This page lists drugs seniors should generally avoid.

WHEN YOU HAVE A DISEASE OR CONDITION:

Another component of the Beers criteria outlines drugs not to be used by seniors who have certain conditions or diseases, such as heart failure, hypertension, and depression.

CBC News has made a Canadian version available here

They are included here because they are either ineffective in the elderly or put seniors at an unnecessarily high risk when safer alternatives are available, as outlined by a widely cited study known as the Beers criteria.

The list was originally compiled by Dr. Mark Beers in 1991, and was most recently updated in 2003. It is based on drugs available in the U.S., some of which are not available in Canada. As such, CBC News has edited the list on this page to reflect only those drugs available in Canada.

Conversely, there are a number of benzodiazepines that are available in Canada and not south of the border. These have been added under the entry: benzodiazepines (Canada).

This page is ordered alphabetically by the drug's active ingredient. Each of the 67 ingredients listed below is linked to an information page from MedlinePlus, a service of the U.S. National Library of Medicine and the U.S. National Institutes of Health. It will tell you how it's used and list some known side effects.

A number of entries below contain suggested alternatives put forward by a Saskatchewan study called Improving the Quality of Drug Management of Saskatchewan Seniors in Long-Term Care. (Not all entries have proposed alternatives because the study only considered prescription drugs covered by that province's formulary.)

Instructions:

Use your internet browser's search to help find the drug that interests you – Ctrl F on most browsers.

Enter either the active ingredient or the brand name.

If you're uncertain about a medical term, check the glossary.

Search tip:

If you have a generic version of a drug, such as Apo-Alpraz or Novo-Propamide, ensure you find what you're looking for by stripping off the prefix. So, for Apo-Alpraz enter Alpraz, and for Novo-Propamide enter Propamide. Generic prefixes include: Alti, Apo, Bio, Co, Dom, Euro, Gen, Novo, Nu, PHL, PMS, Ratio, Riva, Rhoxal, and Sab.

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Disclaimer: This edited online Canadian version of the Beers list is intended solely to give you convenient access to the drug information published in "Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults." It is not a substitute for professional medical advice. If you have a medical concern, consult a qualified health professional.

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A (Top)

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alprazolam

Brand Names in Canada:
Apo-Alpraz, Apo-Alpraz TS, Gen-Alprazolam, Novo-Alprazol , Nu-Alpraz, Ratio-Alprazolam, Xanax, Xanax TS

Reason(s) it's on the Beers list:
Because of increased sensitivity to benzodiazepines in elderly patients, smaller doses may be effective as well as safer.

Beers Condition:
Total daily dosage of alprazolam should rarely exceed 2 mg.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
If dosage exceed suggested maximum, try to slowly reduce it over time.

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amiodarone

Brand Names in Canada:
Amiodarone Hydrochloride For Injection, Cordarone Intravenous, Cordarone, Gen-Amiodarone, Novo-Amiodarone, Pms-Amiodarone, Ratio-Amiodarone, Ratio-Amiodarone I.V., Rhoxal-Amiodarone, Riva-Amiodarone

Reason(s) it's on the Beers list:
Lack of efficacy in older adults. It is associated with QT interval problems and risk of provoking torsades de pointes.

Beers Condition:
None. Should be avoided

Beers Severity Rating:
High

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amitriptyline

Brand Names in Canada:
Amitriptyline, Apo Amitriptyline, Levate, Novo-Triptyn, PMS-Amitriptyline. (See also perphenazine-amitriptyline.)

Reason(s) it's on the Beers list:
Because of its strong anticholinergic and sedation properties, amitriptyline is rarely the antidepressant of choice for elderly patients. May produce ataxia, impaired psychomotor function, syncope, and additional falls.

Considering diagnoses or conditions:
For those with stress incontinence, it may produce polyuria and worsening of incontinence.
For those with arrhythmias, there is concern due to proarrhythmic effects and ability to produce QT interval changes.
Amitryptyline in combination with chlordiazepoxide can have adverse effects on the central nervous system; may induce respiratory depression; may exacerbate or cause respiratory depression.
In treating those with chronic constipation, it may exacerbate the condition. (Low severity rating)

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
SSRIs (if treating depression), nortriptyline or desipramine (alternative tricyclic antidepressants with less anticholinergic effects) or gabapentin (for treating pain)

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amphetamines

Brand Names in Canada:
Dexedrine Spansule, Dexedrine

Reason(s) it's on the Beers list:
These drugs have potential for causing dependence, hypertension, angina, and myocardial infarction. Also, there is concern due to the altering effects on the central nervous system (CNS).

Considering diagnoses or conditions:
In those with hypertension, may produce elevation of blood pressure secondary to sympathomimetic activity.
It should also not be used by those experiencing insomnia, cognitive impairment, or loss of appetite.

Beers Condition:
None. Should be avoided

Beers Severity Rating:
High

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anorexic agents

Brand Names in Canada:
Tenuate, Tenuate Dospan

Reason(s) it's on the Beers list:
These drugs have potential for causing dependence, hypertension, angina, and myocardial infarction.

