前言 2001 2004 65 Beer's Criteria 19.1% 2001 Akazawa M (1.68 ) ( 33%) 高雄榮民總醫院家庭醫學部 potentially inappropriate medication; STOPP; START 評估工具 i m p l i c i t prescribing indicators (Medication Appropriateness Index, MAI) 370 家庭醫學與基層醫療 第九期
e x p l i c i t prescribing indicators McLeod Canadian Criteria (Defining inappropriate p r a c t i c e s i n p r e s c r i b i n g f o r e l d e r l y people) Beer's ( B e e r ' s C r i t e r i a ), S T O P P ( S c r e e n i n g To o l o f O l d e r P e o p l e ' s Potentially Inappropriate Prescriptions), START (Screening Tool to Alert Doctors to the Right Treatment for Older People) Beer's Criteria, McLeod Canadian Criteria, STOPP, START Beer's Criteria Beer's Criteria Beer's Criteria 1. 2. 3. McLeod Canadian Criteria 1997 McLeod (8 ) (12 ) (11 ) (7 ) Implicit and explicit criteria 1997 r e s e r p i n e - blockers COPD McLeod Canadian criteria STOPP 準則 2007 STOPP 18 (9 3 3 2 1 ) Delphi method 65 STOPP 家庭醫學與基層醫療 第九期 371
STOPP # Beer's Criteria A. 1. 125µg digoxin ( ). 2. ( )# 3. ( ). 4. thiazide ( )# 5. -blocker ( ). 6. -blocker verapamil ( ). 7. NYHA Class III or IV diltiazem or verapamil ( ). 8. ( ). 9. aspirin warfarin histamine H 2 receptor antagonist (cimetidine warfarin ) or proton pump inhibitor(ppi) ( ). 10. dipyridamole ( ). 11. aspirin histamine H2 receptor antagonist or PPI ( ). 12.aspirin > 150mg ( ). 13. aspirin ( ). 14. aspirin ( )# 15. warfarin 6 ( ). 16. warfarin 12 ( ). 17. aspirin, clopidogrel, dipyridamole or warfarin ( ). B. 1. ( ). 2. ( )# 3. ( " " ). 4. ( ). 5. ( ). 6. prostatism ( ) ( ). 7. ( ) benzodiazepines chlordiazepoxide, fluazepam, nitrazepam, chlorazepate benzodiazepines diazepam ( ). 8. ( 1 ) ( )# 9. ( ) (parkinsonism) ( ) 10. phenothiazines ( ). 11. ( )# 12. (SSRIs)( 2 <130mmol/l ). 13. ( ) diphenydramine, chlorpheniramine, cyclizine, promethazine ( ). 續下頁 372 家庭醫學與基層醫療 第九期
STOPP # Beer's Criteria C. 1. diphenoxylate, loperamide or codeine phosphate ( ). 2. diphenoxylate, loperamide or codeine phosphate ( ) 3.prochlorperazine or metoclopramide (parkinsonism) ( ) 4. PPI 8 ( )# 5. ( ). D. 1. ( )# 2. (COPD) ( ). 3. ipratropium ( ). E. 1. histamine H2 receptor antagonist, PPI or misoprostol( ). 2. ( ) # 3. ( )# 4. ( 3 ) ( ) 5. warfarin ( ). 6. ( )# 7. ( 3 ) ( ). 8.colchicine allopurinol( ) (allopurinol ) F. 1. bladder antimuscarinic drugs ( ). 2. bladder antimuscarinic drugs ( ). 3. bladder antimuscarinic drugs ( ). 4. bladder antimuscarinic drugs prostatism ( ). 5. -blocker ( )# 6. -blocker 2 ( ). G. 1. glibenclamide or chlorpropamide ( ). 2. -blocker ( ) ( )# 3. ( )# 4. oestrogens progestogen( ). H. ( ) 1.benzodiazepines ( ). 續下頁 家庭醫學與基層醫療 第九期 373
