug therapy (cool environment, layered clothing), SSRIs, gabapentin, venlafaxine Bone Density: Calcium, Vitamin D, Bisphosphonates, Raloxifene (Evista) Evidence of carcinogenic potential (breast and endometrium); lack of cardio protective effect and cognitive protection in older women. Evidence that vaginal estrogens for treatment of vaginal dryness is safe and effective in women with breast cancer, especially at dosages of estradiol <25 mcg twice weekly. Vaginal Symptoms, Recurrent UTI: Vaginal Estrogen Cream Megestrol (Megace) Alternatives: Feeding assistance, liberalizing food choices, nutritional supplements or snacks between meals, environment conductive to optimal oral intake, Mirtazapine (Remeron) for depressed patient. Increases risk of thrombotic events and possibly death in older adults. Minimal effect on weight. 3

4 High Risk Medication to Avoid: Generic (Brand) Alternatives for Consideration Reason to Avoid Prescribing Parameters and Tips Hydroxyzine (Atarax, Vistaril) Pruritis, Urticaria, seasonal or perennial allergy: Levocetirizine (Xyzal) In addition, there are OTC Options that ATRIO covers at no charge to the member: Cetirizine (Zyrtec), Cetirizine/Pseudoephedrine (Zyrtec D), Loratadine (Claritin), Loratadine/Pseudoephedrine (Claritin D) Insomnia: Ramelteon (Rozerem), low dose Trazodone Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; increased risk of confusion, dry mouth, constipation, and other anticholinergic effects/toxicity. Use of diphenhydramine in special situations such as acute treatment of severe allergic reaction may be appropriate. Ondansetron is on formulary with PA for B vs D determination. Anxiety: Buspirone (Buspar), Mirtazapine (Remeron), Paroxetine (Paxil), Fluoxetine (Prozac), Sertraline (Zoloft), Venlafaxine (Effexer) Nausea or vomiting: Ondansetron (Zofran) Cough: Drugs for treatment of cough are not covered under Part D 4

5 Additional High Risk Medications to Avoid (HRM) with Formulary Alternatives: Alternatives for Consideration Reason to Avoid Prescribing Parameters and Tips Anticholinergics (excludes TCAs) First generation antihistamines (as single agent or as part of combination products) Brompheniramine Carbinoxamine Chlorpheniramine Clemastine Cyproheptadine Dexbrompheniramine Dexchlorpheniramine Diphenhydramine (oral) Doxylamine Hydroxyzine Promethazine Triprolidine Pruritis, Urticaria, seasonal or perennial allergy: Levocetirizine (Xyzal) In addition, there are OTC Options that ATRIO covers at no charge to the member: Cetirizine (Zyrtec), Cetirizine/Pseudoephedrine (Zyrtec D), Loratadine (Claritin), Loratadine/Pseudoephedrine (Claritin D) Insomnia: Ramelteon (Rozerem), low dose Trazodone Anxiety: Buspirone (Buspar), Mirtazapine (Remeron), Paroxetine (Paxil), Fluoxetine (Prozac), Sertraline (Zoloft), Venlafaxine (Effexer) Nausea or vomiting: Ondansetron (Zofran) Cough: Drugs for treatment of cough are not covered under Part D Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; increased risk of confusion, dry mouth, constipation, and other anticholinergic effects/toxicity. Use of diphenhydramine in special situations such as acute treatment of severe allergic reaction may be appropriate. Use of diphenhydramine in special situations such as acute treatment of severe allergic reaction may be appropriate. 5

6 Alternatives for Consideration Reason to Avoid Prescribing Parameters and Tips Anticholinergics (excludes TCAs) Antiparkinson agents Benztropine (oral) Trihexyphenidyl Parkinson: Pramiperxole (Mirapex), Ropinirole (Requip), Selegiline (Eldepryl) Not recommended for prevention of extrapyramidal symptoms with antipsychotics. More effective agents available for treatment of Parkinson disease. Antispasmodics Belladonna alkaloids Clidinium chlordiazepox Dicyclomine Hyoscyamine Propantheline Scopolamine Chronic Constipation: Fiber, Psyllium, Polyethylene Glycol, Lactulose. Diarrhea: Loperamide (Imodium), Aluminum Hydroxide (Amphojel), Cholestyramine (Questran) Highly anticholinergic. Uncertain effectiveness. Antiplatelet Agents and Anticoagulants Dipyridamole, oral short acting (does not apply to the extendedrelease combination with aspirin) For Secondary Prevention of Noncardioembolic Stroke or TIA: Clopidogrel (Plavix), ASA/Dipyridamole (Aggrenox), Low Dose ASA or Cilostazol (Pletal) May cause orthostatic hypotension; more effective alternatives available. IV form acceptable for use in cardiac stress testing. 6