Beers Condition:
None. Should be avoided

Beers Severity Rating:
High

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barbiturates

Brand Names in Canada:
Amytal Sodium Ampoule , Tuinal Pulvule 304, Cafergot Pb Sup, Euthansol Inj, Euthanyl, Euthanyl Forte, Nembutal Sodium Inj , Novo-Pentobarb , Somnotol Inj , Barbilixir Elx , Bellergal Spacetabs, Diclophen, Phenaphen No.3 , Phenobarbital Tablet , PMS-Phenobarbital Elixir, Phenobarbital Sodium Inj , Prosedyl , Quinobarb Tablet , Novo-Secobarb

Reason(s) it's on the Beers list:
These drugs are highly addictive and cause more adverse effects than most sedative or hypnotic drugs in elderly patients.

Considering diagnoses or conditions:
Should not be used by those with cognitive impairment due to altering effects on the central nervous system.

Beers Condition:
Should only be used to control seizures.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Non-drug measures for sleep, anxiety, behaviour. Drugs: Zaleplon (Starnoc), Zopiclone (Imovane), various shorter-acting benzodiazepines (which are all also on this list, but can be used at lower dosages).

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belladonna alkaloids

Brand Names in Canada:
Bentylol, Buscopan, Formulex, Gastrozepin, Levsin, Pro-Banthine, Propanthel, Robinul, Robinul Forte, Spasmoban, Transderm-V, and many other health products. (More than 300 are listed in Health Canada's Drug Product Database)

Reason(s) it's on the Beers list:
GI antispasmodic drugs are highly anticholinergic and have uncertain effectiveness. These drugs should be avoided (especially for long-term use).

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

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benzodiazepines (Canada)

bromazepam, clobazam, clonazepam, nitrazepam

These four molecules are not on the Beers list because they are available in Canada and not the U.S.

When compared to similar benzodiazepines, these would all fall into the Beers category of short-acting benzodiazepines, which includes, alprazolam, lorazepam, oxazepam, temazepam, and triazelam.

Reason(s) short-acting benzodiazepines are on the Beers list:
Because of increased sensitivity to benzodiazepines in elderly patients, smaller doses may be effective as well as safer.

Beers Condition:
Beers sets certain maximum dosages for short-acting benzodiazepines. But because bromazepam, clobazam, clonazepam, and nitrazepam are not available in the U.S., no maximum dosage levels have been set by Beers.

However, e-CPS (Compendium of Pharmaceuticals and Specialties, online version) says:

"Elderly or debilitated patients, children, and patients with liver disease or low serum albumin are most likely to experience CNS adverse effects. Generally it is recommended that therapy be initiated with low dosages and gradually titrated up to the lowest effective dose, to minimize the possibility of ataxia, dizziness and oversedation."

It goes on to say that dosages for benzodiazepines used by elderly patients tend to be approximately one-third to one-half of the recommended dose for younger adults.

Beers Severity Rating: for short-acting benzodiazepines
High

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bisacodyl

Brand Names in Canada:
Alophen, Apo Bisacodyl, Bekunis Dragees, Bicholate Lilas, Bisacolax , Carter's Little Pills, Correctol Laxative, Dulcolax , Feen-A-Mint, Fruitatives, Laxcodyl, PMS-Bisacodyl, Ratio-Bisacodyl, Royvac Bowel Evacuant Kit, Soflax, The Magic Bullet, Women's Laxative

Reason(s) it's on the Beers list:
May exacerbate bowel dysfunction.

Beers Condition:
Not for long-term use.

Beers Severity Rating:
High

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cascara sagrada

Brand Names in Canada:
Alsilax, Aromatic Cascara Sagrada Compound, Bicholate Lilas, Bilonat, Bio Tab, Biolax, Cascara Aromatic, Cascara Aromatique, Cascara Sagrada, Cascara Tab, Cascaraplex, Cas-Mag, Cc Formula, Cholasyn Ii, Cholasyn Plus, Cholerytyl 140, Choletol, Cholinat, Cir Formule, Control, Cynara Complex Drops Depuratex, Depuratif Des Trappistes, Deratin Liq, Doulax Tab, Eliminex, Elixir 101, Enrtox, Formula 100, Formula B-1, Formula T5 Tea, Formule 515 Plus, Formule C2 Tab, Formule C5 Tab, Formule L9 Liq, Formule T2 Tea, Garilax 2x, Genplex Ii, Gerbelax Liq, Geribile, Gerinet, Gingerplex Ii, Globucel-Tea, Hepabyl, Hepaticol, Herb Lax, Herba Tone, Herbal Fibre 650, Herbal Laxative Formula Caplet, Herbal Laxative Plus Yogurt, Herbal Laxative, Herbal Laxative Tea Bags, Herbalis, Herbanat, Herbolax, Herborex, Herborex Fort Lax Liq, Hp5, Laxaco Herbal Laxative, Laxaherb, Laxanat Tab, Laxative, Lb-Extract, Lbs Ii - Tab, Le 500 D, Liquid Extract Cascara, Melange De Plantes Formula L1 Laxatif, Metab Herbs Cap No 1, Mtb-Tox, Mucinum (Cascara And Senna Tablets), Multilax 2, Multilax 3, Nature's Remedy, Nerv Eze Tea Thunas, Nutraide Cascara Sagrada, Nutraide Diuretic Tab, Pharma Lax Tablets, Phenobile, Phenobile Ii, Pro-Bilax, Psoforce, Rhamnus Purshiana, Slb Capsules, Special Balsam Bedwetting, Stomach Ease Herbal Laxative Tablets, Thuna Laxative Tab, Thuna Special Formula Brf, Thunas Lkb Compound, Thunas Natural Aid, Thunas Worm Balsam, Toux Nil Syr, Traditional Herbal Laxative, Traditional Laxative, Ultra-Lax, Urinatone Tea Thunas, Vermex, Vermopt, Vesilax+, Vita-Lax, Yesteryear Laxative

