STOPP START Toolkit. Supporting Medication Review. STOPP: Screening Tool of Older People s Potentially Inappropriate Prescriptions

Transcription

1 STOPP START Tlkit Supprting Medicatin Review STOPP: Screening Tl f Older Peple s Ptentially Inapprpriate Prescriptins START: Screening Tl t Alert Dctrs t Right (i.e. apprpriate, indicated) Treatments

2 Cntents Intrductin Gastrintestinal BNF Sectin 1 Cardivascular System BNF Sectin 2 Respiratry System BNF Sectin 3 Central Nervus System and Analgesic Drugs BNF Sectin 4 Endcrine System BNF Sectin 6 Urgenital System BNF Sectin 7 Musculskeletal System BNF Sectin 10 References STOPP: Screening Tl f Older Peple s Ptentially Inapprpriate Prescriptins 1 Prescriptins that are ptentially inapprpriate in persns aged 65 years f age START: Screening Tl t Alert Dctrs t Right (i.e. apprpriate, indicated) Treatments 1 Medicatin that shuld be cnsidered fr peple 65 years f age where n cntraindicatins exist

3 Intrductin An evidence based apprach t prescribing in the elderly A definitin f medicatin review is a structured, critical examinatin f a patient s medicines with the bjective f reaching an agreement with the patient abut treatment, ptimising the impact f medicines, minimising the number f medicatin-related prblems and reducing waste. 2 It is cmmnly agreed that lder peple are at greater risk f adverse effects frm their medicines due t age related changes in their majr rgans which in turn alter pharmackinetics and pharmacdynamics. They als ften have multiple c-mrbidities leading t drug-drug interactins r cautins and cntraindicatins t preferred treatments. These patients hwever are ften excluded frm drug trials making it difficult fr a clinician t weigh up the benefits versus risks, let alne explain them t the patient. Furthermre, althugh with increasing age a patient can mve frm benefiting frm a treatment t being at significant risk frm it, there can be difficulty in stpping medicatin fr the fear f being accused f ageism. This dcument is based n the STOPP START Tl, a medicatin review tl designed t identify medicatin where the risks utweigh the benefits in the elderly and vice versa. Eighteen experts in geriatric pharmactherapy initially cntributed t suggesting and then rating the criteria. The STOPP criteria were evaluated (alng with Beer s criteria 3 ) against hspital admissins. One third f the patients with "ptentially inapprpriate prescriptins" accrding t STOPP criteria presented with an assciated adverse drug event. All recmmendatins frm the STOPP START Tl are included here, and where space allws lcal and natinal guidance. The recmmendatins are gruped accrding t British Natinal Frmulary chapters 4 with the STOPP items clured red and the START items n the clured green. The ratinale fr the interventin is given in italics. The tl was validated in patients aged 65 and ver but there is still a place fr clinical judgement in deciding whether a persn is "elderly" in terms f the ptential effects f medicatin. Clur Key Medicatin t cnsider stpping in patients ver 65 frm the STOPP Tl 1 Medicatin t cnsider starting in patients ver 65 frm the START Tl 1 Natinal and lcal guidance e.g. NICE Guidelines 5

4 Gastrintestinal System BNF Sectin 1 STOPP Diphenxylate (c-phentrpe), lperamide r cdeine phsphate fr treatment f diarrhea f unknwn cause risk f delayed diagnsis may exacerbate cnstipatin with verflw diarrhea may precipitate txic megacln in inflammatry bwel disease may delay recvery in unrecgnised gastrenteritis fr treatment f severe infective gastrenteritis i.e. bldy diarrhea, high fever r severe systemic txicity risk f exacerbatin r prtractin f infectin Prchlrperazine r metclpramide in patients with Parkinsnism risk f exacerbating Parkinsnism Prtn pump inhibitr at treatment dse fr peptic ulcer disease at full therapeutic dsage fr > 8 weeks risk f unnecessarily prlnged treatment and masking symptms f gastric cancer; earlier discntinuatin r dse reductin fr maintenance/ prphylactic treatment f peptic ulcer disease, esphagitis r GORD risk f C. difficile Antichlinergic antispasmdic drugs (e.g. hyscine butylbrmide, dicyclverine) fr patients with chrnic cnstipatin risk f exacerbatin f cnstipatin Stimulant laxatives (e.g. senna, bisacdyl) fr patients with intestinal bstructin risk f bwel perfratin

