Table 4.
Criteria usage information
| Criteria number | Description of issue | Details |
|---|---|---|
| 1 | Blood pressure targets (mm Hg) | Proteinuria >1 g/day (with or without diabetes) <125/75. CHD, diabetes, chronic kidney disease, proteinuria (>300 mg/day), stroke or TIA<130/80. Others <140/90.39 Current blood pressure guidelines may not be appropriate for all older patients, such as the oldest old; in palliative care; and for those who are/become hypotensive and/or fall47 49–52 73 |
| 2 | Patients at high risk of a cardiovascular event (>15% within the next 5 years) | Age >75 years; history of diabetes, moderate or severe chronic kidney disease (persistent proteinuria, GFR<60 ml/min, eGFR<45 ml/min/1.73 m2), hypercholesterolaemia (familial, TC>7.5 mmol/l), SBP≥180 or DBP≥110 mm Hg, ISH (SBP≥160 and DBP≤70 mm Hg), CHD, stroke, TIA, PAD, heart failure, aortic disease, LVH, family history of premature CVD.39 74 The benefits of statins and risks of adverse effects are uncertain towards the end of life75 |
| 4 | Antiplatelet agents and oral anticoagulants | Antiplatelet agents: aspirin, clopidogrel, dipyridamole and ticlopidine. Oral anticoagulants: dabigatran, phenindione, rivaroxaban and warfarin |
| 5 | Use of ACEI or A2A in CHD | A high incidence of comorbid disease in CHD (typically arthritis and/or respiratory disease) or other clinical factors (eg, dizziness or falls, cognitive impairment, use of >5 medicines, patient preference) may be considerations in determining medication prescribing priorities30 34 72 |
| 8 | Medications that may exacerbate heart failure | HF-LVSD: anti-arrhythmic medicines (except for heart failure-specific β-blockers and amiodarone), non-dihydropyridine calcium-channel blockers (eg, verapamil or diltiazem), clozapine, corticosteroids, NSAIDs (excluding low-dose aspirin), thiazolidinediones, TNF-α inhibitors, topical β-blockers (when added to systemic β-blockers), tricyclic antidepressants.49 76 77 HFPEF: venodilators (eg, isosorbide dinitrate), potent arterial vasodilators (eg, hydrallazine), digoxin (unless AF), excessive use of diuretics. Note; verapamil and diltiazem may improve diastolic function in HFPEF60 |
| 9 | Stroke risk and bleeding risk | Stroke risk can be calculated using CHADS2 or CHA2DS2-VASc.78 Risk factors for coumarin-related bleeding complications: advanced age, uncontrolled hypertension, history of MI or IHD, cerebrovascular disease, anaemia or a history of bleeding, concomitant use of aspirin/polypharmacy79 |
| 12 | Risk factors for statin myopathy; high dose of high-potency statins | Age >70 years, presence of disease states (diabetes, hypothyroidism, renal and hepatic disease), concurrent use of ciclosporin, fibrates, CYP3A4 inhibitors (eg, diltiazem, macrolides, protease inhibitors, verapamil (except for pravastatin and rosuvastatin), severe intercurrent illness (infection, trauma and metabolic disorder), dose≥40 mg daily. High dose of high-potency statins ; ≥40 mg atorvastatin or simvastatin; >10 mg rosuvastatin39 80 |
| 14 | Smoking cessation options | Counselling (extended, brief, telephone), support services (professional, family, social, work), pharmacotherapy |
| 17 | Medications that may affect glycaemic control | Increase blood glucose: baclofen, clozapine, ciclosporin, glucocorticoids, haloperidol, olanzapine, paliperidone, phenytoin, protease inhibitors, quetiapine, risperidone, sirolimus, tacrolimus and tricyclic antidepressants. Decrease blood glucose: excessive alcohol, disopyramide, perhexiline, quinine, trimethoprim/sulphamethoxazole39 |
| 18 | Six-monthly HbA1c measurements | Treatment intensification in response to less than optimally controlled HbA1c may be inappropriate in patients with limited life expectancy or in frail older patients81 82 |
| 19 | Metformin dose | Based on creatinine clearance: 60–90 ml/min, maximum 2 g daily; 30–60 ml/min, maximum 1 g daily; <30 ml/min avoid use.39 Based on eGFR: review dose if eGFR<45 ml/min/1.73 m2; avoid if eGFR<30 ml/min/1.73 m2 83 |
| 24 | Risk factors for impaired renal function | Volume depletion, age >60 years, salt-restricted diet, concomitant use of ACEIs, A2As, ciclosporin or aspirin, GFR ≤60 ml/min, cirrhosis, heart failure84 |
| 26 | Benzodiazepine use | Benzodiazepines increase the risk of oversedation, ataxia, confusion, falls, respiratory depression and short-term memory impairment, and are recommended for short-term use only39 |
