Table 4

Actual messages in e-prescribing software—cardiovascular medications

Trigger drugShort warningText displayed if prescriber presses the more buttonAlternative medications shown
AmiodaroneWarning—evidence of safety and efficacy is limited in the elderly and high risk of QT prolongation and torsade … more‘Amiodarone is an important drug in the management of arrhythmias, however, published evidence of its safety and efficacy in elderly is still limited. Major studies such as the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) have enrolled elderly patients, but the mean age was only 70 years. AFFIRM and other studies have generally not supported the superiority of rhythm over rate control in AF. In addition, adverse effects from antiarrhythmic agents have been common. Amiodarone has been associated with prolongation of the QT interval and precipitating torsade de pointes especially in the presence of risk factors such as hypokalemia and hypomagnesemia, although its risk may be lower than that of quinidine, sotalol and other antiarrhythmic agents. In addition, amiodarone carries a significant risk of hyper- or hypothyroidism (the latter especially in elderly patients), as well as pulmonary and opthalmologic adverse effects. Drugs interactions can be common including with warfarin. Appropriate anticoagulation is a key therapy for preventing stroke in patients with AF.’

  • β blockers

  • Diltiazem

  • Verapamil

  • Warfarin or aspirin to reduce thromboembolism from atrial fibrillation

Digoxin >0.125 mg/dayWarning—dose alert, increased risk of toxicity in the elderly … more‘Digoxin continues to have a role in the management of heart failure and atrial fibrillation (AF). Digoxin is considered an adjunctive therapy in HF where it has been shown to reduce hospitalisations for worsening HF. However ACE inhibitors (or ARBs) and β-blockers such as carvedilol are preferred therapies because of established benefits on morbidity and mortality in patients with HF. Although digoxin may be useful for rate control in AF, β-blockers, diltiazem and verapamil are preferred for many patients with AF. (Anticoagulation remains a key therapy in AF.) Dosages of digoxin greater than 0.125 mg daily may result in toxicity due to the decreased renal function commonly present in elderly patients.’

  • Diltiazem, verpamil, and/or metoprolol may be appropriate alternatives depending on the individual patients

  • Maintain digoxin concentrations between 0.5 and 1.0 ng/ml

DoxazosinWarning—high risk of hypotension and dry mouth in the elderly … more‘Doxazosin has been a useful drug for treating hypertension and BPH which are present commonly in many elderly men. Unfortunately doxazosin, similar to prazosin and terazosin, has a significant potential for dizziness and postural hypotension which may increase the risk of falls and fractures. In addition, the drug may cause dry mouth, somnolence, and asthenia. In the Medical Therapy of Prostatic Symptoms (MTOPS) study, doxazosin did not decrease the risk of acute urinary retention and the need for invasive therapy in men with progressive BPH unlike finasteride (alone or in combination with doxazosin). The Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) also demonstrated a significantly increased risk of heart failure with doxazosin as compared with chlorthalidone. Although combining doxazosin with other antihypertensive agents may mitigate this risk of HF, current data suggest that it is not eliminated.’

  • Flomax: Boehringer-Ingelheim Pharmaceuticals, Ridgefield, CT

  • Uroxatrol: Sanofi-Aventis Pharmaceuticals, Bridgewater, NJ

  • AF, atrial fibrillation; HF, heart failure; ARB, angiotensin receptor blocker; BPH, benign prostatic hyperplasia.