Drug Classes To Avoid in Older Persons with HIV

Drug class	Problems	Alternatives
First generation antihistamines e.g., clemastine, diphenhydramine, doxylamine, hydroxyzine	Strong anticholinergic properties, risk of impaired cognition, delirium, falls, peripheral anticholinergic adverse reactions (dry mouth, constipation, blurred vision, urinary retention).	cetirizine, desloratadine, loratadine
Tricyclic antidepressants e.g., amitryptiline, clomipramine, doxepin, imipramine, trimipramine	Strong anticholinergic properties, risk of impaired cognition, delirium, falls, peripheral anticholinergic adverse reactions (dry mouth, constipation, blurred vision, urinary retention).	citalopram, escitalopram, mirtazapine, venlafaxine
Benzodiazepines Long and short acting benzodiazepines e.g., clonazepam, diazepam, midazolam Non-benzodiazepines hypnotics, Z-drugs e.g., zapleton, zolpidem, zopiclone	Elderly are more sensitive to their effect, risk of falls, fractures, delirium, cognitive impairment, drug dependency. Use with caution, at the lowest dose and for a short duration.	non-pharmacological treatment of sleep disturbance/sleep hygiene
Atypical antipsychotics e.g., clozapine, olanzapine, quetiapine	Anticholinergic adverse reactions, increased risk of stroke and mortality (all antipsychotics).	aripiprazole, ziprasidone
Urological spasmolytic agents e.g., oxybutynin, solifenacin, tolterodine	Strong anticholinergic properties, risk of impaired cognition, delirium, falls, peripheral anticholinergic adverse reactions (dry mouth, constipation, blurred vision, urinary retention).	non-pharmacological treatment (pelvic floor exercises)
Stimulant laxatives e.g., senna, bisacodyl	Long-term use may cause bowel dysfunction.	fibres, hydration, osmotic laxatives
NSAIDs e.g., diclofenac, indomethacin, ketorolac, naproxen	Avoid regular, long-term use of NSAIDs due to risk of gastrointestinal bleeding, renal failure, worsening of heart failure.	paracetamol, weak opioids
Digoxin Dosage > 0.125 mg/day	Avoid doses higher than 0.125 mg/day due to risk of toxicity.	for atrial fibrillation: beta-blockers
Long acting sulfonylureas e.g., glyburide, chlorpropamide	Can cause severe prolonged hypoglycemia.	metformin or other antidiabetic classes
Cold medications Most of these products contain antihistamines (e.g., diphenhydramine) and decongestants (e.g., phenylephrine, pseudoephedrine)	First generation antihistamines can cause central and peripheral anticholinergic adverse reactions as described above. Oral decongestants can increase blood pressure.

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NSAID nonsteroidal anti-inflammatory drug