5 Gastrintestinal System BNF Sectin 1 START Prtn Pump Inhibitr fr severe gastr-esphageal acid reflux disease r peptic stricture requiring dilatatin; cnsider referring t GP fr fllw-up in cmmunity fr patients ver 80 years ld n anti-platelets and SSRIs Fibre supplement fr chrnic, symptmatic diverticular disease with cnstipatin Gastrintestinal System BNF Sectin 1 Natinal and lcal guidance e.g. NICE Guidelines MUST Tl Review need fr enteral nutritin. Assess patient accrding t MUST Tl: This dcument is lcated in all patient ntes at ELHT. Re-Feeding Syndrme Lcal guidance available via the intranet hmepage: Hme page: Plicies and Prcedures>Search: Re-feeding NICE CG17 Dyspepsia

6 Cardivascular System BNF Sectin 2 STOPP Digxin at a lng-term dse >125micrgram/day with impaired renal functin (egfr <50mL/minute) increased risk f txicity (e.g. nausea, diarrhea, arrhythmias) levels can be taken (must be > 6 hurs pst dse) if there is a risk f txicity and/r txicity suspected Lp diuretic (e.g. fursemide, bumetanide) fr dependent ankle edema nly i.e. n clinical signs f heart failure n evidence f efficacy cmpressin hsiery usually mre apprpriate as first-line mntherapy fr hypertensin safer, mre effective alternatives available Thiazide diuretic (e.g bendrflumethiazide) with a histry f gut risk f exacerbating gut Beta-blcker in cmbinatin with verapamil risk f symptmatic heart blck Nn-cardiselective beta-blcker (e.g. prpranll, stall) in patients with COPD risk f brnchspasm Calcium channel blckers with chrnic cnstipatin may exacerbate cnstipatin Use f diltiazem r verapamil with NYHA Class III r IV heart failure may wrsen heart failure if ankle edema present may be result f calcium channel blcker

7 Vasdilatr drugs (e.g. hydralazine, minxidil) with persistent pstural hyptensin i.e. recurrent > 20 mmhg drp in systlic bld pressure risk f syncpe and falls stp if patient has fallen in past 3 mnths Aspirin at dse >150 mg/day; restart at 75mg if still indicated increased bleeding risk, n evidence fr increased efficacy with cncurrent bleeding disrder high risk f bleeding Warfarin after 6 mnths f treatment fr first, uncmplicated deep venus thrmbsis n prven added benefit beynd 6 mnths after 12 mnths f treatment fr first uncmplicated pulmnary emblus n prven benefit beynd 12 mnths with cncurrent bleeding disrder high risk f bleeding hepatic impairment with impaired cltting ability and raised INR increased risk f bleeding as a result f impaired ability t prduce cltting factrs Clpidgrel with cncurrent bleeding disrder high risk f bleeding Dipyridamle as mntherapy fr cardivascular secndary preventin, unless intlerant t aspirin and clpidgrel (secndary preventin TIA) n evidence fr efficacy with cncurrent bleeding disrder high risk f bleeding immediate release tablets n evidence fr efficacy and nn-frmulary

8 Statins Atrvastatin 80mg fr lnger than 6 mnths pst-mi Reduce t maintenance simvastatin after this perid except in exceptinal circumstances highlighted in the Trust frmulary In patients displaying symptms f muscle weakness and pain Risk f mypathy and rhabdmylysis Check creatinine kinase if patient presents with muscular symptms START Cardivascular System BNF Sectin 2 Warfarin in the presence f chrnic atrial fibrillatin fllwing diagnsis f deep vein thrmbsis r pulmnary emblism if benefit utweighs risk f treatment Aspirin in the presence f chrnic atrial fibrillatin, where warfarin is cntraindicated, but nt aspirin Aspirin r clpidgrel with a dcumented histry f athersclertic crnary, cerebral r peripheral vascular disease in patients with sinus rhythm fllwing an acute mycardial infarctin Antihypertensive therapy where systlic bld pressure cnsistently >160 mmhg Statin therapy with a dcumented histry f crnary, cerebral r peripheral vascular disease Angitensin Cnverting Enzyme (ACE) inhibitr with chrnic heart failure fllwing acute mycardial infarctin Beta-blcker

9 with chrnic stable angina fllwing an episde f ACS if n cntra-indicatins Prtn pump inhibitr with aspirin and warfarin in cmbinatin Natinal and lcal guidance e.g. NICE Guidelines ELHT Falls Preventin Refer t lcal guidance available in the intranet and encurage the use f medicatin review sheets n drug charts at ELHT. Each ward has a falls champin t fllw this input up. Search: Slips, trips and falls preventin plicy n Trust intranet Statin Therapy The current NHS East Lancashire Medicines Management Bard Lipid Mdificatin Prescribing Guidelines are available frm the Medicines Management intranet pages 6. These guidelines d nt specify degree f independence r life expectancy - the decisin t start a statin is between the clinician and patient. Simvastatin 40 mg is the treatment f chice in mst scenaris. Dse and chice f statin shuld n lnger be based n target chlesterl, except in diabetes. Maximum dse f simvastatin is 20mg at night when given with cncmitant amldipine, verapamil, diltiazem, amidarne NICE CG127 Hypertensin NICE CG36 Atrial Fibrillatin

