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Quality of Drug Prescribing

Worst Pills, Best Pills Newsletter article March, 2011

In the Nov. 3, 2010, New England Journal of Medicine, researchers from the University of Pittsburgh, the Harvard School of Public Health and Harvard Medical School reported that doctors’ quality of drug prescribing for the elderly varied substantially among different geographic regions in the U.S. (The measure of quality was not being prescribed a high-risk drug.)

People age 65 and up are twice as likely to experience adverse events associated with medications than people under age 65,...

In the Nov. 3, 2010, New England Journal of Medicine, researchers from the University of Pittsburgh, the Harvard School of Public Health and Harvard Medical School reported that doctors’ quality of drug prescribing for the elderly varied substantially among different geographic regions in the U.S. (The measure of quality was not being prescribed a high-risk drug.)

People age 65 and up are twice as likely to experience adverse events associated with medications than people under age 65, and they are almost seven times more likely to be hospitalized as a result, according to the National Committee for Quality Assurance (the committee that accredits health care organizations).

The New England Journal of Medicine study utilized two quality measures from data collected by the National Committee for Quality Assurance: 1) the use of drugs that are considered to be high-risk for the elderly and 2) potentially harmful drug-disease interactions. (In this article we review just the first topic: the prescribing of high-risk drugs for the elderly.)

The researchers calculated, by U.S. geographic region, the proportion of Medicare beneficiaries who had received at least one high-risk drug in 2007. The median was 24.9 percent and the range was 11.4 percent to 44 percent. These percentages are too high; even one prescription being written for a high-risk drug is too many.

The results were consistent with an association between lower-quality prescribing and more adverse drug events that may cost more to treat.

High-risk drugs

In Table 1, we compare the list of medications that are considered high-risk for the elderly, as presented in the New England Journal of Medicine article, with our own recommendations for using (or not using) the drugs. Of the 77 drugs listed in the article, we had classified all 67 that we previously reviewed as “Do Not Use” or “Limited Use” on WorstPills.org. Of those 67, we listed 60 (90 percent) of them as “Do Not Use.”

Many of the drugs in the table are fixed combinations of drugs, in which at least one ingredient has not been proven to be effective or the second ingredient has not been proven to significantly add to the effectiveness of the first. In these cases, we list combination drugs as “Do Not Use.”

The antihistamine category in the table includes many drugs that contain oral decongestants, such as phenylephrine and pseudoephedrine, which are prescribed for the common cold. We do not recommend the use of any nasal decongestants that are taken by mouth for treatment of a cold because much smaller doses in the form of nose sprays or drops are safer and just as effective.

Ten of the drugs in the table have not been reviewed on WorstPills.org. These are listed as “not reviewed by WPBP.”

(Note: Worst Pills, Best Pills News and WorstPills.org cover drug use in all age groups, and in some cases when a drug is listed as “Limited Use,” this refers to younger age groups — not the elderly.)

What You Can Do

Before you get a new prescription filled, you should always read about the drug in Worst Pills, Best Pills News or on WorstPills.org. If you have concerns after checking out your drug, talk with your prescriber about better, safer alternatives. This will improve the quality of drugs you receive and may prevent needless adverse drug reactions.

Table 1. New England Journal of Medicine List of High-Risk Medications, With WorstPills.org Classification

 

Category

Drugs and Drug Combinations
Generic name (BRAND NAME)

WorstPills.org Classification

Antianxiety (includes combination drugs)

 

aspirin–meprobamate (EQUAGESIC, MICRAININ)

Do Not Use

 

meprobamate (EQUANIL, MILTOWN)

Do Not Use

Antiemetics

 

scopolamine (TRANSDERM-SCOP)

not reviewed by WPBP

 

trimethobenzamide (TIGAN)

Do Not Use

Analgesics (includes combination drugs)

 

ketorolac (TORADOL)

Do Not Use

Antihistamines (includes combination drugs)

 

APAP/dextromethorphan/diphenhydramine (DIABETIC TUSSIN NIGHT TIME FORMULA)

Do Not Use

 

APAP/diphenhydramine/phenylephrine (BENADRYL ALLERGY & COLD, BENADRYL ALLERGY & SINUS, SUDAFED PE SEVERE COLD, THERAFLU WARMING SEVERE COLD NIGHTTIME)

