Alternative treatments

Allergic rhinitis and associated symptoms

• avoid 1st G Antihistamines

Oral - Loratadine, Ceterizine, Levoceterizine, Fexofenadine

Nasal - sprays (Azelastine or olopatadine, which are absorbed less than oral agents and have fewer adverse effects)

Nasal corticosteroids - fluticasone, budesonide, trimacinolone

Masal mast cell stabilizers - cromolyn

Pruitis

• avoid 1st G antihistamines

Dry skin - hydrating emollients BID, short showers (< 3 min) in lukewarm water, humidifers, address underlying condition

Localized pruitis, consider topical agents:

• Topical anesthetics (lidocaine, pramoxine)

• Cooling agents (Menthol)

• Topical steroids (Hydrocortisone, Triamcinolone)

• Topical antihistamines (Topical doxepin)

• Capsaicin

If using oral antihistamine, use 2nd or 3rd G oral antihistamine

Pain

• Avoid: TCAs, NSAIDs, Meperidine, Skeletal muscle relaxants, Combination of Gabapentinoids

non-pharm

• educational intervention

• exercise therapy

• physical therapy

• needling therapies (acupuncture)

• psychological interventions

• peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS)

pharm

• short term use of NSAIDs

• Topical NSAIDs

• COX-2 inhibitors

• Other topicals - capsaicin, rubefacients, lidocaine, menthol

• acetaminophen

• intra-articular corticosteroids

neuropathic pain

• SNRIs

• gabapentinoids

• other topicals (listed above)

Diabetes

• Sliding scale insulin

• Sulfonylureas

sliding scale alternatives

• addition of basal insulin = safe d/c

  • if glucose level uncontrolled on basal insulin, add pre-prandial bolus insulin

• up-titration of basal insulin and d/c sliding scale

sulfonylureas alternatives

• metformin

• SLGT2-i, GLP-1RA’s. DPP4-i

Weigh loss (involuntary or undesired)

• Avoid Megestrol

• feeding assistance

• addressing underlying factors

• appealing foods provided

• social support

• access to food

Atrial fibrillation/flutter and venous thromboembolism (anticoagulation)

• Warfarin

• Rivaroxaban

• consider other DOACs - apixaban, edoxaban)

  • AF pts - full dose preferred; reduced doses for renal dysfunction

  • long term VTE tx - reduce dose after 6 months

    • apixaban - reduce dose to 2.5 mg bid

• consider non-pharm alternative - percutaneous left atrial appendage occlusion and surgical left atrial appendage ligation or removal

  • NVAF pts at mod-high stroke or major bleeding risk

Atrial fibrillation/flutter (rate/rhythm control)

• amiodarone

• dronedarone

• digoxin

rhythm

• preferred therapy depends on presence/absence of structual heart disease and HF

• dofetilide and sotalol preferred - initiation requires hospitalization and referral

• pt has normal LV, no CAD or prior MI, and no significant structural HD - other options - dronedarone, flecainide, propafenone

rate

• beta blockers

• If LVEF > 40% - non-DHP CCBs - diltiazem, verapamil

• non-pharm - AV nodal ablation w permanent pacemaker

HF

• Avoid digoxin

• initiate GDMT for HFrEF before considering digoxin

• 1st line - Entresto (or ACE-i/ARB), BB, MRA, and SGLT2-i

• hydralazine-nitrates may be used for Black patients with NYHA class III-IV HFrEF

• diuretics for fluid retention

• non-pharm adjuncts for HFrEF - cardiac resynchronization therapy (CRT)

Hypertension

• non-selective peripheral alpha-1 blockers

  • doxazosin, prazosin, terazosin

• central alpha-1 agonists

  • guafnfacine, clonidine

• IR nifedipine

• non-pharm

  • DASH diet, exercise and weight loss, treatment of obstructive sleep apnea

• First-line drug therapies for HTN include thiazide diuretics, calcium channel blockers, ACEIs, and ARBs. Beta blockers may be indicated in some cases (e.g., recent MI or acute coronary syndrome, HFrEF, AF, or angina)

