Table 4 Clinical importance of potentially inappropriate prescribing criteria according to the expert panel
Examples | |||
|---|---|---|---|
Major clinical importance (n = 43) | Modification of the treatment according to this criteria may prevent serious morbidity, including readmission, serious organ dysfunction, serious adverse drug event | ||
Criterion: START-PIP “Angiotensin converting enzyme (ACE) inhibitor with chronic heart failure”. | Context: The GP reports chronic heart failure, with marked limitation of physical activity and dyspnea, and a recent episode of congestive heart failure. | ||
Criterion: STOPP-PIP “Calcium channel blockers with NYHA class III or IV heart failure”/Beers- PIP “Diltiazem in heart failure”. | Context: The medical history and the clinical examination confirm that the patient has NYHA class III heart failure. | ||
Criterion: Beers- PIP “Anticholinergics in dementia and cognitive impairment”. | Context: The patient has cognitive impairment (MMSE = 22/30a) and takes several drugs with anticholinergic properties (amisulpride, trihexyfenidyl). | ||
Moderate clinical importance (n = 33) | Modification of the treatment according to this criteria brings care to a more acceptable and appropriate level of practice or that may prevent an adverse drug event of moderate importance | ||
Criterion: START-PIP “Statin therapy in diabetes mellitus if coexisting major cardiovascular risk factors present”. | Context: The patient is 87 years, and still has good cognitive and functional status. She has diabetes, hypertension and hypercholesterolemia. | ||
Criterion: STOPP-PIP “Long-term long-acting benzodiazepines”. | Context: The patient has been taking 8mg prazepam every day for more than a month. She has low fall risk (Tinetti score 26/28b) but she has cognitive impairment (MMSE=18/30). | ||
Criterion: STOPP-PIP/Beers-PIP “Aspirin in primary cardiovascular prevention”. | Context: The patient has no history of coronary, cerebral or peripheral vascular symptoms or occlusive event. | ||
Criterion: Beers- PIP “Tertiary tricyclic antidepressants”. | Context: The patient is on clomipramine for “depressive tendencies” according to the GP. The GDS-15 score is low (3/15c). Non pharmacologic or safer alternatives are available. | ||
Minor clinical importance (n = 2) | Modification of the treatment according to these criteria brings no benefit or minor benefit, depending on professional interpretation | ||
Criterion: Beers-PIP “Avoid antiarrhythmic drugs as first-line treatment of atrial fibrillation”. | Context: This patient receives amiodarone and does not suffer from any side effect of this drug. | ||
Criterion: Beers-PIP “Avoid long duration sulfonylurea”. | Context: The patient is on gliclazide extended release formula. He is intolerant to metformine. No hypoglycemia were reported. | ||
Deleterious clinical importance (n = 1) | Modification of the treatment according to this may lead to adverse outcome. | ||
Criterion: START-PIP “Statin therapy in diabetes mellitus if coexisting major cardiovascular risk factors present”. | Context: The patient has a documented allergy to statins. | ||
Non applicable (n = 40) | The criterion is not applicable to the individual context of the patient. | ||
Criterion: START-PIP “beta-blocker with chronic stable angina”. | Context: The patient had a single episode of suspected angina in the past, and he has asthma. | ||
Criterion: START-PIP “Aspirin therapy in diabetes mellitus if coexisting major cardiovascular risk factors present”. | Context: The patient is already on anti-vitamin K and he has no acute coronary disease. | ||
Criterion: STOPP-PIP “Any duplicate drug class prescription”. | Context: The prescription includes a patch of nitroglycerin and tablets of isosorbide dinitrate. However, in his notes, the GP specifies that the patient uses the tablets “as needed” only. | ||
Criterion: STOPP-PIP “Long-term use of NSAID for symptom relief of mild osteoarthritis”. | Context: The 83 year old patient has chronic knee pain despite the use of paracetamol. Unfortunately, his severe respiratory and cardiac status is a contra-indication to surgery and he is intolerant to alternatives to NSAID. He is on proton-pump inhibitor. | ||
Criterion: Beers-PIP “Avoid antipsychotics in dementia & cognitive impairment”. | Context: This patient has cognitive impairment but also a long story of psychiatric disorders. | ||
Criterion: Beers-PIP “Avoid benzodiazepines for the treatment of insomnia, agitation, or delirium”. | Context: This patient received alprazolam to improve her sleep in a context of severe chronic anxiety. |