Reason(s) it's on the Beers list:
May exacerbate bowel dysfunction.

Beers Condition:
Not for long-term use.

Beers Severity Rating:
High

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chlordiazepoxide

Brand Names in Canada:
Apo Chlordiazepoxide HCL, Apo Chlorax, Chlordiazepoxyde HCL (See also chlordiazepoxide-amitriptyline and clidinium-chlordiazepoxide.)

Reason(s) it's on the Beers list:
This has a long half-life in elderly patients (often several days), producing prolonged sedation and increasing the risk of falls and fractures. Short- and intermediate-acting benzodiazepines are preferred if a benzodiazepine is required.

Considering diagnoses or conditions:
In those with chronic obstructive pulmonary disease, this can have adverse effects on the central nervous system; may induce respiratory depression; may exacerbate or cause respiratory depression.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Lorazepam, oxazepam, temazepam, clonazepam (which are all also on this list, but can be used at lower dosages)

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chlorpheniramine

Brand Names in Canada:
Used in many cough and cold remedies, including: Buckley's, Children's Nyquil Liquid, Children's Tylenol Cold, Chlor-Tripolon, Dimetapp, Dristan, Extra Strength Tylenol Allergy Sinus, Extra Strength Tylenol Cold Nighttime Caplet, Jack & Jill Children's Formula, Neo Citran, Polaramine, Sinutab, Triaminic, Vasofrinic, Vicks Formula 44m)

Reason(s) it's on the Beers list:
All nonprescription and many prescription antihistamines may have potent anticholinergic properties. Nonanticholinergic antihistamines are preferred in elderly patients when treating allergic reactions.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

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chlorpropamide

Brand Names in Canada:
Apo Chlorpropamide, Chlorpropamide, Novo-Propamide

Reason(s) it's on the Beers list:
It has a prolonged half-life in elderly patients and could cause prolonged hypoglycemia. Additionally, it is the only oral hypoglycemic agent that causes SIADH (syndrome of inappropriate antidiuretic hormone secretion).

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Glyburide, glimepiride, gliclazide, or other non-sulfonylurea oral hypoglycemic agents.

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chlorzoxazone

Brand Names in Canada:
Acetazone Forte C8, Acetazone Forte, Back-Aid Forte, Extra Strength Tylenol Aches And Strains, Parafon Forte

Reason(s) it's on the Beers list:
Most muscle relaxants and antispasmodic drugs are poorly tolerated by elderly patients, since these cause anticholinergic adverse effects, sedation, and weakness. Additionally, their effectiveness at doses tolerated by elderly patients is questionable.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

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cimetidine

Brand Names in Canada:
Apo Cimetidine, Cimetidine, Dom-Cimetidine, Gaviscon Prevent, Gen-Cimetidine, Novo-Cimetine, Nu-Cimet Tab, Peptol Tab, PMS-Cimetidine, Apo-Cimetidine Oral Solution, Novo-Cimetine Injection, Tagamet Liquid

Reason(s) it's on the Beers list:
Adverse effects on the central nervous system, including confusion.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
Low

Alternative suggested by Saskatchewan's Health Quality Council:
Ranitidine (zantac) or other H2 blocker (dose may need to be decreased if reduced renal function)

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clidinium-chlordiazepoxide

Brand Names in Canada:
Corium, Librax, Novo-Poxide, Pro Chlorax

Reason(s) it's on the Beers list:
Long-acting benzodiazepines have a long half-life in elderly patients (often several days), producing prolonged sedation and increasing the risk of falls and fractures. Short- and intermediate-acting benzodiazepines are preferred if a benzodiazepine is required.

Considering diagnoses or conditions:
In those with chronic obstructive pulmonary disease, this can have adverse effects on the central nervous system; may induce respiratory depression; may exacerbate or cause respiratory depression.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

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clonidine

Brand Names in Canada:
Iopidine, Apo-Clonidine, Catapres, Clonidine HCL, Dixarit, Novo-Clonidine Tablets, Nu-Clonidine Tab

Reason(s) it's on the Beers list:
Potential for orthostatic hypotension and central nervous system adverse effects.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
Low

Alternative suggested by Saskatchewan's Health Quality Council:
Dependent on clinical scenario and other medical conditions, but may include: thiazide diuretics, ACE inhibitors, calcium channel blockers, beta-blockers, or angiotensin receptor blockers.