• nifedipine alternatives

  • other CCBs - amlodipine, felodipine, nifedipine ER

• resistant HTN - spironolactone and hydralazine

Insomnia

• BZDs, Z-drugs, 1st G antihistamines, TCAs, Barbiturates

• cognitive behavioral therapy (CBT), sleep hygiene

• lower risk meds

  • digoxin < 6 mg

  • dual orexin receptor antagonists - daridorexant, lemborexant, suvorexant

  • ramelteon

• trazadone, mirtazepine, melatonin (not recommended for insomnia disorder in adults of any other age)

Anxiety symptoms

• BZDs, 1st G antihistamines, TCAs, Barbiturates, Meprobamate

SNRIs

• GAD - escitalopram, sertraline, venlafaxine, duloxetine, buspirone, pregabalin

• PD - sertraline, escitalopram, venlafaxine

• SAD - sertraline, venlafaxine, escitalopram (also: BB’s: propranolol)

• PTSD, global symptoms - sertraline, venlafaxine

• PTSD, nightmaires - prazosin

Delirium

• Antipsycotics

• 1st line - interventions - AGS CoCare: HELP Program

• No pharmacological treatment is recommended as a routine response to delirium in all populations

• antipsychotics and sedatives considered for short terms (hours to days)

Agitation and/or aggression in people with dementia

• Avoid antipsychotics

• address potential contributing factors - pain, constipation, urinary retention, acute illness

• non-pharm strategies are first line

• if non-pharm intervention fail, antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision makers

Parkinson’s disease

• avoid benztropine and trihexyphenidyl

• optimize exercise/strengthening, balance, and physical therapy

• 1st line meds - levodopa (often combine with carbidopa) and dopamine agonists (pramipexole, ropinirole, and rotigotine) are typically preferred

• if mild symptoms or daily dosing preferred - MOA-B-i (rasagiline)

• Amantadine - manage levodopa induced dyskinesia

• surgical therapies - deep brain stimulation

Tardive dyskinesia

• avoid bentropine and trihexyphenidyl

• reversible causes should be identified and addressed

• if not resolved - FDA approved meds - valbenazine, deutetrabenazine

GERD and associated sypmtoms

• Avoid PPI’s

non-pharm (1st line)

• lifestyle changes, dietary, relaxation, weight management, not eating within 2-3 hours of bedtime

• elevating of the bed

• awareness of the connection between the gut and brain

breakthrough symptoms

• acid containing products with alginate

nocturnal symtoms

• nighttime H2-RA’s

Gastroparesis

• Avoid metoclopramide

• 1st line dietary changes

  • foods that are soft and easy to chew, avoid spicy/acidic, high fiber meals

• treatment of symptomatic relief

  • ginger 1 mg bid or ondansetron for nausea

  • short course erythromycin 50-100 mg 4 times a day

  • for DM, control glucose

Intestinal cramping and diarrhea

• Avoid GI antispasmodics

• identify and address underlying etiology

• encourage dietary changes - avoid triggering foods

• gut directed psychotherapies

• for diarrhea

  • antidiarrheal such as loperamide for short-term use

Constipaion

• avoid mineral oil

• identify and address underlying cause

• 1st line - lifestyle (scheduled toileting after meals, increased fluids, fiber, exercise and ambulation)

• stimulant laxatives (senna) and/or osmotic laxatives (polyethylene glycol, magnesium-containing laxatives)

• still no response - secretagogies (lubipostone, linaclotide, plecanitide) and seretotnin type 4 agonist (prucalopride)

Nocturia and nocturnal polyuria

• avoid desmopressin

Genitourinary syndrome of menopause (GSM)

• avoid systemic estrogens

Recurrent UTIs in women

• avoid systemic estrogens