7 Alternatives for Consideration Reason to Avoid Prescribing Parameters and Tips Antiplatelet Agents and Anticoagulants Ticlopidine Alternatives: Clopidogrel (Plavix), Parasugrel (Effient), (post ACS), Ticagrelor (Brilinta) (post ACS) Safer, effective alternatives available. All the alternatives are on formulary without PA. Cardiovascular Alpha1 blockers Doxazosin Prazosin Terazosin Calcium Channel Blockers: Amlodipine (Norvasc), Felodipine (Plendil), Nifedipine (Procardia XL), longacting ACE Inhibitors: Benazepril (Lotensin), Captopril (Capoten), Enalapril (Vasotec), Fosinopril (Monopril), Lisinopril (Zestril, Prinivil), Quinapril (Accupril), Ramipril (Altace), Moexipril (Univasc), Perindopril (Aceon), Trandolapril (Mavik) High risk of orthostatic hypotension; not recommended as routine treatment for hypertension. Alternative agents have superior risk/benefit profile. Combination products also covered from the groups listed. ARB: Losartan (Cozaar), Irbesartan (Avapro), Olmesartan (Benicar), Valsartan (Diovan) Beta Blockers: Atenolol (Tenormin), Bisoprolol (Zebeta), Carvedilol (Coreg), Metoprolol (Lopressor, Toprol XL), Nadolol (Corgard), Acebutolol (Sectral), Betaxolol (Kerlone), Labetalol (Trandate), Sotalol (Betapace), Timolol (Blocadren), Propranolol (Inderal) Thiazide: Hydrochlorothiazide (Microzide), Chlorothiazide (Diuril) 7

8 Alternatives for Consideration Reason to Avoid Prescribing Parameters and Tips Cardiovascular Alpha blockers, central Clonidine Guanabenz Guanfacine Methyldopa Reserpine (>0.1 mg/day) Calcium Channel Blockers: Amlodipine (Norvasc), Felodipine (Plendil), Isradipine (Dynacirc CR), Nicardipine (Cardene SR), Nisoldipine (Sular), Nifedipine (Adalat CC, Afeditab CR, Procardia XL, Nifedical XL, Nifediac CC), long acting ACE Inhibitors: Benazepril (Lotensin), Captopril (Capoten), Enalapril (Vasotec), Fosinopril (Monopril), Lisinopril (Zestril, Prinivil), Quinapril (Accupril), Ramipril (Altace), Moexipril (Univasc), Perindopril (Aceon), Trandolapril (Mavik) High risk of adverse CNS effects; may cause bradycardia and orthostatic hypotension; not recommended as routine treatment for hypertension. Combination products also covered from the groups listed. ARB: Losartan (Cozaar), Irbesartan (Avapro), Olmesartan (Benicar), Valsartan (Diovan) Beta Blockers: Atenolol (Tenormin), Bisoprolol (Zebeta), Carvedilol (Coreg), Metoprolol (Lopressor, Toprol XL), Nadolol (Corgard), Acebutolol (Sectral), Betaxolol (Kerlone), Labetalol (Trandate), Sotalol (Betapace), Timolol (Blocadren), Propranolol (Inderal) Thiazide: Hydrochlorothiazide (Microzide), Chlorothiazide (Diuril) 8