10 Respiratry System BNF Sectin 3 STOPP Thephylline as mntherapy fr COPD safer, mre effective alternative; risk f adverse effects due t narrw therapeutic index ral thephylline if patient n aminphylline infusin risk f txicity if ral cntinued during i/v therapy; risk f adverse effects due t narrw therapeutic index Systemic crticsterids instead f inhaled crticsterids fr maintenance therapy in mderate-severe COPD unnecessary expsure t lng-term side-effects f systemic sterids Nebulised ipratrpium Prescribing as required (prn) in additin t regular Can lead t exceeding licensed dsage and therefre exacerbate side effects with glaucma may exacerbate glaucma Adapted masks can be used t reduce direct ptical expsure t ipratrpium First generatin antihistamines Stp if patient has fallen in past 3 mnths sedative, may impair sensrium Carbcisteine if n benefit after 4 weeks unnecessary if n benefit shwn Antibitics Review i/v antibitics after 48 hurs and switch t ral if pssible Cultures and sensitivities may be available by this pint; if i/v antibitics cntinue beynd 48 hurs review daily

11 START Respiratry System BNF Sectin 3 Beta- 2 agnist r antichlinergic (antimuscarinic) agent fr mild t mderate asthma r COPD Review patients with mild r mderate COPD at least nce a year, and severe r very severe COPD (FEV 1 <50% predicted) at least twice a year. Fllw NICE guidance regarding treatment selectin Calcium supplement and bisphsphnate in patients at high risk f steprsis due t lng term treatment with sterids Spacer fr MDI devices fr patients struggling with inhaler technique and/r with dexterity prblems T reduce incidence f ral thrush resulting frm inhaled crticsterids Natinal and lcal guidance e.g. NICE Guidelines NICE CG 101 COPD 5 Oxygen Assess the need fr xygen therapy in peple with any f the fllwing: -very severe airflw bstructin (FEV 1 <30% predicted) -cyansis -plycythaemia -peripheral edema -raised jugular venus pressure -xygen saturatins less than r equal t 92% breathing air Give peple at risk f exacerbatins a curse f antibitic and ral crticsterid tablets t keep at hme. Thephylline Only ffer thephylline after trials f shrt- and lng- acting brnchdilatrs r t peple wh cannt use inhaled therapy.

12 Lcal guidance available n intranet Hme page: Plicies and prcedures>guidelines>medicines and prescribing>aminphylline lading and maintenance dsing Oral Crticsterids Maintenance use f ral crticsterid therapy in COPD is nt nrmally recmmended. Sme peple with advanced COPD may need maintenance ral crticsterids if treatment cannt be stpped after an exacerbatin. Keep the dse as lw as pssible, mnitr fr steprsis and ffer prphylaxis.

13 Central Nervus System & Psychtrpic Drugs BNF Sectin 4 STOPP Tricyclic antidepressants (TCAs) NB. In mst cases these drugs shuld be withdrawn gradually** with dementia risk f wrsening cgnitive impairment with glaucma likely t exacerbate glaucma with cardiac cnductive abnrmalities pr-arrhythmic effects with cnstipatin likely t wrsen cnstipatin with an piate r calcium channel blcker risk f severe cnstipatin with prstatism r prir histry f urinary retentin risk f urinary retentin Benzdiazepines NB. In cases where a patient has been n benzdiazepine fr a prlnged perid they shuld be withdrawn very slwly** if lng-term (i.e. > 1 mnth) and lng-acting (e.g. chlrdiazepxide, xazepam, nitrazepam) and benzdiazepines with lng-acting metablites (e.g. diazepam) risk f prlnged sedatin, cnfusin, impaired balance, falls if fallen in past 3 mnths Antipsychtics (Neurleptics) lng-term (i.e. > 1 mnth) as hypntics risk f cnfusin, hyptensin, extra-pyramidal side effects, falls lng-term ( > 1 mnth) in thse with parkinsnism likely t wrsen extra-pyramidal symptms