Do Not Use

 

APAP/diphenhydramine/pseudoephedrine (ACTIFED SINUS DAY AND NIGHT, BENADRYL ALLERGY COLD, BENADRYL ALLERGY/SINUS HEADACHE, BENADRYL COLD, BENADRYL SEVERE ALLERGY & SINUS HEADACHE, CHILDREN’S TYLENOL ALLERGY-D, CONTAC DAY AND NIGHT ALLERGY, SUDAFED SINUS NIGHTTIME PLUS PAIN, TYLENOL ALLERGY COMPLETE NIGHTTIME, TYLENOL ALLERGY SINUS NIGHTTIME, TYLENOL NIGHTIME FLU GELCAP MAXIMUM STRENGTH, TYLENOL NIGHTIME HOT LIQUID MAXIMUM STRENGTH

Do Not Use

 

acetaminophen-diphenhydramine (TYLENOL COLD RELIEF, TYLENOL SEVERE ALLERGY)

Do Not Use

 

carbetapentane/diphenhydramine/phenylephrine (DYTAN-CS)

Do Not Use

 

codeine/phenylephrine/promethazine

Do Not Use

 

codeine-promethazine (PHENERGAN with codeine)

Do Not Use

 

cyproheptadine (PERIACTIN)

n/a

 

dexchlorpheniramine (POLARAMINE)

not reviewed by WPBP

 

dexchlorpheniramine/dextromethorphan/PSE (BROMATAN PLUS, DURATAN FORTE, TANAFED DMX, TANDUR DM, TANNATE DMP-DEX, C-PHED DPD TANN, TANAFED-DMX, DUR-TANN FORTE, SUTAN-DM, TANNATE PD-DM)

Do Not Use

 

dexchlorpheniramine/guaifenesin/PSE (POLARAMINE EXPECTORANT)

Do Not Use

 

dexchlorpheniramine/hydrocodone/phenylephrine (HYDEX PD, ZOTEX HC)

Do Not Use

 

dexchlorpheniramine/methscopolamine/PSE (DURAHIST D)

Do Not Use

 

dexchlorpheniramine-pseudoephedrine (DUOTAN PD, TANAFED DP)

Do Not Use

 

dextromethorphan-promethazine (PHENERGAN with dextromethorphan)

Do Not Use

 

diphenhydramine (BENADRYL)

n/a

 

diphenhydramine-magnesium salicylate (DOAN’S PM)

not reviewed by WPBP

 

diphenhydramine-phenylephrine (ALAHIST LQ, ALDEX-CT, CHILDREN’S TRIACTING NIGHT TIME, D-TANN, DIMETAPP NIGHTTIME COLD & CONGESTION, DIPHENMAX D, DYTAN-D, PEDIACARE CHILDREN’S ALLERGY & COLD, ROBITUSSIN NIGHT TIME COUGH & COLD, ROBITUSSIN NIGHT TIME COUGH & COLD CHILDREN’S, ROBITUSSIN NIGHT TIME COUGH & COLD PEDIATRIC, TRIAMINIC NIGHT TIME COLD & COUGH, DIPHENTANN-D, UNI-TANN D

Do Not Use

 

diphenhydramine-pseudoephedrine (RESPA SA)

Do Not Use

 

hydroxyzine hydrochloride (ATARAX, VISTARIL)

n/a

 

hydroxyzine pamoate (VISTARIL)

n/a

 

phenylephrine-promethazine

Do Not Use

 

promethazine (PHENERGAN, PROMETHEGAN, ROMERGAN, FARGAN, FARGANESSE, PROTHIAZINE, AVOMINE, ATOSIL, RECEPTOZINE, LERGIGAN)

Do Not Use

Antipsychotic, typical

 

thioridazine (MELLARIL)

Do Not Use

Amphetamines

 

amphetamine dextroamphetamine (ADDERALL)

Limited Use

 

benzphetamine (DIDREX)

Do Not Use

 

dexmethylphenidate (FOCALIN)

Limited Use

 

dextroamphetamine (DEXEDRINE, DEXTROSTAT)

Limited Use

 

diethylpropion (DURAD, TENUATE, TEPANIL)

