Table 7. Non-Indicated Use and Recent Guidelines Off-label, non-
Indicated Use (N)
Drug Class Guidelines in Past 10 Years (Author, Year)
Discussion in Guideline Atrial Fibrillation
(107)
Metoprolol IR and ER 1.University of Michigan Health System, 201433
2. January CT, 201434
1.Discussed as a therapeutic option
2. Usually not considered effective for maintaining sinus rhythm, but may be helpful combined with anti-
arrhythmic Amiodarone 1. National Clinical Guideline Centre,
201434
January CT, 201434
1.Discussed as therapeutic option for cardioversion 2. Discussed as therapeutic option
Aspirin 1. National Clinical Guideline Centre, 201435
2. Bushnell C, 201436 3. Culebras A, 201437
1.Aspirin should not be offered 2. Discussed as therapeutic option
3. Newer agents discussed as more effective than aspirin
Agitation (189) Haloperidol None N/A
Clonazepam None N/A
Diazepam Barr J, 201338 Non-specific treatment option as a sedative
Fentanyl Barr J, 201338 Discussed as therapy for pain
Lorazepam Barr J, 201338 Discussed as a therapeutic option
Midazolam Barr J, 201338 Discussed as a therapeutic option
Quetiapine None N/A
Risperidone None N/A
Alcohol Withdrawal (47)
Lorazepam National Clinical Guideline Centre for Acute and Chronic Conditions, 201039
Discussed as therapy option for delirium tremens and alcohol withdrawal seizures
Midazolam None N/A Folic acid
supplementation (110)
Folic acid None N/A
Anxiety (90) Clonazepam None N/A
Haloperidol None N/A
Mirtazapine None N/A
Olanzapine None N/A
Quetiapine None N/A
Risperidone None N/A
Sertraline None N/A
Trazodone None N/A
Haloperidol None N/A
Asthma (45) Albuterol-ipratropium None N/A
Ipratropium 1.Sveum R, 201240 2.Lalloo UG, 201341
1. Discussed as a therapeutic option 2. Discussed as a therapeutic option Tiotropium Sveum R, 201240 Discussed as a therapeutic option Non-diabetic
hyperglycemia (247)
Insulin Umpierrez, GE 201243 Discussed as a therapeutic option C. Diff (122) Metronidazole 1. Surawicz CM, 201343
2.Cohen, 201044
1. “Strong recommendation, high-quality evidence” for mild- moderate
2.Treatment option
Constipation (213) Metoclopramide None N/A
Naloxone None N/A
Senna McKay SL, 200945 Discussed as a therapeutic option
COPD/COPD EXACERBATION(
68)
Prednisone GOLD, 201346 Discussed as a therapeutic option
Albuterol GOLD, 201346 Discussed as a therapeutic option
Budesonide GOLD, 201346 Discussed as a therapeutic option as alternative therapy Methylprednisolone GOLD, 201346 Discussed as a therapeutic option
Montelukast None N/A
Azithromycin GOLD, 201346 Currently not recommended as treatment option Delirium Treatment
(122)
Haloperidol Barr J, 201346 No evidence to support use
Olanzapine Barr J, 201346 May reduce the duration of delirium Quetiapine Barr J, 201346 May reduce the duration of delirium Risperidone Barr J, 201346 May reduce the duration of delirium
Trazodone None N/A
Dyspnea (49) Albuterol GOLD, 201346 Short Acting B2 agonists improve “FEV1 and symptoms”
COPD
Albuterol-ipratropium GOLD, 201346 Combinations of short-acting beta2-agonists and anticholinergics are also superior compared to either medication alone in improving FEV1 and symptoms Sepsis/septic shock
(309)
Acyclovir None N/A
Azithromycin Dellinger RP, 201247 Discussed as a therapeutic option Cefepime 1. Dellinger RP, 201247
2. Bodmann KF, 200548
1. Discussed as treatment option 2. Discussed as treatment option Ciprofloxacin Dellinger RP, 201247 Discussed as a therapeutic option
Hydrocortisone Dellinger RP, 201247 Discussed as a therapeutic option Meropenem 1. Dellinger RP, 201247
2. Bodmann KF, 200548
1. Discussed as treatment option 2. Discussed as treatment option
Methylprednisolone None N/A
Metronidazole None N/A
Piperacillin/tazobactam Bodmann KF, 200548 Discussed as a therapeutic option Vancomycin Dellinger RP, 201247 Discussed as a therapeutic option Epinephrine Dellinger RP, 201247 Discussed as a therapeutic option Dobutamine Dellinger RP, 201247 Discussed as a therapeutic option
