“Consensus Based” Alternative Recommendations Are Disconcerting

The PRISCUS List is a very important instrument for the evaluation of medications for elderly people (1). Such lists have an enormous standardizing effect—non-adherence will have to be supported by sound reasons in case of a dispute. This is especially so for drugs that were unequivocally categorized as “potentially inadequate medication” (PIM). We were involved in the development process of the list—and we still have concerns regarding the substances named as alternatives to the PIM. The consensus process does not always allow for sufficient discussion. The following examples of “consented” alternative recommendations, however, seem disconcerting to us:

• Melatonin is a largely ineffective substance that is barely prescribable, which is suggested as an alternative to levomepromazine and promethazine in sleep disorders. The potential for harm caused by those two substances is undisputed—pharmacological measures should not have been recommended as an alternative.

• DPP4 inhibitors are suggested as alternatives for sulfonylureas. Their potentially most severe adverse effect—hypoglycemia—is well known. Instead of suggesting a largely ineffective substance (2), the guideline conform alternative is aiming for higher targets for glycated hemoglobin in older persons.

• Potential adverse effects of tricyclic antidepressants are a problem. The suggested alternative, however—citalopram—is just as poorly tolerated (3).

• Memantine is named as an alternative to pentoxifylline and naftidrofuryl, pyritinol and piracetam, as well as ginkgo, nicergoline, and nimodipine. Memantine is licensed with restrictions only for moderate to severe dementia—and was withdrawn from the market in France because of its lack of effectiveness (4).

We worry that healthcare provision for older people will not improve if prescribing behavior changes as a result of the PRISCUS List without satisfactory proof of benefit for the suggested alternatives.