STOPP # Beer's Criteria 2. ( )# 3. ( ). 4.>20mmHg( )# 5. ( ). I. 止痛藥物 1. morphine or fentanyl ( 2.WHO analgesic ladder ). 3. ( 2 ) ( )# 4.( ) ( ). J. 重複用藥 (ACEIs) ( )# 2-agonists estimated GFR <50ml/min. 資料來源 : 參考資料 8 - - Gallagher 2008 STOPP Beer's Criteria 715 STOPP Beer's Criteria 77 6 STOPP 336 247 4 7 Beer's Criteria 226 177 43 STOPP Beer's Criteria STOPP STOPP Beer's criteria STOPP Beer's Criteria # START 準則 START START 22 600 START 57.9% statins ( ) (26%) warfarin( ) (9.5%) 374 家庭醫學與基層醫療 第九期
START A. 心血管系統 1. warfarin 2. warfarin aspirin 3. aspirin or clopidogrel 4. 160 mmhg 5. statin 6. (ACEIs) 7. 8. -blocker B. 呼吸系統 1. 2-agonists 2. 3. (PO2<8.0kPa, PCO2 <6.5kPa) (PO2< 8.0kPa, PCO2> 6.5kPa) C. 中樞神經系統 1. L-DOPA (idiopathic Parkinson's disease, ) 2. D. 消化道系統 1. PPI 2. E. 骨骼肌肉系統 1. disease-modifying anti-rheumatic drug (DMARD) 12 2. bisphosphonate 3. ( ) D F. 內分泌系統 1. metformin ( *) 2. ACEI angiotension receptor blocker(arb) overt dipstick proteinuria or microalbuminuria (>30 mg/24 h) serum biochemical renal impairment*. 3. ( ) aspirin 4. statin estimated GFR <50ml/min. 資料來源 : 參考資料 8 家庭醫學與基層醫療 第九期 375
( ) (7.3%) D( ) (6%) 結論 參考資料 1. Juurlink DN, Mamdami M, Kopp A et al: Drug-drug interactions among elderly patients hospitalised for drug toxicity. JAMA 2003; 289: 1652. 2. Lai HY, Hwang SJ, Chen YC, Chen TJ, Lin MH, Chen LK: Prevalence of the Prescribing of Potentially Inappropriate Medications at Ambulatory Care Visits by Elderly Patients Covered by the Taiwanese National Health Insurance Program. Clinical Therapeutics 2009; 31: 1859-70. 3. Goldberg RM, Mabee J, Chan L, Wong S: Drug-drug and drug-disease interactions in the emergency department: analysis of a high-risk population. Am J Emerg Med 1996; 14: 447 50. 4. Mangoni AA, Jackson SHD: Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. Br J Clin Pharmacol 2003; 57: 6 14. 5. Fick DM, Cooper JW, WadeWet al.: Updating the beers criteria for potentially inappropriate medication use in older adults results of a US consensus panel of experts. Arch Intern Med 2003; 163: 2716 24. 6. Gallagher P, O Mahony D: STOPP (Screening Tool of Older Persons Potentially Inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beer;s criteria. Age Aging 2008;37:673-9. 7. G a l l a g h e r P, R y a n C, B y r n e S e t a l. : STOPP (Screening Tool of Older Persons Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment): consensus validation. Int J Clin Pharm Ther 2008; 46: 72 83. 8. Barry P, Gallagher P, Ryan C, O Mahony D: START (Screening Tool to Alert Doctors to Right Treatment). An evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing 2007; 36: 628 31. 9. Akazawa M, Imai H, Igarashi A, Tsutani K: Potentially inappropriate medication use in elderly Japanese patients. Am J Geriatr Pharmacother. 2010; 8:146-60. 10. McLeod PJ, Huang AR, Tamblyn RM, Gayton DC: Defining inappropriate practices in prescribing for elderly people: a national consensus panel. CMAJ. 1997; 156:385-91. 376 家庭醫學與基層醫療 第九期