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clorazepate

Brand Names in Canada:
Apo-Clorazepate Cap, Novo-Clopate Cap, Tranxene Cap

Reason(s) it's on the Beers list:
Long-acting benzodiazepines have a long half-life in elderly patients (often several days), producing prolonged sedation and increasing the risk of falls and fractures. Short- and intermediate-acting benzodiazepines are preferred if a benzodiazepine is required.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Lorazepam, oxazepam, temazepam, clonazepam (which are all also on this list, but can be used at lower dosages)

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cyclobenzaprine

Brand Names in Canada:
Alti-Cyclobenzaprine, Apo-Cyclobenzaprine, Cyclobenzaprine-10, Dom-Cyclobenzaprine, Flexeril, Gen-Cyclobenzaprine, Novo-Cycloprine, Nu-Cyclobenzaprine-Tab, PMS-Cyclobenzaprine, PHL-Cyclobenzaprine, Ratio-Cyclobenzaprine, Riva-Cycloprine

Reason(s) it's on the Beers list:
Most muscle relaxants and antispasmodic drugs are poorly tolerated by elderly patients, since these cause anticholinergic adverse effects, sedation, and weakness. Additionally, their effectiveness at doses tolerated by elderly patients is questionable.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

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cyproheptadine

Brand Names in Canada:
Euro-Cyproheptadine, PMS-Cyproheptadine HCL

Reason(s) it's on the Beers list:
All nonprescription and many prescription antihistamines may have potent anticholinergic properties. Nonanticholinergic antihistamines are preferred in elderly patients when treating allergic reactions.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

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dessicated thyroid

Brand Names in Canada:
Parathormone, Parathyroidinum, Cimicifuga Plex, Geri Tabs, Thyroidinum

Reason(s) it's on the Beers list:
Concerns about cardiac effects. Safer alternatives available.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Levothyroxine (Eltroxin, Synthroid)

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diazepam

Brand Names in Canada:
Apo Diazepam, Bio-Diazepam, Diazepam, Diazemuls, E Pam, Diastat Rectal Delivery System, Novo-Dipam, PMS-Diazepam, Valium, Vivol

Reason(s) it's on the Beers list:
Long-acting benzodiazepines have a long half-life in elderly patients (often several days), producing prolonged sedation and increasing the risk of falls and fractures. Short- and intermediate-acting benzodiazepines are preferred if a benzodiazepine is required.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Lorazepam, oxazepam, temazepam, clonazepam (which are all also on this list, but can be used at lower dosages)

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dicyclomine

Brand Names in Canada:
Bentylol, Dicyclomine HCL, Diclophen, Lomine, Formulex, Protylol

Reason(s) it's on the Beers list:
GI antispasmodic drugs are highly anticholinergic and have uncertain effectiveness. These drugs should be avoided (especially for long-term use).

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Dependent on clinical scenario - consult GI or internal medicine if needed.

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digoxin

Brand Names in Canada:
Lanoxin Digoxin, Pediatric Digoxin Injection, Digoxin Injection

Reason(s) it's on the Beers list:
Decreased renal clearance may lead to increased risk of toxic effects.

Beers Condition:
Daily dosage should not exceed 0.125 mg, except when treating atrial arrhythmias.

Beers Severity Rating:
Low

Alternative suggested by Saskatchewan's Health Quality Council:
Consider periodic digoxin serum levels to ensure appropriateness of dosage as the patient ages (reduced renal clearance with age may necessitate periodic dosage reduction)

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diphenhydramine

Brand Names in Canada:
Aller Aide Plus, Allerdryl, Allergy Elixir, Allergy Formula, Allernix, Balminil Night-Time, Benadryl, Buckley's Bedtime, Calmex, Calmylin, Children's Tylenol Allergy, Contac, Contac Night Caplets, Diphenhydramine HCL Children's Liquid, Diphenist, DM Cough Syrup, Dormex Extra Fort, Dormiphen Comprime, Ergodryl, Insomnal, Jack And Jill Bedtime, Nadryl, Nytol Extra Strength, PMS-Diphenhydramine, Pulmorex DM, Scheinpharm Diphenhydramine, Simply Sleep, Sinutab N.T. Extra Strength, Sleep Aid, Sleep-Eze D , Sominex, Unisom Nighttime Sleep Aid

Reason(s) it's on the Beers list:
All nonprescription and many prescription antihistamines may have potent anticholinergic properties. Nonanticholinergic antihistamines are preferred in elderly patients when treating allergic reactions.

