Table 4.

STOPP: screening tool of older persons’ potentially inappropriate prescriptions^a,⁴³,⁴⁴

System	Drug or drug class	Conditions and concerns (in italics)
Cardiovascular	Aspirin	In combination with warfarin without a histamine type 2 receptor antagonist (except cimetidine due to warfarin interaction) or PPI due to high risk of GI bleeding. With a past history of PUD without a histamine 2 receptor antagonist due to risk of bleeding. In doses exceeding 150 mg/day due to increased bleeding risk and lack of evidence for increased efficacy. With no history of coronary, cerebral, or peripheral vascular symptoms or occlusive event as aspirin is not indicated. To treat dizziness not clearly attributable to cerebrovascular disease as aspirin is not indicated. With concurrent bleeding disorder due to high risk of bleeding.
	β-blockers	With COPD due to risk of increased bronchospasm. In combination with verapamil due to increased risk of symptomatic heart block.
	Calcium channel blockers	Use of verapamil or diltiazem in patients with NYHA class III or IV heart failure due to increased risk of toxicity. With chronic constipation as this may exacerbated constipation.
	Clopidogrel	With concurrent bleeding disorder due to high risk of bleeding.
	Digoxin	For long term use in doses >125 mcg/day with impaired renal function (GFR < 50 ml/min) due to increased risk of toxicity.
	Dipyridamole	As monotherapy for cardiovascular secondary prevention due to lack of evidence. With concurrent bleeding disorder due to high risk of bleeding.
	Loop diuretics	For dependent ankle edema only (ie, no clinical signs of heart failure) due to lack of evidence and compression hosiery usually more appropriate.
	Thiazide diuretics	With a history of gout as this may exacerbate gout.
	Warfarin	In combination with aspirin without a histamine type 2 receptor antagonist (except cimetidine due to warfarin interaction) or PPI due to high risk of GI bleeding. For 1st uncomplicated pulmonary embolism for longer than 12 months duration due to lack of proven benefit. With concurrent bleeding disorder due to high risk of bleeding.
CNS	Anticholinergics	To treat extra-pyramidal side effects of neuroleptic medications due to risk of anticholinergic toxicity.
	Antihistamines (first generation): diphenydramine, chlorpheniramine, cyclizine, promethazine	Prolonged use (>1 week) due to risk of sedation and anticholinergic side effects.
	Benzodiazepines (long-acting): chlordiazepoxide, fluazepam, nitrazepam, chlorazepate	Avoid due to high risk of prolonged sedation, confusion, impaired balance, and falls.
	Benzodiazepines (with long metabolites): dizaepam	Avoid due to high risk of prolonged sedation, confusion, impaired balance, and falls.
	Neuroleptics	With long term use of >1 month due to high risk of confusion, hypotension, extra-pyramidal side effects, and falls. With long term use of >1 month in patients with Parkinson’s disease due to risk worsening, extra-pyramidal symptoms.
	Phenothiazines	In patients with epilepsy as phenothiazines may lower seizure threshold.
	SSRIs	With a history of clinically significant hyponatremia defined as noniatrogenic sodium <130 meq/L within the previous two months.
	TCAs	With dementia due to risk of worsening cognitive impairment. With glaucoma as TCAs may exacerbate glaucoma. With cardiac conduction abnormalities due to TCAs’ pro-arrhythmic effects. With constipation as TCAs may worsen constipation. With opiate or calcium channel blockers as TCAs may worsen constipation. With prostatism or prior history of urinary retention due to increased risk of urinary retention.
GI	Anticholinergic antispasmodic drugs	With chronic constipation due to risk of constipation exacerbation.
	Diphenoxylate, loperamide, or codeine phosphate	For treatment of diarrhea of unknown cause due to risk of delayed diagnosis, possible exacerbation of constipation with overflow diarrhea, precipitation of toxic megacolon in inflammatory bowel disease, and delayed recovery in unrecognized gastroenteritis. For treatment of severe infective gastroenteritis (ie, bloody diarrhea, high fever or severe systemic toxicity) due to risk of exacerbation or protraction of infection.
	Prochlorperazine, metoclopramide	With Parkinsonism due to risk of exacerbating Parkinsonism.
	PPIs	For PUD at full therapeutic dosage for >8 weeks.