Linezolid None N/A
Norepinephrine Dellinger RP, 201247 First choice vasopressor
GIB (86) Esomerazole NICE, 201249 Discussed as a therapeutic option
Pantoprazole NICE, 201249 Discussed as a therapeutic option
Phytonadione None N/A
Octreotide None N/A
ICU Sedation (272) Fentanyl None N/A
Lorazepam Barr J, 201338 Discussed as treatment option, but second to non- benzodiazepines
midazolam Barr J, 201338 Discussed as treatment option, but second to non- benzodiazepines
Insomnia/sleep (70) Amitriptyline 1. University of Texas at Austin School of Nursing, Family Nurse Practitioner Program, 201450
2. Guideline Development Group for the Management of Patients with Insomnia in Primary Care, 200951
1.TCAs not recommended, except low dose doxepin 2. Insufficient evidence to recommend
Chlorpromazine University of Texas at Austin School of Nursing, Family Nurse Practitioner Program, 201450
Antihistamines not recommended
Trazodone 1. University of Texas at Austin School of Nursing, Family Nurse Practitioner Program, 201450
2. Guideline Development Group for the Management of Patients with Insomnia in Primary Care, 2009 3. Pinto Jr LR, 201051
1.Discussed as treatment option 2. Insufficient evidence to recommend 3. Discussed as therapy option
Melatonin 1. University of Texas at Austin School of Nursing, Family Nurse Practitioner Program, 201449
2. Guideline Development Group for the Management of Patients with Insomnia in Primary Care, 200951
1.No well-designed studies, but use professional judgment if patient wants “natural remedy”
2. Not enough evidence to recommend for insomnia or to replace BZDs (B), but slow release may be used in patients over 55 in Spain to improve quality of sleep Nortriptyline University of Texas at Austin School
of Nursing, Family Nurse Practitioner Program, 201450
TCAs not recommended, except low dose doxepin
Sertraline Guideline Development Group for the Management of Patients with
Insomnia in Primary Care, 200951
Anti-depressants may be used for insomnia associated with depressive disorder
Immunosuppression for Lung transplant (60)
Tacrolimus RP Baughman, 201252 Discussed as a therapeutic option Prednisone RP Baughman, 201252 Discussed as a therapeutic option Mycophenolate RP Baughman, 201252 Discussed as a therapeutic option Cyclosporine RP Baughman, 201252 Discussed as a therapeutic option
Oral
decontamination (525)
Chlorhexidine Dellinger RP, 201247 Discussed as a prevention option for sepsis in ventilator associated pneumonia
Hospital acquired Pneumonia (66)
Ampicillin- sulbactam American Thoracic Society and IDSA, 200453
Discussed as a therapeutic option
Doripenem None N/A
Meropenem American Thoracic Society and IDSA, 200453
Discussed as a therapeutic option Tobramycin American Thoracic Society and
IDSA, 200453
Discussed as a therapeutic option Vancomycin American Thoracic Society and
IDSA, 200453
Discussed as a therapeutic option Azithromycin American Thoracic Society and
IDSA, 200453
Discussed as a therapeutic option Non-status
epilepticus Seizure (51)
Midazolam None N/A
Lorazepam None N/A
Acute Analgesia (39)
Fentanyl Barr J, 201338 Discussed as a therapeutic option
Shortness of Breath (175)
Budesonide None N/A
Levalbuterol None N/A
Ipratropium None N/A
Stress Ulcer Prophylaxis (782)
Pantoprazole Dellinger RP, 201247 Discussed as a therapeutic option Famotidine Dellinger RP, 201247 Discussed as a therapeutic option Lansoprazole Dellinger RP, 201247 Discussed as a therapeutic option
Hypertension (37) Esmolol None N/A
Isosorbide dinitrate Rosendorff C, 200754 Consider as therapy option for patients with more severe heart failure
Isosorbide mononitrate None N/A
Bumetanide None N/A
Furosemide Luehr D, 201255 Discussed as a therapeutic option Neuropathic pain
(41)
Gabapentin 1.NICE, 201356 2.Attal N, 201057
1.Recommended as initial treatment 2. Discussed as therapy option N/A = not applicable