“What Medicines Do You Take?” – Medication Influence in Older Adult Musculoskeletal Care

By Janis Henricksen, PT, DPT, Sc.D., COMT, CEEAA; Brad Allen, PT, Sc.D., CHT, COMT; Jean-Michel Brismée, PT, Sc.D., OCS, FAAOMPT; Matthew D. Geddie, OTR, Ph.D., MBA

Address correspondence to Janis Henricksen, Plano, TX. Email: janis.henricksen@gmail.com

The presence of chronic conditions increases with age. Eighty percent of older adults have at least one chronic disease, 68% have at least two¹. The most common conditions for Americans 65 years of age and older are osteoarthritis, hypertension, diabetes mellitus, pulmonary disease, cancer, and osteoporosis⁶. Hypertension with diabetes and hypertension with osteoarthritis represent two of the most common disease clusters⁶. When considering combinations of comorbidities, the symptoms of depression are commonly noted⁷. Depression prevalence among older adults ranges from one to four percent and the presence of depressive symptoms ranges between 15-32%⁵. The chronic diseases themselves, as well as the medications to treat them, often impact provision of conservative musculoskeletal care. As therapists treat older adults or those with multiple comorbidities, awareness of medication indications and side effects plays a significant role in assessment and treatment.

The following reference sheet, taken from the course New Trends in Conservative Musculoskeletal Management of Older Adults, provides common medication classes, their indications, and side effects influencing therapy services for common chronic conditions^4,2. Conditions included on this reference sheet are cardiovascular diseases, pulmonary disorders, osteoarthritis, diabetes mellitus, depression and osteoporosis³.