| 27 | Falls and psychotropic medications | Psychotropic medications=antidepressants (all), anxiolytics/hypnotics, antipsychotics.85 86 Medications causing (postural) hypotension (eg, cardiovascular medicines) or cognitive impairment (eg, opioids) may also increase the risk of falls49 87 |
| 28 | Medications that may contribute to serotonin syndrome | Antidepressants: desvenlafaxine, duloxetine, St John's wort, MAOIs (including moclobemide), SSRIs, TCAs, venlafaxine. Opioids: dextromethorphan, fentanyl, pethidine, tramadol. Others: selegiline, linezolid, lithium, tryptophan39 |
| 29 and 30 | Medications with significant anticholinergic activity | Amantadine, amitriptyline, atropine*, belladonna alkaloids*, benzhexol, benztropine, biperiden, brompheniramine*, chlorpheniramine, chlorpromazine, clomipramine, clozapine, cyclizine, cyclopentolate, cyproheptadine*, darifenacin, dexchlorpheniramine*, dimenhydrinate*, diphenhydramine*, disopyramide, dothiepin, doxepin, glycopyrrolate, homatropine, hyoscine* (butylbromide or hydrobromide), imipramine, ipratropium (nebulised), mianserin, nortriptyline, olanzapine, orphenadrine, oxybutynin, pericyazine, pheniramine*, pimozide, pizotifen, prochlorperazine, promethazine*, propantheline, solifenacin, tiotropium, tolterodine, trimeprazine*, trimipramine, triprolidine*, tropicamide (*available over-the-counter in Australia)39 |
| 31 | Medications that may cause dyspepsia | Drugs with anticholinergic effects, aspirin, benzodiazepines, bisphosphonates, calcium channel antagonists, oral corticosteroids, dopaminergic drugs, doxycycline, erythromycin, ferrous sulphate, nitrates, NSAIDs, potassium chloride (slow release)38 39 49 88 |
| 35 | Medications that may worsen asthma | Aspirin, β-blockers (including eye drops), carbamazepine, echinacea, NSAIDs, royal jelly39 89 |
| 38 | Non-specific URTI | Acute bronchitis, pharyngitis, tonsillitis, non-suppurative otitis media and sinusitis38 |
| 39 | Appropriate antiosteoporotic medication | RDI of calcium from dietary sources and/or supplements=1300–1500 mg daily. RDI for vitamin D from sunlight and/or dietary sources and/or supplements=600 IU daily. Antiosteoporotic medication=bisphosphonates, calcitriol, denosumab, HRT, raloxifene, strontium, teriparatide.39 Evidence for fracture risk reduction in women ≥75 years is either absent or lacking in NVF for alendronate, risedronate and teriparatide, and in HF for alendronate, risedronate, zoledronic acid and teriparatide. There are no data available for denosumab in VF, NVF or HF.90 The optimal duration of bisphosphonate therapy is uncertain. Evidence supports the use of strontium for 5 years, raloxifene for 4 years and zoledronic acid and denosumab for 3 years. Exposure to teriparatide should be limited to 18 months.91 Data are limited for non-ambulatory patients and those with significant comorbidities.92 It should be noted that bone strength is only one of many determinants of fracture risk93 |
| 42 | Clinically significant medication interactions | Medication interactions that may interfere with the outcome of therapy |
A2A, angiotensin 2 receptor antagonist; ACEI, ACE inhibitor; AF, atrial fibrillation; CHADS2, cardiac failure, hypertension, age, diabetes, stroke (doubled); CHA2DS2-VASc, cardiac failure or dysfunction, hypertension, age over 75 years (doubled), diabetes, stroke (doubled), vascular disease, age 65–74 years, sex category (female); CHD, coronary heart disease; CVD, cardiovascular disease; DBP, diastolic blood pressure; GFR, glomerular filtration rate; HF, hip fracture; HF-LVSD, heart failure with left ventricular systolic dysfunction; HFPEF, heart failure with preserved ejection fraction; HRT, hormone replacement therapy; IHD, ischaemic heart disease; ISH, isolated systolic hypertension; LVH, left ventricular hypertrophy; MAOI, monoamine oxidase inhibitor; MI, myocardial infarct; NSAID, non-steroidal anti-inflammatory drug; NVF, non-vertebral fracture; PAD, peripheral arterial disease; RDI, recommended daily intake; SBP, systolic blood pressure; SSRI, selective serotonin reuptake inhibitor; TC, total cholesterol; TCA, tricyclic antidepressant; TIA, transient ischaemic attack; TNF, tumour necrosis factor; URTI, upper respiratory tract infection; VF, vertebral fracture.