9 Alternatives for Consideration Reason to Avoid Prescribing Parameters and Tips Cardiovascular Antiarrhythmic drugs (Class Ia, Ic, III) Amiodarone Dofetilide Dronedarone Flecainide Ibutilide Procainamide Propafenone Quinidine Sotalol Rate control preferred for atrial fibrillation. Amiodarone is associated with multiple toxicities, including thyroid disease, pulmonary disorders, and QT interval prolongation. Data suggest that rate control yields better balance of benefits and harms than rhythm control in elderly (better risk/benefit ratio). Disopyramide Rate control preferred for atrial fibrillation. Disopyramide is a potent negative inotrope and therefore may induce heart failure in older adults due to being strongly anticholinergic. Other antiarrhythmic drugs preferred. Dronedarone Rate control preferred for atrial fibrillation. Worse outcomes have been reported in patients taking dronedarone who have permanent atrial fibrillation or heart failure. In general, rate control is preferred over rhythm control for atrial fibrillation. 9

10 Alternatives for Consideration Reason to Avoid Prescribing Parameters and Tips Cardiovascular Digoxin >0.125 mg/day Digoxin 0.125mg/day No additional efficacy for higher dose vs lower doses: increased toxicity due to reduced renal clearance recommendation of dose reduction, with monitoring. In heart failure, higher dosages associated with no additional benefit and may increase risk of toxicity; decreased renal clearance may lead to increased risk of toxic effects. Digoxin 0.125mg is on formulary with PA required and quantity edit of 30 for 30 days. Nifedipine, immediate release Calcium Channel Blockers: Amlodipine (Norvasc), Felodipine (Plendil), Nifedipine (Procardia XL), longacting Potential for hypotension; risk of precipitating myocardial ischemia. Combination products also covered from the groups listed. ACE Inhibitors: Benazepril (Lotensin), Captopril (Capoten), Enalapril (Vasotec), Fosinopril (Monopril), Lisinopril (Zestril, Prinivil), Quinapril (Accupril), Ramipril (Altace), Moexipril (Univasc), Perindopril (Aceon), Trandolapril (Mavik) ARB: Losartan (Cozaar), Irbesartan (Avapro), Olmesartan (Benicar), Valsartan (Diovan) Beta Blockers: Atenolol (Tenormin), Bisoprolol (Zebeta), Carvedilol (Coreg), Metoprolol (Lopressor, Toprol XL), Nadolol (Corgard), Acebutolol (Sectral), Betaxolol (Kerlone), Labetalol (Trandate), Sotalol (Betapace), Timolol (Blocadren), Propranolol (Inderal) Thiazide: Hydrochlorothiazide (Microzide), Chlorothiazide (Diuril) 10

11 Alternatives for Consideration Reason to Avoid Prescribing Parameters and Tips Central Nervous System Tertiary TCAs, alone or in combination: Amitriptyline Chlordiazepoxideamitriptyline Clomipramine Doxepin >6 mg/day Imipramine Perphenazineamitriptyline Trimipramine Alternative: Nortriptyline (Pamelor), Desipramine (Norpramin), Low dose Doxepin (Silenor), Trazodone, Ramelteon (Rozerem) Highly anticholinergic, sedating, and cause orthostatic hypotension. The safety profile of low dose doxepin ( 6 mg/day, Silenor) is comparable to that of placebo. Antipsychotics, First (conventional) Chlorpromazine Fluphenazine Haloperidol Loxapine Molindone Perphenazine Pimozide Promazine Thioridazine Thiothixene Trifluoperazine Triflupromazine Discuss risks/benefits with patient/family. Increased risk of cerebrovascular accident (stroke) and mortality in persons with dementia. 11

12 Alternatives for Consideration Reason to Avoid Prescribing Parameters and Tips Central Nervous System Antipsychotics, Second (atypical) generation Aripiprazole Asenapine Clozapine Iloperidone Lurasidone Olanzapine Paliperidone Quetiapine Risperidone Ziprasidone Discuss risks/benefits with patient/family. Increased risk of cerebrovascular accident (stroke) and mortality in persons with dementia. Thioridazine Mesoridazine Schizophrenia/Psychosis: Olanzapine (Zyprexa), Quetiapine (Seroquel), Risperidone (Risperidone), Ziprasidone (Geodon) Highly anticholinergic and greater risk of QT interval prolongation. Seroquel is more cost effective for patient versus Seroquel XR. Barbiturates Amobarbital Butabarbital Butalbital Mephobarbital Pentobarbital Phenobarbital Secobarbital Insomnia: Ramelteon (Rozerem), low dose Trazodone Seizures: Divalproex (Depakote), Levetiracetam (Keppra), Lamotrigine (Lamictal), Carbamazepine (Tegretol) High rate of physical dependence; tolerance to sleep benefits; greater risk of overdose at low dosages. For sleep: Consider nonpharmacologic interventions, focusing on proper sleep hygiene. When sedative hyponotic medications are deemed clinically necessary, should be at the lowest possible dose for the shortest possible time. 12