Common Medications and Side Effects for Chronic Disease

Medication	Indication/Diseases	Common Generic (and Brand) Names	Side Effects
Anti-anginal	Chest pain Coronary Artery Disease	Nitrates isosorbide dinitrate (Isordil, Dilatrate-SR, Isochron, IsoDitrate), isosorbide mononitrate (Ismo, Imdur, Monoket), nitroglycerin (NitroQuick, Nitrostat, Nitro-Bid, Nitrolingual, Nitro TD Patch-A)	Exaggerated response to systemic heat Orthostatic hypotension Dizziness
Anti-arrhythmic	Elevated blood pressure Arrhythmias Angina Coronary Artery Disease Hypertension Reynaud’s Disease	Cardiac specific Beta Blockers (-olol): acebutolol (Sectral), atenolol (Tenormin), bisoprolol (Zebeta), metoprolol (Kapspargo Sprinkle, Lopressor, Toprol-XL), nebivolol (Bystolic) Non-cardiac specific Beta Blockers (-olol): carvedilol (Coreg), labetalol (Trandate, Normodyne), nadolol (Corgard), pindolol (Visken), propranolol (Hemangeol, Inderal, InnoPran), timolol (Blocadren) Calcium Channel blockers: amlodipine (Katerzia, Norvasc), diltiazem (Cardizem, Cartia, Dilacor, Diltia, Diltzac, Matzim, Taztia, Tiazac), felodipine (Plendil), nicardipine (Cardene IV, Cardene, SR, Cardene), nifedipine (Adalat, Afeditab, Nifediac, Procardia), verapamil (Calan, Isoptin, Verelan, Covera-HS)	Swelling of feet and ankles Altered heart rate (may not control dysrhythmias during exercise) Bronchoconstriction Mask hypoglycemia Reflex tachycardia Reduce heat tolerance and premature fatigue
Anti-coagulants	Blood clotting disorders Arrhythmias Cerebrovascular Disease/Accident Coronary Artery Disease Deep Vein Thrombosis Lupus Myocardial Infarction Recent surgery	Coumarins: warfarin (Jantoven, Coumadin) Factor Xa inhibitors: apixaban (Eliquis), betrixaban (Bevyxxa), edoxaban (Savaysa), fondparinux (Arixtra), rivaroxaban (Xarelto) Heparins: dalteparin (Fragmin), enoxaparin (Lovenox) Thrombin Inhibitors: bivalirudin (Angiomax), dabigatran (Pradaxa)	Increased risk of: Bleeding Bruising Dizziness Headache Stomach upset
Anti-depressants	Depression Anxiety Fibromyaliga Hot flashes Obsessive-Compulsive Disorder Panic Disorder Post-Traumatic Stress Disorder	Selective serotonin reuptake inhibitors (SSRIs) citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem, Selfemra, Rapiflux), paroxetine (Brisdelle, Paxil, Pexeva), fluvoxamine (Luvox), sertraline (Zoloft)	Exacerbate hyponatremia Ataxia Impaired psychomotor function Increased risk of bleeding
Depression, Chronic Pain Anxiety Bipolar Depression Chronic Pain Depression Diabetic Neuropathy Fibromyalgia Panis Disorder Social Phobia	Serotonin-norepinephrine reuptake inhibitors (SNRIs) desvenlafaxine (Pristiq, Khedezla), duloxetine (Cymbalta, Irenka), levomilnacipran (Fetzima), venlafaxine (Effexor), milnacipran (Savella)	Orthostatic hypotension Increased heart rate Decreased blood pressure Increased risk for arrhythmias Increased risk of bleeding
Depression, Chronic Pain Anxiety Chronic nerve-related pain Migraine prevention Obsessive-compulsive Disorder Panic Attacks Post-Traumatic Stress Disorder	Tricyclic anti-depressants (TCAs) amitriptyline (Vanatrip, Elavil, Endep), amoxapine (Asendin), clomipramine (Anafranil), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), nortriptyline (Pamelor, Aventyl HCL)	Orthostatic hypotension Falls Sedation Urinary retention Bradycardia Dry mouth
Anti-hypertensives	Elevated blood pressure Chronic kidney conditions Coronary Artery Disease Heart Failure Hypertension	ACE inhibitors (-pril): benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec), lisinopril (Prinivil, Zestril), ramipril (Altace) Angiotensin receptor blockers (-artan): azilsartan medoxomil (Edarbi), candesartan (Atacand), eprosartan (Teveten), irbesartan (Avapro), losartan (Cozaar), olmesartan (Benicar), telmisartan (Micardis), valsartan (Diovan)	Blunt rise of blood pressure during exercise Orthostatic hypotension Kyperkalemia – cardiac dysrhythmia, dehydration, kidney dysfunction
Anti-inflammatory	Inflammation, pain Allergies Asthma Chronic Obstructive Pulmonary Disease Crohn’s Diease Lupus Multiple Sclerosis Organ Transplants Osteoarthritis Rheumatoid Arthritis Skin Conditions Tendinitis	Glucocorticoids / corticosteroids budesonide (Entrocort, Uceris), dexamethasone (Baycadron, Decadron, DexPak, TaperDex, Zema-Pak, ZoDex, Zonacort), hydrocortisone (Cortef), methylprednisolone (Medrol), prednisolone (Flo-Pred, Millipred, Orapred, Pediapred, Medicort, Predicort), prednisone (Rayos, Sterapred, Daltasone), triamcinolone (Aristocort)	Steroid myopathy Muscular atrophy Tendon rupture Osteoporosis Elevated blood sugar Fluid retention
