Drug class

Considerations

Guideline available

Clinical pearls

Diuretics (loop diuretics, thiazide diuretics)

The indication for a loop diuretic should be reassessed in patients without clinical signs of HF and if used solely for ankle edema

Yes (BPAC, PHT)

Replace furosemide with hydrochlorothiazide for primary hypertension in gout

Antihypertensives

Consider patient’s age, indication for treatment (eg, HF, AF, hypertension, CKD)

Yes (BPAC, PHT)

Use and dose should be reevaluated in normotensive or hypotensive patients and those successful with lifestyle modifications (eg, dietary modification, weight loss, smoking cessation)

Aspirin

ASA dosed >150 mg/d should be reassessed, ASA for primary prevention is not recommended

Yes (PHT)

– Inappropriate prescription of ASA in patients with no history of coronary, cerebral, or peripheral vascular symptoms or occlusive event

 – ASA should not be prescribed to treat dizziness not clearly attributable to cerebrovascular disease

Warfarin

– Assess benefits at 6 or 12 months for uncomplicated DVT or PE, respectively

– May not be of benefit unless the patient has chronic AF

Yes (BPAC, PHT)

– Warfarin and NSAIDs should not be used together due to higher risk of gastric ulcer and bleeding

– Continuous use of unnecessary warfarin complicates the lifestyle measures and puts financial burdens

Alpha-blockers

– Harms (headache, dizziness, increased susceptibility to infection, incontinence) outweigh benefits

– Long-term use may also increase the risk of HF

– Reassess the use of alpha-blockers for benign prostatic hyperplasia in men

Yes (PHT)

In older men with >1 episode of incontinence daily another agent should be offered for better control of urinary incontinence

Antihyperlipidemics (eg, statins, fibrates)

Consider patient’s age and time needed to reach therapeutic benefit. Antihyperlipidemics will be part of future cardiovascular event prevention in 5-10 years

Yes (BPAC, DPO, PHT)

Deprescribing may be appropriate in patients with life expectancy <10 years

Benzodiazepines

Harm outweighs benefit. Benzodiazepines should not be used for insomnia, agitation, and delirium due to high risk of falls

Yes (BPAC, DPO, NSW TAG, PHT)

Benzodiazepines should be reserved for alcohol withdrawal symptoms/delirium tremens or severe generalized anxiety disorder unresponsive to other therapies

Antipsychotics

Harm outweighs benefit. May cause confusion, delirium, and falls

Yes (DPO, NSW TAG, PHT)

Antipsychotics should be reserved for patients with severe BPSD and reassessed with close monitoring

Bisphosphonates

Drug holiday should be considered if used >5 years

Yes (BPAC, PHT)

Unnecessary long-term bisphosphonate use can lead to atypical femoral fracture and jaw osteonecrosis

Anticholinergics (TCA, oxybutynin)

Harms (constipation, dizziness, drowsiness, urinary retention, falls) outweigh benefit

Yes (NSW TAG, PHT)

– Mirabegron may be a better option for overactive bladder disorder in older adults

– Other antidepressants like SSRI or SNRI should be considered over TCA

Fluoxetine (long-acting antidepressant)

Longer half-life can exaggerate the adverse effects of SSRI (agitation, insomnia, anorexia)

Yes (BPAC, NSW TAG)

SSRIs with shorter half-life should be considered (sertraline, escitalopram)

First-generation antihistamines (diphenhydramine, chlorpheniramine)

Harms (drowsiness, dizziness, falls, memory loss, urinary retention) outweigh benefits

Yes (NSW TAG)

Antihistamine use should be limited to 1-2 weeks; for long-term use, a newer generation antihistamine should be considered

NSAIDs

Harms (gastric ulcers, HF worsening, potential drug-drug interactions) outweigh benefits

Yes (BPAC, PHT)

– If employed, NSAIDs should only be used short term

– Use a COX-1 selective agent if possible

– Use gastroprotective agents like PPIs when appropriate

PPIs

Insignificant benefit in patients not requiring gastroprotective measures 

Yes (BPAC, DPO, NSW TAG, PHT)

Ongoing PPI use following cessation of NSAIDs or glucocorticoid therapy should be avoided

Stimulant laxative

May worsen bowel function if used long term unless used concurrently with opiates

No

Consider increasing fiber intake and replace with PEG or lactulose