Over 65? Don’t Let the ER Prescribe One of These Meds

. . . . at least, not without a full discussion.  It seems almost 17% of older patients going to the ER were given one or other of these medications that are deemed “potentially inappropriate”. This is the finding of a University of Michigan study published in Academic Emergency Medicine.

The data for this study came from the National Hospital Ambulatory Medical Care Survey.  This survey reported 19.5 million ER visits between 2000 and 2006 where a patient over 65 was given a “potentially inappropriate medicine”, or PIM, and sent home.  APIM is one where, in older patients, the potential benefits are outweighed by potential problems.  Ten medications accounted for over 85% of the PIMs used in the ER; here are the most popular five:

• ·       Promethazine (Phenergan): All non-prescription and many prescription antihistamines may have marked anticholinergic properties (flushing, dry skin and mouth, fever, difficulty focusing, altered mental status).  Ask for a non-anticholinergic antihistamine to treat your allergic reaction.
• ·       Ketorolac (Toradol):  This analgesic can cause peptic ulcers, gastrointestinal bleeding and/or perforation of the stomach or intestines.  Elderly patients are at greater risk, as they often have undiagnosed GI disorders.  
• ·       Propoxyphene (Darvon): Elderly patients are more susceptible to this analgesic’s neurological side effects. Also there’s risk of overdose when there’s the likelihood of decreased liver, kidney, or cardiac function.  Acetaminophen (Tylenol) works just as well, and is non-addictive.
• ·       Meperidine (Demerol): A narcotic sedative (like morphine), Demerol has a lot of side effects and is no more effective than milder analgesics, such as acetaminophen (Tylenol).
• ·       Diphenhydramine (Benedryl):  same as promethazine, above.

The first two – promethazine and ketorolac – account for 40% of the PIMs prescribed.  Here are the next five:

• ·       Clonidine (Catapres):  This drug has the potential for low blood pressure and neurological effects in older people.
• ·       Hydroxyzine (Vistaryl, Atarax): An antihistamine with anticholinergic properties – see promethazine above.
• ·       Diazepam (Valium):  This benzodiazepine ‘minor tranquillizer’ can stay a long time in the body – a matter of days – and its sedative effect can thus increase the risk of falls and fractures.  Ask for a short-acting form.  
• ·       Cyclobenzaprine (Flexaril):  Most muscle relaxants can cause anticholinergic effects (see promethazine above), sedation, and weakness in elderly patients.
• ·       Nifedipine (Procardia, Adalat):  This one has the potential to cause low blood pressure and constipation in older persons.

Please note that the PIM designation doesn’t include possible participation in drug-drug interactions, which can carry risks of their own.  The author of this study gives the following practical advice:  Talk to your primary care physician (family doctor) during or after your ER visit; know the meds you take regularly, and tell the ER doctors and nurses; and get a list of the meds you are given in the ER, with their possible side effects.  Forewarned is forearmed.