Pain, inflammation Colds/flu Fever Headache Musculoskeletal Pain/Injury Osteoarthritis	Non-steroidal anti-inflammatory drugs (NSAIDS) diclofenac (Cambia, Zipsor, Zorvolex, Cataflam, Voltaren, Dyloject), etodolac (Lodine), ibuprofen (Advil, Midol, Motrin), indomethacin (Indocin, Tivorbex), ketorolac (Toradol), meloxicam (Mobic), naproxen (Aleve, Naprosyn, Flanax, Midol ER, Anaprox)	Gastrointestinal disturbance Hypertension Leg swelling Liver or kidney problems Increased risk of myocardial infarction or cerebrovascular accident Headache Dizziness
Bronchodilators	Bronchoconstriction Asthma Chronic Obstructive Pulmonary Disease (Chronic Bronchitis and Emphysema)	Adrenergic: albuterol (ProAir, Proventil, Ventolin, AccuNeb), arformoterol (Brovana), epinephrine inhalation (Primatene), formoterol (Perforomist, Foradil), isoproterenol (Isuprel), levalbuterol (Xopenex), racepinephrine (Asthmanefrin, S2 inhalant, Nephron, Micronefrin), salmeterol (Serevent) Anticholinergic: ipratropium (Atrovent), aclidinium (Tudorza Pressair), tiotropium (Spiriva) Combinations: albuterol/ipratropium (Combivent, DuoNeb), flucticasone/salmeterol (Advair, AirDuo, Wixela), budesonide and formoterol (Symbicort), fluticasone and vilanterol (Breo Ellipta) Methylxanthines: theophylline (Elixophyllin, Theo-24, Respbid etc)	Dysrhythmia Premature ventricular contraction Increased heart rate Increased blood pressure
Diabetes Type I/II	Elevated blood glucose Diabetes Type I Diabetes Type II (Diabetes Mellitus)	Biguanides (non-sulfonylureas) metformin (Glumetza, Riomet)	Hypoglycemia Gastrointestinal upset B12 deficiency
Insulin: Insulin aspart and insulin aspart protamine (NovoLOG), insulin degludec (Tresiba), insulin detemir (Levemir), insulin glargine (Lantus, Basaglar, Toujeo), insulin lispro (Admelog, HumaLOG), insulin isophane (Humalin N, NovoLIN N, ReliOn/NovoLIN), insulin regular (Humalin R, Myxredlin, NovoLIN R) Sulfonylureas: glimepiride (Amaryl), glipizide (Glucotrol), glyburide (DiaBeta, Glynase, Micronase)	Hypoglycemia Weight gain
Thiazolidinediones pioglitazone (Actos), rosiglitazone (Avandia)	Fluid retention Weight gain Bone fractures Heart failure
Diuretics	Elevated blood pressure Heart Failure Hypertension Liver Failure Tissue swelling (edema)	Thiazide Diuretics: chlorthaliadone (Hygroton, Thalitone), hydrochlorothiazide (Aquazide H, Esidrix, HydroDiuril, Microzide), indapamide (Lozol) Loop Diuretics: Furosemide (Lasix, Diaqua-2, Lo-Aqua), torsemide (Demadex) Potassium-sparing diuretics: amiloride (Midamor), eplerenone (Inspra), spironolactone (Aldactone, CaroSpir)	Orthostatic hypotension Fluid depletion Muscle cramping Impaired glucose and lipid metabolism Hypo- or hyperkalemia Altered sodium content
Hyperlipidemia	Elevated cholesterol Hyperlipidemia	Statin Medications atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Altoprev, Mevacor, Altocor), pitavastatin (Livalo, Zypitamag), pravastatin (Pravachol), rosuvastatin (Crestor), simvastatin (Zocor)	Myopathy Weakness Liver damage Muscle cramping
Osteoporosis	Bone loss Osteoporosis	Parathyroid hormone and analogs: abaloparatide (Tymlos), parathyroid hormone (Natpara), teriparatide (Forteo) Bone resorption inhibitors: romosozumab (Evenity), denosumab (Prolia)	Parathyroid hormone and analogs: Dizziness, vertigo, muscle cramp, arthralgia, hypotension, hyperuricemia, hypercalcemia, Bone resorption inhibitors: Dyspnea, arthralgia, hypocalcemia, atrial fibrillation
Bone loss Osteoporosis Paget’s Disease	Bisphosphonates: alendronate (Fosamax, Binosto), ibandronate (Boniva, Bondronat), pamidronate (Aredia), risedronate (Actonel, Atelvia), zoledronic acid (Reclast, Zometa, Aclasta) Selective Estrogen receptor modulators (SERMs): raloxifene (Evista)	Bisphosphonates: Muscle and joint pain, osteonecrosis of the jaw, muscle cramps, increased serum calcium, increased atypical femoral fractures SERMs: Muscle cramps, arthralgia, peripheral edema, increased blood pressure, sinusitis