Also, it causes confusion and sedation. It should not be used as a hypnotic, and when used to treat emergency allergic reactions, it should be used in the smallest possible dose.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Nonanticholinergic antihistamines: Cetirizine (Reactine), fexofenadine (Allegra), loratadine (Claritin), desloratadine (Aerius)

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dipyridamole

Brand Names in Canada:
Aggrenox, Apo-Dipyridamole, Dipyridamole, Novo-Dipiradol, Persantine

Reason(s) it's on the Beers list:
Short-acting dipyridamole may cause orthostatic hypotension. Do not consider the long-acting dipyridamole (which has better properties than the short-acting in older adults) except with patients with artificial heart valves.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
Low

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disopyramide

Brand Names in Canada:
Rythmodan

Reason(s) it's on the Beers list:
Of all antiarrhythmic drugs, this is the most potent negative inotrope and therefore may induce heart failure in elderly patients. It is also strongly anticholinergic. Other antiarrhythmic drugs should be used.

Considering diagnoses or conditions:
In treating those with heart failure, it has negative inotropic effect. There is also potential to promote fluid retention and exacerbation of heart failure.

Beers Condition:
The non–extended release formulation should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Depends highly on clinical scenario - consult cardiology or internal medicine if needed

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doxazosin

Brand Names in Canada:
Apo-Doxazosin, Cardura, Dom-Doxazosin, Doxazosin, Gen-Doxazosin, Novo-Doxazosin, PMS-Doxazosin, Ratio-Doxazosin

Reason(s) it's on the Beers list:
Potential for hypotension, dry mouth, and urinary problems. (Low severity rating)

Considering diagnoses or conditions:
In those with stress incontinence, it may produce polyuria and worsening of incontinence. (High severity rating)

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
Generally low, but high with regard to those with stress incontinence.

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doxepin

Brand Names in Canada:
Alti-Doxepin, Apo-Doxepin, Doxepine, Sinequan, Novo-Doxepin, Triadapin

Reason(s) it's on the Beers list:
Because of its strong anticholinergic and sedating properties, doxepin is rarely the antidepressant of choice for elderly patients.

Considering diagnoses or conditions:
For those with stress incontinence, it may produce polyuria and worsening of incontinence.
For those with arrhythmias, there is concern due to proarrhythmic effects and ability to produce QT interval changes.
In treating those with a history of falls, it may produce ataxia, impaired psychomotor function, syncope, and additional falls.
In treating those with chronic constipation, it may exacerbate the condition. (Low severity rating)

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
SSRIs (if treating depression), nortriptyline or desipramine (alternative tricyclic antidepressants with less anticholinergic effects) or gabapentin (for treating pain)

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ergot mesyloids

Brand Names in Canada:
Bellergal Spacetabs, Cafergot, Dihydroergotamine (DHE), Dihydroergotamine Mesylate, Ergodryl, Gravergol Capsules, Migranal Nasal Spray, Pekana - Secale Cornutum, Secale Cornutum, Secale Silicea Comp.

Reason(s) it's on the Beers list:
Have not been shown to be effective in the doses studied.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
Low

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estrogens (oral)

Brand Names in Canada:
Apo-Conest, Bi-Est (Extemporaneous Compound), CES, Climacteron, Climara, Clovone, Congest, Conjugated Estrogens, Estalis, Estalis-Sequi, Estinyl, Estrace, Estracomb, Estraderm, Estraderm TTS, Estradiol-17b, Estradot, Estring, Estrogel, Femhrt, Lifepak, Neo Estrone, Oesclim, Osti-Fix, Phyto Soya, Phyto Soya Vaginal Gel, PMS-Conjugated Estrogens, Premarin, Premarin C Methyltestosterone, Premarin Vaginal Cream, Premarin With Phenobarbital, Premplus, Promensil, Provelle, Remifemin, Rhoxal-Estradiol Derm, Rimostil, Tri-Est (Extemporaneous Compound), Vagifem, Vivelle

Reason(s) it's on the Beers list:
Evidence of the carcinogenic (breast and endometrial cancer) potential of these agents and lack of cardioprotective effect in older women.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
Low

Alternative suggested by Saskatchewan's Health Quality Council:
Depends on reason for use

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ethacrynic acid

Brand Names in Canada:
Edecrin

Reason(s) it's on the Beers list:
Potential for hypertension and fluid imbalances. Safer alternatives available.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
Low

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F (Top)

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ferrous sulfate (a form of iron found in many products)

Reason(s) it's on the Beers list:
Doses greater than 325 mg per day do not dramatically increase the amount absorbed but greatly increase the incidence of constipation.

Beers Condition:
Daily dosage should not exceed 325 mg.

Beers Severity Rating:
Low

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fluoxetine

Brand Names in Canada:
Prozac, FXT, and numerous generics with fluoxetine in the name

Reason(s) it's on the Beers list:
Long half-life of drug and risk of producing excessive central nervous system stimulation, sleep disturbances, and increasing agitation. Safer alternatives exist.