Do Not Use

 

methamphetamine (DESOXYN)

not reviewed by WPBP

 

methylphenidate (CONCERTA, METADATE, METHYLIN, METHYLIN ER, RITALIN)

Limited Use

 

phendimetrazine (PLEGINE)

n/a

 

phentermine (ADIPEX-P, ATTI PLEX P, IONAMIN, KRAFTOBESE, PANSHAPE M, PHENTERCOT, PHENTRIDE, PRO-FAST, RAPHTRE, SUPRAMINE, TARA-8, TERAMINE, TERMENE)

Do Not Use

Barbiturates

 

butabarbital (BUTISOL SODIUM)

Do Not Use

 

mephobarbital (MEBARAL)

not reviewed by WPBP

 

pentobarbital (NEMBUTOL)

not reviewed by WPBP

 

phenobarbital (LUMINAL SODIUM)

Limited Use

 

secobarbital (SECONAL SODIUM)

not reviewed by WPBP

Long-acting benzodiazepines (includes combination drugs)

 

amitriptyline-chlordiazepoxide (LIMBITROL)

Do Not Use

 

chlordiazepoxide (H-TRAN, LIBRITABS, LIBRIUM, MITRAN, POXI)

Do Not Use

 

chlordiazepoxide-clidinium (LIBRAX)

Do Not Use

 

diazepam (VALIUM)

Do Not Use

 

flurazepam (DALMANE)

Do Not Use

Calcium channel blockers

 

nifedipine—short-acting only (ADALAT, PROCARDIA)

Do Not Use

Belladonna alkaloids (includes combination drugs)

 

atropine (ATREZA, ATROPEN, SAL-TROPINE)

Do Not Use

 

atropine/CPM/hyoscyamine/PE/scopolamine (ACCUHIST LA, BELLAHIST-D LA)

Do Not Use

 

atropine/hyoscyamine/PB/scopolamine (DONNATAL)

Do Not Use

 

atropine-difenoxin (MOTOFEN)

Do Not Use

 

atropine-diphenoxylate (LOMOTIL, LONOX)

Do Not Use

 

atropine-edrophonium (ENLON-PLUS)

Do Not Use

 

belladonna (BELLADONNA TINCTURE, BELLADONNA LEAF)

Do Not Use

 

belladonna/ergotamine/phenobarbital (BELLAMINE S, BELLASPAS)

Do Not Use

 

butabarbital/hyoscyamine/phenazopyridine (PHENAZOFORTE PLUS, URELIEF PLUS)

Do Not Use

 

digestive enzymes/hyoscyamine/phenyltoloxamine (DIGEX)

Do Not Use

 

hyoscyamine (LEVBID, LEVSIN)

Do Not Use

 

atropine, hyoscyamine, methenamine, methylene blue, phenyl salicylate and benzoic acid (PROSED/DS, URITACT DS)

Do Not Use

Skeletal muscle relaxants (includes combination drugs)

 

ASA/caffeine/orphenadrine (NORGESIC, NORGESIC FORTE, ORPHENGESIC, ORPHENGESIC FORTE)

Do Not Use

 

ASA/carisoprodol/codeine (SOMA COMPOUND with codeine)

Do Not Use

 

aspirin-carisoprodol (SOMA COMPOUND)

Do Not Use

 

aspirin-methocarbamol (ROBAXISAL)

Do Not Use

 

carisoprodol (SOMA)

Do Not Use

 

chlorzoxazone (PARAFON FORTE DSC)

Do Not Use

 

cyclobenzaprine (FLEXERIL)

Do Not Use

 

metaxalone (SKELAXIN)

not reviewed by WPBP

 

methocarbamol (ROBAXIN)

Do Not Use

 

orphenadrine (NORFLEX)

Do Not Use

Oral estrogens (includes combination drugs)

 

conjugated estrogen (PREMARIN)

Limited Use

 

conjugated estrogen medroxyprogesterone (PREMPRO, PREMPHASE)

Limited Use

 

esterified estrogen (ESTRATAB, MENEST)

not reviewed by WPBP

 

esterified estrogen methyltestosterone (ESTRATEST, ESTRATEST HS)

Do Not Use

 

estropipate (OGEN, ORTHO-EST)

not reviewed by WPBP