Medication

Indication/Diseases

Common Generic (and Brand) Names

Side Effects

Anti-anginal

Chest pain

Coronary Artery Disease

Nitrates

isosorbide dinitrate (Isordil, Dilatrate-SR, Isochron, IsoDitrate), isosorbide mononitrate (Ismo, Imdur, Monoket), nitroglycerin (NitroQuick, Nitrostat, Nitro-Bid, Nitrolingual, Nitro TD Patch-A)

Exaggerated response to systemic heat

Orthostatic hypotension

Dizziness

Anti-arrhythmic

Elevated blood pressure

Arrhythmias
Angina
Coronary Artery Disease
Hypertension
Reynaud’s Disease

Cardiac specific Beta Blockers (-olol):

acebutolol (Sectral),

atenolol (Tenormin), bisoprolol (Zebeta), metoprolol (Kapspargo Sprinkle, Lopressor, Toprol-XL), nebivolol (Bystolic)

Non-cardiac specific Beta Blockers (-olol):

carvedilol (Coreg), labetalol (Trandate, Normodyne), nadolol (Corgard), pindolol (Visken), propranolol (Hemangeol, Inderal, InnoPran), timolol (Blocadren)

Calcium Channel blockers:

amlodipine (Katerzia, Norvasc), diltiazem (Cardizem, Cartia, Dilacor, Diltia, Diltzac, Matzim, Taztia, Tiazac), felodipine (Plendil), nicardipine (Cardene IV, Cardene, SR, Cardene), nifedipine (Adalat, Afeditab, Nifediac, Procardia), verapamil (Calan, Isoptin, Verelan, Covera-HS)

Swelling of feet and ankles

Altered heart rate (may not control dysrhythmias during exercise)

Bronchoconstriction

Mask hypoglycemia

Reflex tachycardia

Reduce heat tolerance and premature fatigue

Anti-coagulants

Blood clotting disorders

Arrhythmias
Cerebrovascular Disease/Accident
Coronary Artery Disease
Deep Vein Thrombosis
Lupus
Myocardial Infarction
Recent surgery

Coumarins:

warfarin (Jantoven, Coumadin)

Factor Xa inhibitors: apixaban (Eliquis), betrixaban (Bevyxxa), edoxaban (Savaysa), fondparinux (Arixtra), rivaroxaban (Xarelto)

Heparins:

dalteparin (Fragmin), enoxaparin (Lovenox)

Thrombin Inhibitors:

bivalirudin (Angiomax), dabigatran (Pradaxa)

Increased risk of:

Bleeding

Bruising

Dizziness

Headache

Stomach upset

Anti-depressants

Depression

Anxiety
Fibromyaliga
Hot flashes
Obsessive-Compulsive Disorder
Panic Disorder
Post-Traumatic Stress Disorder

Selective serotonin reuptake inhibitors (SSRIs)

citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem, Selfemra, Rapiflux), paroxetine (Brisdelle, Paxil, Pexeva), fluvoxamine (Luvox), sertraline (Zoloft)

Exacerbate hyponatremia

Ataxia

Impaired psychomotor function

Increased risk of bleeding

Depression, Chronic Pain

Anxiety
Bipolar Depression
Chronic Pain
Depression
Diabetic Neuropathy
Fibromyalgia
Panis Disorder
Social Phobia

Serotonin-norepinephrine reuptake inhibitors (SNRIs)

desvenlafaxine (Pristiq, Khedezla), duloxetine (Cymbalta, Irenka), levomilnacipran (Fetzima), venlafaxine (Effexor), milnacipran (Savella)

Orthostatic hypotension

Increased heart rate

Decreased blood pressure

Increased risk for arrhythmias

Increased risk of bleeding

Depression, Chronic Pain

Anxiety
Chronic nerve-related pain
Migraine prevention
Obsessive-compulsive Disorder
Panic Attacks
Post-Traumatic Stress Disorder

Tricyclic anti-depressants (TCAs)

amitriptyline (Vanatrip, Elavil, Endep), amoxapine (Asendin), clomipramine (Anafranil), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), nortriptyline (Pamelor, Aventyl HCL)