Respiratory	Corticosteroids (systemic)	For maintenance therapy in moderate to severe COPD instead of inhaled corticosteroids due to unnecessary exposure to long-term side effects of systemic steroids.
	Ipratropium (nebulized)	In patients with glaucoma due to possible glaucoma exacerbation.
	Theophylline	As monotherapy for COPD as more safer, more effective alternatives exist and the risk of adverse effects due to narrow therapeutic index.
Musculoskeletal	NSAIDs	With a history of PUD or GI bleeding, unless with concurrent histamine type 2 receptor blocker, PPI or misoprostol due to risk of PUD relapse. With moderate (160/100–179/109 mmHg) or severe (>180/110 mmHg) hypertension due to risk of exacerbation of hypertension. With heart failure due to risk of heart failure exacerbation. With warfarin concomitantly due to risk of GI bleeding. With chronic renal failure (GFR 20–50 ml/min) due to risk of deterioration in renal function. With long-term use (>3 months) for relief of mild joint pain in osteoarthritis as simple analgesics preferable and usually as effective for pain relief.
	Colchicine	For chronic treatment of gout where there is no contraindication to allopurinol as allopurinol is considered first choice for prophylaxis in gout.
	Corticosteroids	For chronic treatment of gout where there is no contraindication to allopurinol as allopurinol is considered first choice for prophylaxis in gout. As long-term (>3 months) monotherapy for rheumatoid arthritis or osteoarthritis due to risk of major systemic corticosteroid side-effects.
Urogenital	Antimuscarinic drugs	With dementia due to risk of increased confusion and agitation. With chronic glaucoma due to risk of acute exacerbation of glaucoma. With chronic constipation due to risk of exacerbation of constipation. With chronic prostatism due to risk of urinary retention.
	α-blockers	In males with frequent incontinence (ie, one or more episodes of incontinence daily) due to risk of urinary frequency and worsening incontinence. With long term urinary catheter in situ (ie, more than two months) as drug is not indicated.
Endocrine	Chlorpropamide or glibenclamide	With type 2 diabetes due to risk of prolonged hypoglycemia.
	β-blockers	In those with diabetes mellitus and frequent hypoglycemic episodes (ie, ≥1 episodes/month) due to risk of masking hypoglycemic symptoms.
	Estrogen	With a history of breast cancer or VTE due to increased risk of recurrence. Without progestogen in patients with intact uterus due to risk of endometrial cancer.
Drug issues
Analgesic drugs	Opiates	Use of long-term power opiates (eg, morphine or fentanyl) as first line therapy for mild-moderate pain as WHO analgesic ladder is not observed. Regular use for more than two weeks in those with chronic constipation without use of laxitatives due to risk of severe constipation. Long-term use in those with dementia unless indicated for palliative care or management of moderate-severe chronic pain syndrome due to risk of exacerbation of cognitive impairment.
Duplicate drug class	ACE inhibitors Loop diuretics NSAIDs Opiates SSRIs	Use of any two concurrent duplicate medications as optimization of monotherapy within a single drug class should be observed prior to considering a new drug class.
Drugs adversely affecting those prone to fallsb	Antihistamines (first generation)	May cause sedation and impair sensorium.
	Benzodiazepines	May cause sedation and impair sensorium.
	Neuroleptic drugs	May cause gait dyspraxia and Parkinsonism.
	Opiates	Long-term use in those with recurrent falls due to risk of drowsiness, postural hypotension, and vertigo.
	Vasodilators (known to cause hypotension)	In those with persistent postural hypotension (ie, recurrent >20 mmHg drop in systolic blood pressure) due to risk of syncope and falls.

Abbreviations: ACE, angiotensin-converting enzyme; CNS, central nervous system; COPD, chronic obstructive pulmonary disease; GI, gastrointestinal; NYHA, New York Heart Association; NSAIDs, nonsteroidal anti-inflammatory drugs; PPIs, proton pump inhibitors; PUD, peptic ulcer disease; SSRIs, selective serotonin re-uptake inhibitors; TCAs, tricyclic antidepressants; VTE, venous thromboembolism; WHO, World Health Organization.

Notes:

^aThe following prescription drugs are potentially inappropriate in persons ages ≥65 years of age;

^b≥1 fall in the past three months.