CHART B List of Diagnosis Drug Combinations with High

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					                                                                                                                CHART B
                                                                                 List of Diagnosis/Drug Combinations with
                                                                              High Potential for Severe Adverse Outcomes
                                                                                                                    F 329

     Disease Process (Diagnosis)               In Combination with the                Potential Side Effect       Evidence on Record
 Circle if present and risk to Resident         following DRUGS (s)                          (ADR)                     Yes / No:
                                                Circle if present on regime              Circle if Evident        Reason drug of choice /
                                                                                                              Identified risks for using drug /
                                                                                                               Benefit vs Risk of ADR using
                                                                                                               Drug / Continual Assessment
1.    COPD                                •   Flurazepam (Dalmane)                •     Exacerbation of
      • May slow respiration and          •   Chlordiazepoxide (Librium)                COPD symptoms
         increase carbon dioxide          •   Clorazepate (Tranxene)              •     Cough
         retention in persons with        •   Diazepam (Valium)                   •     Increased sputum
         COPD                             •   Clonazepame (Klonopin)                    production
      • There is no data to support       •   Quazepam (Doral)                    •     Shortness of breath
         the practice of using            •   Halazepam (Paxipam)                 •     Tightness in the
         hypnotic / sedative drug         •   Amobarbital (Amytal)                      chest
         use in persons with
                                          •   Butibarbital (Butisol)              •     Burning sensation
         COPD, there is no data to                                                •
                                          •   Pentobarbital (Nembutal)                  Wheezing
         support this practice and
                                          •   Secobarbital (Seconal)
         pulmonologists virtually
         all agree that such drugs        •   Glutethimide (Doriden)
         should be avoided in             •   Methprylon (Noludar)
         COPD patients.                   •   Ethchlorvynol (Placidyl)
                                          •   Meprobamate (Equinal,
                                              Miltown)
                                          • Paraldehyde
                                          • Chloral Hydrate
                                          Exceptions are short acting
                                          benzodiazepines Ativan, Serax,
                                          Xanax to relieve anxiety, on a prn
                                          basis after thorough assessment and
                                          optimal treatment of the symptoms
                                          of COPD.
2.    Active or recurrent gastritis,      • NSAIDs                                •     Nausea
      peptic ulcer disease or GI          • Diclofenac (Cataflam &                •     Dyspepsia
      reflux disease (GERD)                   Voltaren)                           •     Vomiting
      • May exacerbate ulcer              • Diflunisal (Dolobid)                  •     Abdominal Pain
           disease, gastritis and         • Etodolac (Lodine)                     •     Heartburn
           gastroesophageal reflux        • Fenoprofen (Nalfon)                   •     Epigastric Pain
           disease (GERD)                 • Ibuprofen (Motrin & Advil)            •     Diarrhea
                                          • Oxaprozin (Daypro)                    •     Flatulence
                                          • Phenylbutazone
                                          • Piroxicam (Feldene)
                                          • Sulinadac (Clinoril)
                                          • Tolmetin (Tolectin)
3.    Seizures or epilepsy                • Metoclopramide (Reglan)               •     Increased seizure
      • May lower seizure                                                               activity
          threshold                                                               •




Page 1 of 3                                                                                                    CL-INTER-1215b (12/15/01)
                                                                                                               CHART B
                                                                                List of Diagnosis/Drug Combinations with
                                                                             High Potential for Severe Adverse Outcomes
                                                                                                                   F 329