Considering diagnoses or conditions:
In those who are not eating or are malnourished, there is concern due to appetite-suppressing effects. (High severity rating)
For those with hyponatremia/SIADH (syndrome of inappropriate antidiuretic hormone secretion), it may exacerbate or cause SIADH. (Low severity rating)

Beers Condition:
Daily use should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Shorter acting SSRIs include: citalopram (Celexa), paroxetine (Paxil), sertraline (Zoloft)

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flurazepam

Brand Names in Canada:
Apo Flurazepam, Bio-Flurazepam, Dalmane, Flurazepam, Novo-Flupam, PMS-Flurazepam, Somnol, Som Pam

Reason(s) it's on the Beers list:
This benzodiazepine hypnotic has an extremely long half-life in elderly patients (often days), producing prolonged sedation and increasing the incidence of falls and fractures. Medium- or short-acting benzodiazepines are preferable.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Lorazepam, oxazepam, temazepam (which are all also on this list, but can be used at lower dosages)

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G (Top)

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guanethidine

Brand Names in Canada:
Apo Guanethidine

Reason(s) it's on the Beers list:
May cause orthostatic hypotension. Safer alternatives exist.

Considering diagnoses or conditions:
In those with depression in combination with long-term benzodiazepine use, it may produce or exacerbate depression.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

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H (Top)

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hydroxyzine

Brand Names in Canada:
Hydroxyzine, Apo Hydroxyzine, PMS Hydroxyzine, Nu-Hydroxyzine, Novo-Hydroxyzin, Riva-Hydroxyzin, Atarax Syrup

Reason(s) it's on the Beers list:
All nonprescription and many prescription antihistamines may have potent anticholinergic properties. Nonanticholinergic antihistamines are preferred in elderly patients when treating allergic reactions.

Also, it causes confusion and sedation. It should not be used as a hypnotic, and when used to treat emergency allergic reactions, it should be used in the smallest possible dose.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Nonanticholinergic antihistamines: Cetirizine (Reactine), fexofenadine (Allegra), loratadine (Claritin), desloratadine (Aerius)

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hyoscyamine

Brand Names in Canada:
Levsin, Hyoscyaminum, AD HP

Reason(s) it's on the Beers list:
GI antispasmodic drugs are highly anticholinergic and have uncertain effectiveness. These drugs should be avoided (especially for long-term use).

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

I (Top)

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indomethacin

Brand Names in Canada:
Apo Indomethacin, SAB-Indomethacin, Ratio-Indomethacin, Indocid-P.D.A., Pro-Indo, Novo-Methacin, Rhodacine, Nu-Indo

Reason(s) it's on the Beers list:
Of all available nonsteroidal anti-inflammatory drugs, this drug produces the most adverse effects on the central nervous system.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Other NSAIDs such as naproxen or ibuprofen

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K (Top)

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ketorolac

Brand Names in Canada:
Acular, Apo-Ketorolac, Ketorolac Tromethamine, Novo-Ketorolac, Nu-Ketorolac, Ratio-Ketorolac, Toradol

Reason(s) it's on the Beers list:
Immediate and long-term use should be avoided in older persons, since a significant number have asymptomatic GI pathologic conditions.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

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L (Top)

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lorazepam

Brand Names in Canada:
Apo-Lorazepam, Ativan, Dom-Lorazepam, Novo-Lorazem, Nu-Loraz, PMS-Lorazepam, Pro-Lorazepam

Reason(s) it's on the Beers list:
Because of increased sensitivity to benzodiazepines in elderly patients, smaller doses may be effective as well as safer.

Beers Condition:
Total daily dosage of lorazepam should rarely exceed 3 mg.

Beers Severity Rating:
High

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M (Top)

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meperidine

Brand Names in Canada:
Demerol, Meperidine Injection, Pethidine Injection

Reason(s) it's on the Beers list:
Not an effective oral analgesic in doses commonly used. May cause confusion and has many disadvantages to other narcotic drugs.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Morphine, codeine, topical fentanyl patches.

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meprobamate

Brand Names in Canada:
282 Mep, Novo-Mepro

Reason(s) it's on the Beers list:
This is a highly addictive and sedating anxiolytic. Those using meprobamate for prolonged periods may become addicted and may need to be withdrawn slowly.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

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methocarbamol

Brand Names in Canada:
Dodd's Back-Ease, Dodd's Extra Strength Back-Ease, Extra Strength Aspirin Backache, Extra Strength Muscle & Back Pain Relief, Methocarbamol, Methocarbamol Omega, Methoxacet, Methoxisal, Muscle And Back Pain Relief, Muscle Relaxant And Analgesic, PMS-Methocarbamol, Relaxophen, Robax Platinum, Robaximol, Robaxacet, Robaxin, Robaxisal, Spasmhalt

Reason(s) it's on the Beers list:
Most muscle relaxants and antispasmodic drugs are poorly tolerated by elderly patients, since these cause anticholinergic adverse effects, sedation, and weakness. Additionally, their effectiveness at doses tolerated by elderly patients is questionable.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

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methyldopa

Brand Names in Canada:
Apo Methyldopa, Dopamet , Methyldopa, Novo-Medopa, Nu-Medopa

Reason(s) it's on the Beers list:
May cause bradycardia and exacerbate depression in elderly patients.

Considering diagnoses or conditions:
In those with depression in combination with long-term benzodiazepine use, it may produce or exacerbate depression.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Dependant on clinical scenario and other medical conditions, but may include: thiazide diuretics, ACE inhibitors, calcium channel blockers, beta-blockers, or angiotensin receptor blockers.

