Yes, promethazine (Phenergan) is on the Beers List
Promethazine is explicitly listed as a potentially inappropriate medication (PIM) in the American Geriatrics Society Beers Criteria® and should generally be avoided in older adults due to its strong anticholinergic properties and associated risks. 1
Why Promethazine is Problematic in Older Adults
Promethazine appears on the Beers Criteria as one of the most frequently prescribed inappropriate medications in elderly populations. Research consistently identifies it among the top PIMs used in older adults 2, 3, 4.
Key Risks in Elderly Patients:
Strong anticholinergic effects leading to:
- Confusion and delirium
- Increased fall risk
- Cognitive impairment
- Urinary retention
- Constipation
CNS depression causing:
- Excessive sedation
- Impaired mental and physical abilities
- Increased risk when combined with other sedating medications 5
Respiratory depression, particularly dangerous in:
- Patients with COPD or sleep apnea
- Those taking concurrent respiratory depressants 5
Clinical Evidence
Studies demonstrate that promethazine use is associated with increased risk of unplanned hospitalizations in elderly patients. One large study found patients taking promethazine were at particularly high risk for hospitalization compared to other PIMs 6.
In nursing home settings, promethazine accounted for 46.9% of all PIMs prescribed, and providers without geriatric training were significantly more likely to prescribe it (odds ratio 6.25) 4.
Common Pitfall to Avoid
Do not assume promethazine is safe simply because it's available over-the-counter or has been used for decades. The 2019 Beers Criteria explicitly recommend avoiding it in older adults regardless of indication 1. The unfavorable risk-benefit profile in elderly patients outweighs any perceived benefits for nausea, allergies, or sleep.
What to Use Instead
For the conditions promethazine is commonly prescribed:
- Nausea/vomiting: Ondansetron, metoclopramide (with caution), or prochlorperazine
- Allergies: Second-generation antihistamines (cetirizine, loratadine) with minimal anticholinergic effects
- Sleep: Cognitive-behavioral therapy for insomnia (CBT-I) as first-line; avoid sedating antihistamines 7, 8
The evidence is clear: promethazine should be avoided in patients 65 years and older whenever possible, with safer alternatives selected based on the specific indication.