Orthostatic hypotension

Falls

Sedation

Urinary retention

Bradycardia

Dry mouth

Anti-hypertensives

Elevated blood pressure

Chronic kidney conditions
Coronary Artery Disease
Heart Failure
Hypertension

ACE inhibitors (-pril):

benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec),

lisinopril (Prinivil, Zestril), ramipril (Altace)

Angiotensin receptor blockers (-artan):

azilsartan medoxomil (Edarbi), candesartan (Atacand), eprosartan (Teveten), irbesartan (Avapro), losartan (Cozaar), olmesartan (Benicar), telmisartan (Micardis), valsartan (Diovan)

Blunt rise of blood pressure during exercise

Orthostatic hypotension

Kyperkalemia – cardiac dysrhythmia, dehydration, kidney dysfunction

Anti-inflammatory

Inflammation, pain

Allergies
Asthma
Chronic Obstructive Pulmonary Disease
Crohn’s Diease
Lupus
Multiple Sclerosis
Organ Transplants
Osteoarthritis
Rheumatoid Arthritis
Skin Conditions
Tendinitis

Glucocorticoids / corticosteroids budesonide (Entrocort, Uceris), dexamethasone (Baycadron, Decadron, DexPak, TaperDex, Zema-Pak, ZoDex, Zonacort), hydrocortisone (Cortef), methylprednisolone (Medrol), prednisolone (Flo-Pred, Millipred, Orapred, Pediapred, Medicort, Predicort), prednisone (Rayos, Sterapred, Daltasone), triamcinolone (Aristocort)

Steroid myopathy

Muscular atrophy

Tendon rupture

Osteoporosis

Elevated blood sugar

Fluid retention

Pain, inflammation

Colds/flu
Fever
Headache
Musculoskeletal Pain/Injury
Osteoarthritis

Non-steroidal anti-inflammatory drugs (NSAIDS)

diclofenac (Cambia, Zipsor, Zorvolex, Cataflam, Voltaren, Dyloject), etodolac (Lodine), ibuprofen (Advil, Midol, Motrin), indomethacin (Indocin, Tivorbex), ketorolac (Toradol), meloxicam (Mobic), naproxen (Aleve, Naprosyn, Flanax, Midol ER, Anaprox)

Gastrointestinal disturbance

Hypertension

Leg swelling

Liver or kidney problems

Increased risk of myocardial infarction or cerebrovascular accident

Headache

Dizziness

Bronchodilators

Bronchoconstriction

Asthma
Chronic Obstructive Pulmonary Disease (Chronic Bronchitis and Emphysema)

Adrenergic:

albuterol (ProAir, Proventil, Ventolin, AccuNeb), arformoterol (Brovana), epinephrine inhalation (Primatene), formoterol (Perforomist, Foradil), isoproterenol (Isuprel), levalbuterol (Xopenex), racepinephrine (Asthmanefrin, S2 inhalant, Nephron, Micronefrin), salmeterol (Serevent)

Anticholinergic:

ipratropium (Atrovent), aclidinium (Tudorza Pressair), tiotropium (Spiriva)

Combinations:

albuterol/ipratropium (Combivent, DuoNeb), flucticasone/salmeterol (Advair, AirDuo, Wixela), budesonide and formoterol (Symbicort), fluticasone and vilanterol (Breo Ellipta)

Methylxanthines:

theophylline (Elixophyllin, Theo-24, Respbid etc)

Dysrhythmia

Premature ventricular contraction

Increased heart rate

Increased blood pressure

Diabetes Type I/II

Elevated blood glucose

Diabetes Type I
Diabetes Type II (Diabetes Mellitus)

Biguanides (non-sulfonylureas)

metformin (Glumetza, Riomet)

Hypoglycemia

Gastrointestinal upset

B12 deficiency

Insulin:

Insulin aspart and insulin aspart protamine (NovoLOG), insulin degludec (Tresiba), insulin detemir (Levemir), insulin glargine (Lantus, Basaglar, Toujeo), insulin lispro (Admelog, HumaLOG), insulin isophane (Humalin N, NovoLIN N, ReliOn/NovoLIN), insulin regular (Humalin R, Myxredlin, NovoLIN R)