     Disease Process (Diagnosis)               In Combination with the               Potential Side Effect       Evidence on Record
 Circle if present and risk to Resident         following DRUGS (s)                         (ADR)                     Yes / No:
                                               Circle if present on regime              Circle if Evident        Reason drug of choice /
                                                                                                             Identified risks for using drug /
                                                                                                              Benefit vs Risk of ADR using
                                                                                                              Drug / Continual Assessment
4.    Blood Clotting Disorders            NSAIDS                                 •     Bleeding (e.g. from
      • May cause bleeding in             • Diclofenac (Cataflam &                     gums when brushing
          those using anticoagulants         Voltaren)                                 teeth or from small
                                          • Diflunisal (Dolobid)                       abrasions or
                                          • Etodolac (Lodine)                          contusions
                                          • Fenoprofen (Nalfon)                  •     GI bleeding (black
                                          • Ibuprofen (Motrin & Advil)                 tarry stools)
                                          • Oxaprozin (Daypro)                   •     Occult blood in
                                          • Phenylbutazone                             stool
                                          • Piroxicam (Feldene)                  •     Coffee ground
                                          • Sulinadac (Clinoril)                       emesis
                                          • Tolmetin (Tolectin)                  •     Low Hct
5.    Benign Prostatic Hypertrophy        • Chlorpheniramine (Chlor-             •     Urinary retention
      (BPH)                                  Trimeton)                           •     Urinary
      • Anticholinergic drugs             • Diphenhydramine (Benedryl)                 incontinence
          may impair micturation          • Hydroxyzine (Vistaril/Atarax)        •     Reflux
          and cause obstruction in        • Cyproheptadine (Periactin)           •     Pyelonephritis
          persons with BPH                • Promethazine (Phenergan)             •     Nephritis
                                          • Tripelanamine (PBZ)                  •     Low grade
                                          • Dexchlorpheniramine                        temperature
                                             (Polaramine)                        •     Low back pain
                                          • Benztropine (Cogentin)
                                          • Trihexyphenidyl (Artane)
                                          • Procyclidine (Kemarden)
                                          • Biperiden (Akineton)
                                          • *Dicyclomine (Bentyl)
                                          • *Hyoscyamine (Levsin)
                                          • *Propantheline (Probantine)
                                          • *Belladonna Alkaloids
                                             (Donnatal)
                                          • *Clidinium containing Librax
                                          • *Review not necessary if drugs
                                             are used once every three
                                             months for a short duration,
                                             (not over seven days) for
                                             symptoms of an acute, self
                                             limiting illness.
                                          • Amytryptline (Elavil)
                                          • Amoxapine (Asendin)
                                          • Clomipramine (Anafranil)
                                          • Desepramine (Pertofrane)
                                          • Doxepin (Adapin, Sinequan)
                                          • Imipramine (Tofranil)
                                          • Maprotiline (Ludiomil)
                                          • Nortriptyline (Pamelor)
                                          • Protriptyline (Vivactil)


Page 2 of 3                                                                                                   CL-INTER-1215b (12/15/01)
                                                                                                               CHART B
                                                                                List of Diagnosis/Drug Combinations with
                                                                             High Potential for Severe Adverse Outcomes
                                                                                                                   F 329

     Disease Process (Diagnosis)               In Combination with the               Potential Side Effect       Evidence on Record
 Circle if present and risk to Resident         following DRUGS (s)                         (ADR)                     Yes / No:
                                               Circle if present on regime              Circle if Evident        Reason drug of choice /
                                                                                                             Identified risks for using drug /
                                                                                                              Benefit vs Risk of ADR using
                                                                                                              Drug / Continual Assessment
6.    Arrhythmias                         • Amytriptyline (Elavil)               •     Cardiac
      • For all drugs if begun            Date started ___________                     arrhythmia’s
          within 1 month treat as         • Amoxapine (Asendin)                  •
          High Potential – 329            Date started ___________
      • After 1 month, less severe        • Clomipramine (Anafranil)
          – 429                           Date started ___________
                                          • Desipramine (Pertofrane)
                                          Date started ___________
                                          • Doxepin (Adapin, Sinequan)
                                          Date started ___________
                                          • Imipramine (Toranil)
                                          Date started ___________
                                          • Maprotiline (Ludiomil)
                                          Date started ___________
                                          • Nortriptyline (Aventyl,
                                              Pamelor)
                                          Date started ___________
                                          • Protriptyline (Vivactil)
                                          Date started ___________




Page 3 of 3                                                                                                   CL-INTER-1215b (12/15/01)