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Table 2 Selected prescribing criteria and indicators

From: Effectiveness of medicines review with web-based pharmaceutical treatment algorithms in reducing potentially inappropriate prescribing in older people in primary care: a cluster randomized trial (OPTI-SCRIPT study protocol)

Criterion

Concern

Prevalence in Ireland*

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

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

16.69% [11]

7.68% [49]

4.06% [10]

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

Simple analgesics are preferable and usually as effective for pain relief

8.76% [11]

1.05% [49]

1.26% [10]

Long-term (>1 month), long-acting benzodiazepines, for example, chlordiazepoxide, flurazepam, nitrazepam and clorazepate, and benzodiazepines with long-acting metabolites, for example, diazepam

Risk of prolonged sedation, confusion, impaired balance, falls

5.22% [11]

5.19% [49]

3.00% [49]

6.01% [10]

9.09% [10]

Any regular duplicate drug class prescription, for example, two concurrent opiates, NSAIDs, SSRIs, loop diuretics, ACE inhibitors. Excludes duplicate prescribing of drugs that may be required on a p.r.n. basis, for example, inhaled β2 agonists (long and short acting) for asthma or COPD, and opiates for management of breakthrough pain

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

4.78% [11]

2.18% [49]

6.01% [10]

TCAs with an opiate or calcium channel blocker

Risk of severe constipation

2.05% [11]

0.37% [49]

Aspirin at dosage >150 mg/day

Increased bleeding risk, no evidence for increased efficacy

1.69% [11]

0.3% [49]

0.14% [10]

Theophylline as monotherapy for COPD or asthma

Risk of adverse effects due to narrow therapeutic index

1.18% [11]

0.56% [10]

Use of aspirin and warfarin in combination without histamine H2 receptor antagonist (except cimetidine because of interaction with warfarin) or PPI

High risk of GI bleeding

1.09% [11]

0.3% [49]

Doses of short-acting benzodiazepines, doses greater than: lorazepam (Ativan®), 3 mg; oxazepam (Serax®), 60 mg; alprazolam (Xanax®), 2 mg; temazepam (Restoril®), 15 mg; and triazolam (Halcion®), 0.25 mg

Total daily doses should rarely exceed the suggested maximums

0.98% [49]

1.54% [10]

Prolonged use (>1 week) of first-generation antihistamines, that is, diphenhydramine, chlorpheniramine, cyclizine, promethazine

Risk of sedation and anticholinergic side-effects

0.96% [11]

0.15% [49]

Warfarin and NSAID together

Risk of GI bleeding

0.75% [11]

1.68% [10]

Calcium channel blockers with chronic constipation

May exacerbate constipation

0.68% [49]

0.28% [10]

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

0.67% [49]

0.42% [10]

Bladder antimuscarinic drugs with dementia

Risk of increased confusion, agitation

0.46% [11]

0.84% [10]

TCAs with constipation

May worsen constipation

0.45% [49]

0.14% [10]

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

Increased risk of toxicity

0.36% [11]

0.15% [49]

0.55% [10]

Thiazide diuretic with a history of gout

May exacerbate gout

0.36% [11]

0.45% [49]

0.14% [10]

Glibenclamide (with type 2 diabetes mellitus)

Risk of prolonged hypoglycaemia

0.29% [11]

0.22% [49]

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

Risk of bleeding

0.22% [49]

0.28% [10]

Prochlorperazine (Stemetil®) or metoclopramide with parkinsonism

Risk of exacerbating parkinsonism

0.21% [11]

TCAs with dementia

Risk of worsening cognitive impairment

0.18% [11]

0.28% [10]

TCAs with glaucoma

Likely to exacerbate glaucoma

0.14% [11]

0.07% [49]

TCAs with cardiac conductive abnormalities

Pro-arrhythmic effects

0.14% [10]

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

Risk of major systemic corticosteroid side-effects

0.14% [10]

Bladder antimuscarinic drugs with chronic prostatism

Risk of urinary retention

0.14% [10]

NSAID with heart failure

Risk of exacerbation of heart failure

0.07% [49]

0.14% [10]

TCAs with prostatism or prior history of urinary retention

Risk of urinary retention

0.07% [49]

0.14% [10]

Systemic corticosteroids instead of inhaled corticosteroids for maintenance therapy in COPD or asthma

Unnecessary exposure to long-term side-effects of systemic steroids

0.07% [49]

0.56% [10]

Bladder antimuscarinic drugs with chronic glaucoma

Risk of acute exacerbation of glaucoma

<0.01% [11]

NSAID with SSRI

Increased risk of GI bleeding

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 with the 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. ACEI, angiotensin-converting-enzyme inhibitor; COPD, chronic obstructive pulmonary disease; GI, gastro-intestinal; GORD, gastro-oesophageal reflux disease; N/A, not available; NSAID, nonsteroidal anti-inflammatory drug; PPI, proton pump inhibitor; p.r.n., pro re nata, as needed; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic anti-depressant. *Prevalence: the proportion of the study population with one or more potentially inappropriate medications.