13 Alternatives for Consideration Reason to Avoid Prescribing Parameters and Tips Central Nervous System Benzodiazepines Short and intermediateacting: Alprazolam Lorazepam Oxazepam Long acting: Chlorazepate Chlordiazepoxide Chlordiazepoxideamitriptyline Clidiniumchlordiazepoxide Clonazepam Diazepam Quazepam Alternatives: SSRI, SNRI, Buspirone (Buspar) Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long acting agents. In general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults. May be appropriate for seizure disorders, rapid eye movement sleep disorders, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, periprocedural anesthesia, end of life care. Benzodiazepines Insomnia Estazolam Temazepam Triazolam Flurazepam Insomnia: Non pharmacologic treatment (sleep hygiene, cognitive behavior therapy), Melatonin (OTC), Low dose Doxepin (Silenor 6mg or less), Mirtazapine (Remeron), Low dose Trazodone, Ramelteon (Rozerem). Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long acting agents. In general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults. Silenor is on formulary with quantity edit of 30 for 30 days. 13

14 Alternatives for Consideration Reason to Avoid Prescribing Parameters and Tips Central Nervous System Chloral hydrate Insomnia: Non drug therapy, Low dose Trazodone, Low dose Doxepin (Silenor), Ramelteon (Rozerem) Risk outweighs the benefits in light of overdose with doses only 3 times the recommended dose. Tolerance occurs within 10 days. Nonbenzodiazepine hypnotics Eszopiclone Zolpidem Zaleplon Insomnia: Non drug therapy, Low dose Trazodone, Low dose Doxepin (Silenor), Ramelteon (Rozerem) Benzodiazepine receptor agonists that have adverse events similar to those of benzodiazepines in older adults (e.g., delirium, falls, fractures); minimal improvement in sleep latency and duration. Silenor is on formulary with quantity edit of 30 for 30 days. Endocrine Desiccated thyroid Alternative: Levothyroxine (Levoxyl). Concerns about cardiac effects. Safer alternatives available. 14

15 Estrogens with or without progestins Hot Flashes: Nondrug therapy (cool environment, layered clothing), SSRIs, gabapentin, venlafaxine Bone Density: Calcium, Vitamin D, Bisphosphonates, Raloxifene (Evista). Vaginal Symptoms, Recurrent UTI: Vaginal Estrogen Cream Evidence of carcinogenic potential (breast and endometrium); lack of cardio protective effect and cognitive protection in older women. Evidence that vaginal estrogens for treatment of vaginal dryness is safe and effective in women with breast cancer, especially at dosages of estradiol <25 mcg twice weekly. Megestrol Alternatives: Feeding assistance, liberalizing food choices, nutritional supplements or snacks between meals, environment conductive to optimal oral intake, Mirtazapine (Remeron) for depressed patient. Increases risk of thrombotic events and possibly death in older adults. Minimal effect on weight. Insulin, sliding scale Alternatives: Basal insulin with or without rapidacting mealtime insulin; premixed insulin daily or twice daily. Higher risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting. Available in pen or vials. Sulfonylureas, long duration Chlorpropamide Glyburide Alternative Sulfonylureas: Glimepiride (Amaryl), Glipizide (Glucotrol) Chlorpropamide: prolonged half life in older adults; can cause prolonged hypoglycemia; causes SIADH. Avoid Glucotrol XL due to hypoglycemia risk. Glyburide: higher risk of severe prolonged hypoglycemia in older adults. 15