Sulfonylureas:

glimepiride (Amaryl), glipizide (Glucotrol), glyburide (DiaBeta, Glynase, Micronase)

Hypoglycemia

Weight gain

Thiazolidinediones pioglitazone (Actos), rosiglitazone (Avandia)

Fluid retention

Weight gain

Bone fractures

Heart failure

Diuretics

Elevated blood pressure

Heart Failure
Hypertension
Liver Failure
Tissue swelling (edema)

Thiazide Diuretics:

chlorthaliadone (Hygroton, Thalitone), hydrochlorothiazide (Aquazide H, Esidrix, HydroDiuril, Microzide), indapamide (Lozol)

Loop Diuretics:

Furosemide (Lasix, Diaqua-2, Lo-Aqua), torsemide (Demadex)

Potassium-sparing diuretics:

amiloride (Midamor), eplerenone (Inspra),

spironolactone (Aldactone, CaroSpir)

Orthostatic hypotension

Fluid depletion

Muscle cramping

Impaired glucose and lipid metabolism

Hypo- or hyperkalemia

Altered sodium content

Hyperlipidemia

Elevated cholesterol

Hyperlipidemia

Statin Medications atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Altoprev, Mevacor, Altocor), pitavastatin (Livalo, Zypitamag), pravastatin (Pravachol), rosuvastatin (Crestor), simvastatin (Zocor)

Myopathy

Weakness

Liver damage

Muscle cramping

Osteoporosis

Bone loss

Osteoporosis

Parathyroid hormone and analogs:

abaloparatide (Tymlos),

parathyroid hormone (Natpara), teriparatide (Forteo)

Bone resorption inhibitors:

romosozumab (Evenity), denosumab (Prolia)

Parathyroid hormone and analogs: Dizziness, vertigo, muscle cramp, arthralgia, hypotension, hyperuricemia, hypercalcemia,

Bone resorption inhibitors: Dyspnea, arthralgia, hypocalcemia, atrial fibrillation

Bone loss

Osteoporosis
Paget’s Disease

Bisphosphonates: alendronate (Fosamax, Binosto), ibandronate (Boniva, Bondronat), pamidronate (Aredia), risedronate (Actonel, Atelvia), zoledronic acid (Reclast, Zometa, Aclasta)

Selective Estrogen receptor modulators (SERMs):

raloxifene (Evista)

Bisphosphonates: Muscle and joint pain, osteonecrosis of the jaw, muscle cramps, increased serum calcium, increased atypical femoral fractures

SERMs: Muscle cramps, arthralgia, peripheral edema, increased blood pressure, sinusitis

References

1. Chronic Disease Self-Management – Programs & Resources. NCOA. https://www.ncoa.org/healthy-aging/chronic-disease/. Accessed June 2, 2019.

2. Ciccone C. Pharmacology in Rehabilitation. 5th ed. Philadelphia: F.A.Davis Company; 2016.

3. Prescription Drug Information, Interactions & Side Effects. Drugs.com. https://www.drugs.com/. Accessed April 21, 2020.

4. Henricksen J. Comorbidities and Medications. November 2019.

5. Kvelde T, Lord SR, Close JCT, et al. Depressive symptoms increase fall risk in older people, independent of antidepressant use, and reduced executive and physical functioning. Arch Gerontol Geriatr. 2015;60(1):190-195. doi:10.1016/j.archger.2014.09.003.

6. Quiñones AR, Markwardt S, Botoseneanu A. Multimorbidity Combinations and Disability in Older Adults. J Gerontol A Biol Sci Med Sci. 2016;71(6):823-830. doi:10.1093/gerona/glw035.

7. Sinnige J, Braspenning J, Schellevis F, Stirbu-Wagner I, Westert G, Korevaar J. The Prevalence of Disease Clusters in Older Adults with Multiple Chronic Diseases – A Systematic Literature Review. PLoS ONE. 2013;8(11). doi:10.1371/journal.pone.0079641.