Table 3.
Selected prescribing criteria/prescribing indicator [16]
| 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, and 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 | 0.1–1.0 % |
| 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 (except cimetidine because of interaction with warfarin) or PPI | High risk of GI bleeding | 0.3–1.1 % |
| 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 | 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 (Stemetil®) 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 |
Abbreviations: ACEI angiotensin-converting-enzyme inhibitor, COPD chronic obstructive pulmonary disease, GI gastro-intestinal, N/A 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
aPrevalence—the proportion of the study population with 1 or more potentially inappropriate medications from the literature