Overview
The Suboptimal Drug Selection – Multiple CNS-active Agents TIP was created to address the Pharmacy Quality Alliance measure Polypharmacy: Use of Multiple CNS-active Medications in Older Adults (POLY-CNS). Individuals 65 years of age or older are at a greater risk for side effects while taking three or more CNS-active agents. The goal of the TIP is to consult the prescriber to discontinue or change therapy, so the patient is taking two or fewer CNS-active medications.
Common CNS-active Agents
- Antiepileptic
- Carbamazepine
- Divalproex Sodium
- Gabapentin
- Lacosamide
- Lamotrigine
- Levetiracetam
- Oxcarbazepine
- Phenobarbital
- Phenytoin
- Pregabalin
- Topiramate
- Antipsychotics
- Aripiprazole
- Brexpiprazole
- Cariprazine
- Chlorpromazine
- Clozapine
- Fluphenazine
- Haloperidol
- Lurasidone
- Olanzapine
- Paliperidone
- Perphenazine
- Quetiapine
- Risperidone
- Ziprasidone
-
Benzodiazepines and Nonbenzodiazepine Sedative/Hypnotics
- Alprazolam
- Chlordiazepoxide
- Clobazam
- Clonazepam
- Diazepam
- Estazolam
- Eszopiclone
- Lorazepam
- Temazepam
- Zaleplon
- Zolpidem
- Opioids
- Buprenorphine
- Codeine
- Fentanyl
- Hydrocodone
- Hydromorphone
- Methadone
- Morphine
- Opium
- Oxycodone
- Oxymorphone
- Tapentadol
- Tramadol
- Serotonin and Norepinephrine Reuptake Inhibitors
- Desvenlafaxine
- Duloxetine
- Levomilnacipran
- Milnacipran
- Venlafaxine
- Selective Serotonin Reuptake Inhibitors
- Citalopram
- Escitalopram
- Fluoxetine
- Fluvoxamine
- Paroxetine
- Sertraline
- Tricyclic Antidepressants
- Amitriptyline
- Amoxapine
- Clomipramine
- Desipramine
- Doxepin
- Imipramine
- Nortriptyline
Best Practices
When talking with the prescriber:
- Use the clinical guidelines and supporting evidence provided in the TIP overview.
- Have your recommendation ready, “Based on the other medications the patient is taking, I’d like to recommend (name of medication).”
- Keep the patient’s health at the center of the conversation−be prepared to defend your recommendation!
When talking with the patient:
- Discuss the benefits of using the suggested medication.
- Approach this as an “opportunity to improve your drug therapy” rather than a chance to “fix a mistake the prescriber has made.”
Communicate the change to the patient after receiving the prescriber’s approval, “Here is a new medication your doctor has ordered for you.”
Resources:
- By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372