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Table 4 Selected Prescribing Criteria/Prescribing Indicator [16]

From: ‘Potentially inappropriate or specifically appropriate?’ Qualitative evaluation of general practitioners views on prescribing, polypharmacy and potentially inappropriate prescribing in older people

Criteria

Concern

Estimated prevalence in Irelanda

PPI for peptic ulcer disease at full therapeutic dosage for > 8 weeks

Earlier discontinuation or dose reduction for maintenance/ prophylactic treatment of peptic ulcer disease, oesophagitis or GORD indicated

4.1- 16.7 %

NSAID (>3 months) for relief of mild joint pain in osteoarthritis

Simple analgesics preferable and usually as effective for pain relief

1.1 - 8.8 %

Long-term (i.e. >1 month), long-acting benzodiazepines e.g. chlordiazepoxide, flurazepam, nitrazepam, chlorazepate and benzodiazepines with long-acting metabolites e.g. diazepam

Risk of prolonged sedation, confusion, impaired balance, falls

3.0-9.1 %

Any regular duplicate drug class prescription e.g. 2 concurrent opiates, NSAIDs, SSRIs, loop diuretics, ACE inhibitors. Excludes duplicate prescribing of drugs that may be required on a PRN basis e.g. Inhaled beta 2 agonists (long and short acting) for asthma or COPD, and opiates for management of breakthrough pain

Optimisation of monotherapy within a single drug class should be observed prior to considering a new class of drug

2.2 – 6.0 %

TCAs with an opiate or calcium channel blocker

Risk of severe constipation

0.4-2.0 %

Aspirin at dose >150 mg/day

Increased bleeding risk, no evidence for increased efficacy

0.1-1.%

Theophylline as monotherapy for COPD/Asthma

Risk of adverse effects due to narrow therapeutic index

0.6-1.2 %

Use of aspirin and warfarin in combination without histamine H2 receptor antagonist or PPI

high risk of GI bleeding

0.3-1.1 %

Doses of short-acting benzodiazepines, doses greater than: lorazepam 3 mg; oxazepam 60 mg; alprazolam 2 mg; temazepam 15 mg; and triazolam 0.25 mg

Total daily doses should rarely exceed the suggested maximums

1.0-1.5 %

Prolonged use (>1 week) of first generation antihistamines i.e. diphenydramine, chlorpheniramine, cyclizine, promethazine

Risk of sedation and anticholinergic side effects

<1.0 %

Warfarin and NSAID together

Risk of GI bleeding

0.7-1.7 %

Calcium channel blockers with chronic constipation

May exacerbate constipation

<1.0 %

NSAID with history of peptic ulcer disease or GI bleeding, unless with concurrent histamine H2 receptor antagonist, PPI or misoprostol

Risk of peptic ulcer relapse

<1.0 %

Bladder antimuscarinic drugs with dementia

Risk of increased confusion, agitation

<1.0 %

TCAs with constipation

May worsen constipation

<1.0 %

Digoxin at a long-term dose > 125 μg/day (with impaired renal function)

Increased risk of toxicity

<1.0 %

<1.0 %

Thiazide diuretic with a history of gout

May exacerbate gout

<1.0 %

Glibenclamide (with type 2 diabetes mellitus)

Risk of prolonged hypoglycaemia

<1.0 %

Aspirin with a past history of peptic ulcer disease without histamine H2 receptor antagonist or PPI

Risk of bleeding

<1.0 %

Prochlorperazine or metoclopramide with Parkinsonism

Risk of exacerbating Parkinsonism

<1.0 %

TCAs with dementia

Risk of worsening cognitive impairment

<1.0 %

TCAs with glaucoma

Likely to exacerbate glaucoma

<1.0 %

TCAs with cardiac conductive abnormalities

Pro-arrhythmic effects

<1.0 %

Long-term corticosteroids (>3 months) as monotherapy for rheumatoid arthritis or osteoarthritis

Risk of major systemic corticosteroid side-effects

<1.0 %

Bladder antimuscarinic drugs with chronic prostatism

Risk of urinary retention

<1.0 %

NSAID with heart failure

Risk of exacerbation of heart failure

<1.0 %

TCAs with prostatism or prior history of urinary retention

Risk of urinary retention

<1.0 %

Systemic corticosteroids instead of inhaled corticosteroids for maintenance therapy in COPD/Asthma

Unnecessary exposure to long-term side-effects systemic steroids

<1.0 %

Bladder antimuscarinic drugs with chronic glaucoma

Risk of acute exacerbation of glaucoma

<0.01 %

NSAID with SSRI

Increased risk of GI bleed

N/A

Bladder antimuscarinic drugs with chronic constipation

Risk of exacerbation of constipation

N/A

Prednisolone (or equivalent) > 3 months or longer without bisphosphonate

Increased risk of fracture

N/A

NSAID with ACE-inhibitor

Risk of kidney failure, particularly if presence of general arteriosclerosis, dehydration or concurrent use of diuretics

N/A

NSAID with diuretic

May reduce the effect of diuretics and worsen existing heart failure

N/A

  1. Abbreviations – ACEI angiotensin-converting-enzyme inhibitor, COPD chronic obstructive pulmonary disease, GI gastro-intestinal, NA not available, GORD gastro-oesophageal reflux disease, NSAID Nonsteroidal anti-inflammatory drug, PPI Proton Pump Inhibitor, PRN Pro re nata, as needed, SSRI Selective serotonin reuptake inhibitor, TCA Tricyclic Anti-depressant
  2. aPrevalence – the proportion of the study population with 1 or more potentially inappropriate medications from the literature