14 if fallen in past 3 mnths may cause gait dyspraxia, Parkinsnism When used inapprpriately in dementia patients Small increase in risk f CVA Phenthiazines (e.g. prchlrperazine, chlrprmazine) in patients with epilepsy may lwer seizure threshld Antichlinergics t treat extra-pyramidal side-effects f neurleptic medicatins risk f antichlinergic txicity, including cnfusin and urinary retentin Selective sertnin re-uptake inhibitrs (SSRI s) with a histry f clinically significant hypnatraemia (<130 mml/l within the previus 2 mnths) SSRIs can cause/wrsen hypnatraemia First generatin antihistamines (e.g.diphenhydramine, chlrphenamine, cyclizine) if prlnged use (> 1 week) risk f sedatin and anti-chlinergic side effects cyclizine cautined in heart failure Opiids Use f lng-term strng piates as first line therapy fr mild-mderate pain (WHO analgesic ladder nt bserved) Regular piates fr mre than 2 weeks in thse with chrnic cnstipatin withut cncurrent use f laxatives risk f severe cnstipatin lng-term in thse with dementia unless fr palliative care r management f chrnic pain syndrme exacerbatin f cgnitive impairment

15 START Central Nervus System and Psychtrpic Drugs BNF Sectin 4 Levdpa in idipathic Parkinsn s disease with definite functinal impairment and resultant disability specialist initiatin nly, refer where necessary Antidepressant drug in the presence f mderate-severe depressive symptms lasting at least three mnths Laxatives In patients taking piids Prevent cnstipatin Natinal and lcal guidance e.g. NICE Guidelines NICE CG90 Depressin in Adults 5 The first step in mild depressin is nt rutinely t prescribe e.g. ffer CBT **Welsh MeReC Gives guidance n stpping benzdiazepines, antidepressants and antipsychtics available at End f life care See the East Lancashire guidelines fr the management f symptms in the last days f life n the intranet fr mre details Hme page: Plicies and prcedure> Guidelines > Medicines & prescribing WHO analgesic ladder Mild Opiid: cdeine, dihydrcdeine, tramadl, buprenrphine Strng Opiid: mrphine, diamrphine, xycdne, fentanyl, pethidine

16 NICE TG42 Dementia 5 Cvers the use f acetylchlinesterase inhibitrs and memantine in dementia TA217 Alzheimer s disease 5 In elderly patients with dementia, antipsychtic drugs are assciated with a small increased risk f mrtality and an increased risk f strke r transient ischaemic attack. Furthermre, elderly patients are particularly susceptible t pstural hyptensin and t hyper- and hypthermia in ht r cld weather. 6 Refer t NHS actin

17 Endcrine System BNF Sectin 6 STOPP Glibenclamide r chlrprpamide with Type 2 diabetes mellitus risk f prlnged hypglycaemia Beta-blckers in thse with diabetes mellitus and frequent hypglycaemic episdes i.e. > 1 episde per mnth risk f masking hypglycaemic symptms Oestrgens with a histry f breast cancer r venus thrmbemblism increased risk f recurrence withut prgestgen in patients with intact uterus risk f endmetrial cancer Piglitazne in patients with heart failure r at risk f heart failure increased incidence f heart failure with piglitazne Metfrmin in patients with egfr<30 risk f acidsis; use metfrmin with cautin if egfr <45

18 START Endcrine System BNF Sectin 6 Metfrmin with type 2 diabetes +/- metablic syndrme (in the absence f renal impairment - egfr <50mL/ minute) ACE inhibitr r Angitensin Receptr Blcker (ARBs) in diabetes with nephrpathy i.e. vert urinalysis prteinuria r micralbuminuria (>30mg/24 hurs) +/- serum bichemical renal impairment - egfr <50mL/minute Antiplatelet therapy in diabetes mellitus if ne r mre c-existing majr cardivascular risk factrs present (hypertensin, hyperchlesterlaemia, smking histry) Statin therapy in diabetes mellitus if ne r mre c-existing majr cardivascular risk factr present Natinal and lcal guidance e.g. NICE Guidelines NICE CG87 Type 2 Diabetes 5 Cvers: ffering lifestyle advice as well as medicatin t achieve individually set HbA1c levels (and nt t pursue highly intensive management t levels f less than 6.5%) self-mnitring f bld glucse nly when it can be used as part f the verall management which medicatin t use NHS East Lancashire Medicines Management Bard Lipid Mdificatin Prescribing Guidelines Available frm the Medicines Management intranet pages 6. See cardivascular sectin f this guidance.