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methyldopa-hydrochlorothiazide

Brand Names in Canada:
Apo Methazide, Novo-Doparil, PMS-Dopazide

Reason(s) it's on the Beers list:
May cause bradycardia and exacerbate depression in elderly patients.

Considering diagnoses or conditions:
In those with depression in combination with long-term benzodiazepine use, it may produce or exacerbate depression.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Dependant on clinical scenario and other medical conditions, but may include: thiazide diuretics, ACE inhibitors, calcium channel blockers, beta-blockers, or angiotensin receptor blockers.

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mineral oil

Reason(s) it's on the Beers list:
Potential for aspiration and adverse effects. Safer alternatives available.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

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N (Top)

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naproxen

Brand Names in Canada:
Anaprox D.S., Apo-Napro-Na, Apo-Naproxen, Gen-Naproxen, Naprosyn, Novo-Naprox, Nu-Naprox, PMS-Naproxen Suppositories, Ratio-Naproxen, Riva-Naproxen, Sab-Naproxen, Synflex

Reason(s) it's on the Beers list:
Long-term use of full-dosage, longer half-life, non–COX-selective NSAIDs (nonsteroidal anti-inflammatory drugs) have the potential to produce GI bleeding, renal failure, high blood pressure, and heart failure.

Beers Condition:
Not for long-term, full-dosage use.

Beers Severity Rating:
High

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Neoloid

Brand Names in Canada:
castor oil

Reason(s) it's on the Beers list:
May exacerbate bowel dysfunction.

Beers Condition:
Not for long-term use, except in the presence of opiate analgesic use.

Beers Severity Rating:
High

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nifedipine

Brand Names in Canada:
Adalat, Apo-Nifed, Gen Nifedipine, Nu-Nifedipine, Nu-Nifed, Novo-Nifedin, PMS-Nifedipine

Reason(s) it's on the Beers list:
Potential for hypotension and constipation.

Beers Condition:
Short-acting form of the drug should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Long acting nifedipine (Adalat XL), felodipine (Renedil), amlodipine (Norvasc)

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nitrofurantoin

Brand Names in Canada:
Apo Nitrofurantoin, Macrobid, Macrodantin, Novo-Furan, Novo-Furantoin

Reason(s) it's on the Beers list:
Potential for renal impairment. Safer alternatives available.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

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O (Top)

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orphenadrine

Brand Names in Canada:
Norflex, Norgesic, Rhoxal-Orphenadrine, Orfenace

Reason(s) it's on the Beers list:
Causes more sedation and anticholinergic adverse effects than safer alternatives.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Dependent on clinical scenario

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oxaprozin

Brand Names in Canada:
Apo-Oxaprozin, Daypro, Rhoxal-Oxaprozin

Reason(s) it's on the Beers list:
Long-term use of full-dosage, longer half-life, non–COX-selective NSAIDs (nonsteroidal anti-inflammatory drugs) has the potential to produce GI bleeding, renal failure, high blood pressure, and heart failure.

Beers Condition:
Not for long-term, full-dosage use.

Beers Severity Rating:
High

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oxazepam

Brand Names in Canada:
Apo Oxazepam, Bio-Oxazepam, Novoxapam, Oxpam, PMS-Oxazepam, Zapex

Reason(s) it's on the Beers list:
Because of increased sensitivity to benzodiazepines in elderly patients, smaller doses may be effective as well as safer.

Beers Condition:
Total daily dosage of oxazepam should rarely exceed 60 mg.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
If dosage exceed suggested maximum, try to slowly reduce it over time.

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oxybutynin

Brand Names in Canada:
Apo-Oxybutynin, Ditropan, Dom-Oxybutynin, Gen-Oxybutynin, Novo-Oxybutynin, Nu-Oxybutyn, Oxybutynine, Oxybutyn, Oxytrol, PHL-Oxybutynin, PMS-Oxybutynin, Riva-Oxybutynin

Reason(s) it's on the Beers list:
Most muscle relaxants and antispasmodic drugs are poorly tolerated by elderly patients, since these cause anticholinergic adverse effects, sedation, and weakness. Additionally, their effectiveness at doses tolerated by elderly patients is questionable.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

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P (Top)

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pentazocine

Brand Names in Canada:
Talwin

Reason(s) it's on the Beers list:
Narcotic analgesic that causes more central nervous system adverse effects, including confusion and hallucinations, more commonly than other narcotic drugs. Additionally, it is a mixed agonist and antagonist.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Morphine, codeine, topical fentanyl patches

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perphenazine-amitriptyline

Brand Names in Canada:
Apo Peram, Etrafon, PMS-Levazine

Reason(s) it's on the Beers list:
Because of its strong anticholinergic and sedation properties, amitriptyline is rarely the antidepressant of choice for elderly patients. May produce ataxia, impaired psychomotor function, syncope, and additional falls.

