January 7, 2019

High-Risk Over-the-Counter Medications for Older Adults

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By Katie Cummins, PharmD Candidate 2019 and Lisa Hutchison, PharmD, MPH, BCPS, BCGP, FCCP
Donald W. Reynolds Institute on Aging at UAMS


As our patients age, their bodies undergo physiological changes that alter their responses to many drugs. Kidney and liver function decline so that some drugs stay in the body longer or accumulate to dangerous levels. Body composition changes – muscle decreases while the proportion of fat increases – can lead to the need for smaller doses or longer dosing intervals. In addition, older adults are generally more sensitive to many drugs, especially those that affect the central nervous system. Patients are sensitive to both the effects the drugs are designed for as well as their negative side effects.1

Medications that are “potentially inappropriate” for older adults are detailed in the Beers’ Criteria. The Beers’ list is a tool for providers to help identify medications that could be problematic for older patients. It can also be used as a guide for future drug selection. Some of the concerns outlined in the 2015 Beers’ criteria include adverse events like: dizziness, drowsiness, constipation, confusion, bleeding risk, orthostatic hypotension, and delirium.2

However, these side effects are not limited to prescription drugs; the over-the counter (OTC) section of the pharmacy contains medications that may be inappropriate or even dangerous to older adults. Though they may appear to be safer options since they are widely available, they are not without risk for harm. Some of these potentially inappropriate OTC medications are:

  1. Diphenhydramine: also known as Benadryl3
    1. Commonly found in products branded as PM or Nighttime – Tylenol PM, Advil PM, Unisom, ZzzQuil, Delsym Cough+Cold Nighttime, Theraflu Nighttime Severe Cold and Cough
    2. Used as sleep aid or anti-histamine for allergies
    3. Side effects: confusion, drowsiness, dizziness, delirium, dry mouth, constipation
  2. Oxybutynin: also known as Oxytrol for Women4
    1. Topical patch marketed for overactive bladder
    2. Side effects: drowsiness, delirium, dizziness, dry mouth, constipation
  3. Meclizine: also known as Dramamine Less Drowsy, Bonine5
    1. Commonly found in products marketed for motion sickness or vertigo
    2. Side effects: dizziness, drowsiness, dry mouth, constipation, can worsen dementia symptoms
  4. NSAIDs (non-steroidal anti-inflammatory drugs): ibuprofen, naproxen,
    1. Common brand names: Motrin, Advil, Aleve
    2. May increase risk of GI bleeding, cardiac events2
      1. Take extra caution if taking daily aspirin or prescription blood thinners or anti-platelets like warfarin, clopidogrel (Plavix), prasugrel (Effient), apixaban (Eliquis), dabigatran (Pradaxa)
  5. PPIs (proton pump inhibitors): such as omeprazole, lansoprazole
    1. Common brand names: Prilosec, Prevacid
    2. May contribute to bone loss with long-term use which increases fracture risk with a fall
    3. Can increase risk of bacterial C. difficile infections – symptoms include severe diarrhea2

This is not to say that older adults should avoid all OTC products in the community but rather to show that it is important to for providers to ask if they are taking these products. Documenting this information can prevent the need for additional prescriptions to treat side effects that may be caused by an OTC product – halting a prescribing cascade in its tracks.




  1. Hajjar ER, Gray SL, Slattum Jr PW, Hersh LR, Naples JG, Hanlon JT. Geriatrics. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 10e New York, NY: McGraw-Hill; http://accesspharmacy.mhmedical.com/content.aspx bookid=1861&sectionid=146077984. Accessed July 26, 2018.
  2. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society. 2015;63(11):2227-2246. doi:10.1111/jgs.13702.
  3. Diphenhydramine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed July 26, 2018.
  4. Oxybutynin. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed July 26, 2018.
  5. Meclizine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed July 26, 2018.