19 Urgenital System BNF Sectin 7 STOPP Bladder antimuscarinic drugs with dementia with chrnic glaucma risk f increased cnfusin, agitatin risk f acute exacerbatin f glaucma with chrnic cnstipatin with chrnic prstatism risk f exacerbatin f cnstipatin risk f urinary retentin Alpha-blckers in males with frequent incntinence i.e. ne r mre episdes f incntinence daily risk f urinary frequency and wrsening f incntinence with lng-term urinary catheter in situ i.e. mre than 2 mnths drug nt indicated Natinal and lcal guidance e.g. NICE Guidelines NICE CG40 Urinary Incntinence in Wmen 5 There is evidence t supprt the use f pelvic flr muscle training and bladder training ahead f medicatin (see table belw). Pelvic flr muscle training Bladder training Antimuscarinic treatment Stress UI Mixed UI Urge UI r OAB First pregnancy * * * * * * * Immediate release xybutynin shuld be ffered t wmen with veractive bladder syndrme (OAB) r mixed urinary incntinence (UI) if bladder training has been effective. There is n evidence f clinically significant differences between the antimuscarinic drugs.

20 Musculskeletal System BNF Chapter 10 STOPP Nn-steridal anti-inflammatry drug (NSAID) with histry f peptic ulcer disease r gastrintestinal bleeding, unless with cncurrent H 2 receptr antagnist, PPI risk f peptic ulcer relapse with mderate-severe hypertensin (mderate: 160/100mmHg 179/109mmHg; severe: 180/110mmHg) risk f exacerbatin f hypertensin with heart failure risk f exacerbatin f heart failure with warfarin risk f gastrintestinal bleeding with chrnic renal failure - egfr 20-50mL/minute risk f deteriratin in renal functin Lng-term use f NSAID (>3 mnths) fr relief f mild jint pain in stearthritis simple analgesics preferable and usually as effective fr pain relief Lng-term NSAID r clchicine fr chrnic treatment f gut where there is n cntraindicatin t allpurinl allpurinl first chice prphylactic drug in gut Lng-term crticsterids (>3 mnths) as mntherapy fr rheumatid arthritis r stearthritis risk f majr systemic crticsterid side-effects Cycl-xygenase-2 selective inhibitrs, diclfenac and ibuprfen in cardivascular disease Increased risk f thrmbtic events

21 Musculskeletal System BNF Chapter 10 START Disease-mdifying anti-rheumatic drug (DMARD) with active mderate-severe rheumatid disease lasting > 12 weeks Bisphsphnates in patients taking maintenance ral crticsterid therapy. Ensure there are n absrptin interactins with e.g. Calcium. Cunsel patient n the crrect way t take a bisphsphnate Calcium and Vitamin D supplement in patients with knwn steprsis (radilgical evidence r previus fragility fracture r acquired drsal kyphsis). Cnsider making dse times at lunch & teatime t avid absrptin interactins e.g. with levthyrxine, bisphsphnate 400 units fr preventin f deficiency and 800 units fr treatment Natinal and lcal guidance e.g. NICE Guidelines NICE TA160 and TA161 Primary and Secndary Preventin f Osteprsis 5 In primary preventin, wmen aged 75 and ver d nt require a DEXA scan befre starting alendrnic acid if they have tw r mre clinical risk factrs r indicatrs f lw BMD; fr secndary preventin this is reduced t ne r mre. Fr treatments ther than alendrnic acid a DEXA scan is required because the treatments are nly indicated at certain T scres; unless, in secndary preventin, the clinician cnsiders it inapprpriate r unfeasible. Wund Management The current NHS ELMMB Jint Wund Care Frmulary is available frm the Medicines Management intranet pages 6. If after using a silver prduct fr 1-2 weeks, n imprvement in the wund is seen, then a full reassessment f the wund and patient shuld be undertaken. Vitamin D deficiency Lcal guidance available n East Lancashire Medicines Management Bard website

22 References 1. Gallagher P, Ryan C, Byrne S, Kennedy J, O Mahny D. STOPP (Screening Tl f Older Persns Prescriptins) and START (Screening Tl t Alert Dctrs t Right Treatment): Cnsensus Validatin. Int J Clin Pharmacl Ther 2008; 46(2): PMID Task Frce n Medicines Partnership. Rm fr Review. A guide t medicatin review: the agenda fr patients, practitiners and managers. Medicines Partnership. Lndn Beers MH. Explicit Criteria fr Determining Ptentially Inapprpriate Medicatin Use by Elderly. An Update. Arch Intern Med. 1997;157: British Natinal Frmulary available frm: 5. NICE Guidance available frm: guidance/index.jsp 6. East Lancashire Medicines Management Bard Frmulary available frm: Special acknwledgment t NHS Cumbria n whse STOPP START tlkit this dcument was based East Lancashire Hspitals Pharmacy team December 2012