Considering diagnoses or conditions:
For those with stress incontinence, amitriptyline may produce polyuria and worsening of incontinence.
For those with arrhythmias, there is concern due to proarrhythmic effects and ability to produce QT interval changes.
In treating those with chronic constipation, amitriptyline may exacerbate the condition. (Low severity rating)

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

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piroxicam

Brand Names in Canada:
Apo Piroxicam, Dom-Piroxicam, Gen-Piroxicam, Novo-Pirocam, Nu-Pirox, PMS-Piroxicam, Pro-Piroxicam

Reason(s) it's on the Beers list:
Long-term use of full-dosage, longer half-life, non–COX-selective NSAIDs (nonsteroidal anti-inflammatory drugs) has the potential to produce GI bleeding, renal failure, high blood pressure, and heart failure.

Beers Condition:
Not for long-term, full-dosage use.

Beers Severity Rating:
High

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promethazine

Brand Names in Canada:
Bioniche Promethazine, Histantil, Phenergan, PMS-Promethazine, Promethazine

Reason(s) it's on the Beers list:
All nonprescription and many prescription antihistamines may have potent anticholinergic properties. Nonanticholinergic antihistamines are preferred in elderly patients when treating allergic reactions.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Nonanticholinergic antihistamines: Cetirizine (Reactine), fexofenadine (Allegra), loratadine (Claritin), desloratadine (Aerius)

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propantheline

Brand Names in Canada:
Propanthel, Pro-Banthine

Reason(s) it's on the Beers list:
GI antispasmodic drugs are highly anticholinergic and have uncertain effectiveness. These drugs should be avoided (especially for long-term use).

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Dependent on clinical scenario - consult GI or internal medicine if needed.

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propoxyphene

Brand Names in Canada:
642 Tab, 692 Tablet, Darvon, Novo-Propoxyn

Reason(s) it's on the Beers list:
Offers few analgesic advantages over acetaminophen, yet has the adverse effects of other narcotic drugs.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
Low

Alternative suggested by Saskatchewan's Health Quality Council:
Acetaminophen, various NSAIDs, acetaminophen with codeine, morphine

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R (Top)

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reserpine

Brand Names in Canada:
Novo-Reserpine

Reason(s) it's on the Beers list:
May induce depression, impotence, sedation, and orthostatic hypotension.

Considering diagnoses or conditions:
In those with depression in combination with long-term benzodiazepine use, it may produce or exacerbate depression.

Beers Condition:
Doses greater than 0.25 mg should be avoided.

Beers Severity Rating:
Low

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T (Top)

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temazepam

Brand Names in Canada:
Apo-Temazepam, Co Temazepam, Dom-Temazepam, Gen-Temazepam, Nu-Temazepam, Novo-Temazepam, PMS-Temazepam, Ratio-Temazepam, Restoril

Reason(s) it's on the Beers list:
Because of increased sensitivity to benzodiazepines in elderly patients, smaller doses may be effective as well as safer.

Beers Condition:
Total daily dosage of temazepam should rarely exceed 15 mg.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
If dosage exceed suggested maximum, try to slowly reduce it over time.

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thioridazine

Brand Names in Canada:
Apo Thioridazine, PMS-Thioridazine, Novo-Ridazine

Reason(s) it's on the Beers list:
Greater potential for central nervous system and extrapyramidal adverse effects.

Considering diagnoses or conditions:
In those with seizures or epilepsy, thioridazine may lower the seizure threshold.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Depends on clinical scenario - high-potency or atypical antipsychotics (haloperidol, risperidone, quetiapine olanzapine)

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ticlopidine

Brand Names in Canada:
Alti-Ticlopidine, Apo-Ticlopidine, Dom-Ticlopidine, Gen-Ticlopidine, Novo-Ticlopidine, Nu-Ticlopidine, PMS-Ticlopidine, Rhoxal-Ticlopidine, Ticlid

Reason(s) it's on the Beers list:
Has been shown to be no better than aspirin in preventing clotting and may be considerably more toxic. Safer, more effective alternatives exist.

Considering diagnoses or conditions:
In those with blood clotting disorders or receiving anticoagulant therapy, ticlopidine may prolong clotting time and elevate INR values or inhibit platelet aggregation, resulting in an increased potential for bleeding.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
ASA (Aspirin), clopidogrel (Plavix), warfarin

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triazolam

Brand Names in Canada:
Gen-Triazolam, Apo-Triazo, Halcion, Novo-Triolam

Reason(s) it's on the Beers list:
Because of increased sensitivity to benzodiazepines in elderly patients, smaller doses may be effective as well as safer.

Beers Condition:
Total daily dosage of triazolam should rarely exceed 0.25 mg.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
If dosage exceed suggested maximum, try to slowly reduce it over time.

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tripelennamine

Brand Names in Canada:
Vagin-X

Reason(s) it's on the Beers list:
All nonprescription and many prescription antihistamines may have potent anticholinergic properties. Nonanticholinergic antihistamines are preferred in elderly patients when treating allergic reactions.

Beers Condition:
None. Should be avoided.

Beers Severity Rating:
High

Alternative suggested by Saskatchewan's Health Quality Council:
Nonanticholinergic antihistamines: Cetirizine (Reactine), fexofenadine (Allegra), loratadine (Claritin), desloratadine (Aerius)