16 Gastrointestinal Metoclopramide Alternatives for Nausea: Ondansetron (Zofran), Granisetron (Kytril) Can cause extrapyramidal effects including tardive dyskinesia; risk may be further increased in frail older adults. Ondansetron is on formulary with PA for B vs D determination. Trimethobenzamide Alternatives for Nausea: Ondansetron (Zofran), Granisetron (Kytril) Can cause extrapyramidal adverse effects. One of the least effective antiemetic drugs. Pain Medications Meperidine Alternatives for mild to moderate pain: Codeine, Acetaminophen Alternatives for moderate to moderately severe pain: hydrocodone/apap, Oxycodone/APAP Not an effective oral analgesic in dosages commonly used; may cause neurotoxicity. Safer alternatives available. Alternatives for Neuropathic Pain: Doloxetine (Cymbalta), Venlafaxine (Effexor), Pregabalin (Lyrica), Gabapentin (Neurontin), Topical Lidocaine, Capsaicin, Desipramine (Norpramin), Nortriptyline (Pamelor) 16

17 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 Alternatives for mild to moderate pain: Codeine, Acetaminophen Alternatives for moderate to moderately severe pain: hydrocodone/apap, Oxycodone/APAP Alternatives for Neuropathic Pain: Doloxetine (Cymbalta), Venlafaxine (Effexor), Pregabalin (Lyrica), Gabapentin (Neurontin), Topical Lidocaine, Capsaicin, Desipramine (Norpramin), Nortriptyline (Pamelor) Alternatives for Coronary Event Prevention: ASA 81mg Increases risk of GI bleeding/peptic ulcer disease in high risk groups, including those >75 years old or taking oral or parenteral corticosteroids, anticoagulants, or antiplatelet agents. Upper GI ulcers, gross bleeding, or perforation caused by NSAIDs occur in approximately 1% of patients treated for 3 6 months, and in about 2% 4% of patients treated for 1 year. These trends continue with longer duration of use. Use of proton pump inhibitor or misoprostol reduces but does not eliminate risk. Indomethacin Ketorolac, includes parenteral Alternatives for Acute Gout: Alternative NSAID (i.e., not indomethacin or ketorolac), colchicine, prednisone Increases risk of GI bleeding/peptic ulcer disease in high risk groups (See above Non COX selective NSAIDs) Of all the NSAIDs, indomethacin has most adverse effects. 17

18 Pentazocine Alternatives for mild to moderate pain: Codeine, Acetaminophen Alternatives for moderate to moderately severe pain: hydrocodone/apap, Oxycodone/APAP Opioid analgesic that causes CNS adverse effects, including confusion and hallucinations, more commonly than other narcotic drugs; is also a mixed agonist and antagonist. Safer alternatives available. Alternatives for Neuropathic Pain: Doloxetine (Cymbalta), Venlafaxine (Effexor), Pregabalin (Lyrica), Gabapentin (Neurontin), Topical Lidocaine, Capsaicin, Desipramine (Norpramin), Nortriptyline (Pamelor) Skeletal muscle relaxants Carisoprodol Chlorzoxazone Cyclobenzaprine Metaxalone Methocarbamol Orphenadrine Alternatives: Treat underlying problem, physiotherapy, application of heat or cold; correct seating and footwear. For Spasticity: Baclofen, Tizanidine, Nerve Blocks Most muscle relaxants poorly tolerated by older adults, because of anticholinergic adverse effects, sedation, increased risk of fractures. Effectiveness at dosages tolerated by older adults is questionable. High Risk Medications refer to medications specified by the Pharmacy Quality Alliance (PQA) as being potentially high risk to people over the age of 65. PQA adapted their list from the National Committee for Quality Assurance (NCQA) HEDIS measure: Use of High Risk Medications in the Elderly as being potentially unsafe for people over the age of 65. NCQA s list is based on the American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. This list is not inclusive of all High Risk Medications and should not be considered a substitute to sound clinical judgment. If you have questions about this formulary alternatives guide, you can contact: Tom Culhane, M.D., ATRIO Chief Medical Officer Dennis Rogers, RPh, ATRIO Pharmacy Director Cindi Peterburs, Pharmacy Benefits Program Manager