Version May 2024
| Drug | Potential harm | Comment |
| Insulin | Hypoglycemia | May often be appropriate; however, aggressive glycemic control may often yield greater harms than benefits in older adults.[1-3] |
| Sulfonylureas | Hypoglycemia | Older hospitalized patients at significant risk for hypogylcemia; avoid or use with great caution.[4] |
| Warfarin | Gastrointestinal, intracranial bleeding | Although a high-risk drug, benefits of warfarin therapy often outweigh harms; maintenance of prothrombin time/international normalized ratio (INR) in therapeutic range tightly linked to risk/benefit ratio.[5] |
| Digoxin | Impairment of cognition, heart block | May have a third-line role in management of systolic heart failure; suboptimal choice for rate control in atrial fibrillation. |
| Benzodiazepines | Falls | Associated with as much as a 60% increase in fall risk.[6] |
| Diphenhydramine, other first-generation antihistamines | Impaired cognition, urinary retention in men | Poor choice as sleep aid due to anticholinergic effects, next-day sedation, impact on performance including driving; close medication reconciliation important because patients may also obtain over-the-counter drugs. |
| Opioid analgesics | Constipation, sedation, confusion, cardiorespiratory depression, seizures | Codeine, meperidine, pentazocine, butorphanol, and nalbuphine are poor choices for analgesia. Fentanyl, morphine, or oxycodone are often appropriate with careful dose adjustment. |
| Antipsychotics | Death, pneumonia | Elevated risk of death when used to treat behavioral complications of dementia, although, in selected cases, benefits may exceed risks if consistent with patient goals of care.[7] |
| Chemotherapeutic agents | Myelosuppression (neutropenia, anemia), hepatotoxicity, cardiotoxicity | Comprehensive assessment is required for determining goals of treatment, particularly in light of comorbidities. When indicated, chemotherapy dose and schedule should be carefully individualized for organ function and anticipated toxicities of treatment. In general, greater treatment-related toxicity is accepted when the expected outcome of treatment is cure. |
| Selected antimicrobials | ||
| Fluoroquinolones | Tendon inflammation and rupture, hypoglycemia, cardiac arrhythmias, Clostridioides difficile-associated diarrhea, exacerbation of myasthenia gravis | Elevated risk of tendon rupture in combination with glucocorticoids. |
| Nitrofurantoin | In chronic use (rarely): Pulmonary fibrosis, neuropathy, hepatotoxicity | Avoid in older adults with creatinine clearance <30 mL/minute; does not reach therapeutic concentrations in urine and increased risk of toxicity. |
| Trimethoprim-sulfamethoxazole (co-trimoxazole) | Hyperkalemia, hypoglycemia (with sulfonylurea), severe dermatologic reaction (rare) | Drug interactions include warfarin (↑ INR), agents that increase serum potassium, and sulfonylureas (↑ hypoglycemic effect). |
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