Table 2.
Potentially inappropriate medication use in the older patients considering diagnoses or conditions.
| Inappropriate Medication | Disease/Condition | Concern | Average of Likert scales (CI95%)a from panel members | Alternative drugs and/or therapiese | Concern described in other PIM lists | ||
|---|---|---|---|---|---|---|---|
| Beers | STOPPd | Eue (7) - PIM list | |||||
| NSAIDs b | Osteoarthritis | Avoid the long-term use of NSAIDsb (> 3 months) for symptom relief of osteoarthritis pain where safe alternatives are available. | 5.00 (5.00; 5.00)d | Paracetamol; Dipyrone 500–1000 mg q6hr or q8hr,d; Non-pharmacological treatment (e.g., physiotherapy, acupuncture, thermotherapy, electrostimulation, and therapeutic massage)c,d | xj | x | |
| Gout | Avoid the long-term use of NSAIDsb (> 3 months) for chronic treatment of gout where there is no contraindication to a xanthine-oxidase inhibitor e.g. allopurinol. | 4.78 (4.44; 5.12) | Paracetamol; Dipyrone 500–1000 mg q6hr or q8hr,c,d; Non-pharmacological treatment (e.g., physiotherapy, acupuncture, thermotherapy, electrostimulation, and therapeutic massage)c,d | xj | x | ||
| History of peptic ulcer disease or gastrointestinal bleeding | History of peptic ulcer disease or gastrointestinal bleeding (unless with concurrent PPI): Risk of peptic ulcer and gastrointestinal bleeding relapse. | 4.89 (4.63; 5.15) | Paracetamol; Dipyrone 500–1000 mg q6hr or q8hr,c,d; Non-pharmacological treatment (e.g., physiotherapy, acupuncture, thermotherapy, electrostimulation, and therapeutic massage)c,d | xf | xf | ||
| Hypertension | Risk of exacerbation of hypertension. | 4.67 (4.12; 5.21) | Paracetamol; Dipyrone 500–1000 mg q6hr or q8hrc,d; Non-pharmacological treatment (e.g., physiotherapy, acupuncture, thermotherapy, electrostimulation, and therapeutic massage)c,d | x | |||
| NSAIDs b | Heart failure | Potential to promote fluid retention and exacerbate heart failure. | 4.78 (4.44; 5.12) | Paracetamol; Dipyrone 500–1000 mg q6hr or q8hr,c,d; Non-pharmacological treatment (e.g., physiotherapy, acupuncture, thermotherapy, electrostimulation, and therapeutic massage)c,d | x | x | |
| Chronic kidney disease Stages IV or less (creatinine clearance <30 ml/min) | May increase risk of acute kidney injury and further decline of renal function. | 5.00 (5.00; 5.00) | Paracetamol; Dipyrone 500–1000 mg q6hr or q8hr,d; Non-pharmacological treatment (e.g., physiotherapy, acupuncture, thermotherapy, electrostimulation, and therapeutic massage)c,d | x | |||
| eGFR < 50 ml/min/1.73m 2 | NSAIDsb if eGFR < 50 ml/min/1.73m2: risk of deterioration in renal function. | 5.00 (5.00; 5.00) | Paracetamol; Dipyrone 500–1000 mg q6hr or q8hr,d; Non-pharmacological treatment (e.g., physiotherapy, acupuncture, thermotherapy, electrostimulation, and therapeutic massage)c,d | x | |||
| COX-2-selective NSAIDs b | Cardiovascular disease | COX-2 selective NSAIDs with concurrent cardiovascular disease (increased risk of myocardial infarction and stroke). | Paracetamold; Dipyrone 500–1000 mg for q6hr or q8hr,c,d; Non-pharmacological treatment (e.g., physiotherapy, acupuncture, thermotherapy, electrostimulation, and therapeutic massage)c,d | x | |||
| Celecoxib | 4.83 (4.40; 5.26)d | x | |||||
| Etoricoxib | 4.67 (4.28; 5.05) | ||||||
| Orphenadrine and Cyclobenzaprine | |||||||
| Delirium | Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. | 5.00 (5.00; 5.00) | Non-pharmacological treatment (e.g., physiotherapy, acupuncture, thermotherapy, electrostimulation, and therapeutic massage)c,d | xg | |||
| Dementia or cognitive impairment | Avoid because of adverse CNS Effects. | 5.00 (5.00; 5.00) | Non-pharmacological treatment (e.g., physiotherapy, acupuncture, thermotherapy, electrostimulation, and therapeutic massage)c,d | xg | |||
| Lower urinary tract symptoms. benign prostatic hyperplasia: | May decrease urinary flow and cause urinary retention. Avoid in men. | 4.78 (4.44; 5.12) | Non-pharmacological treatment (e.g., physiotherapy, acupuncture, thermotherapy, electrostimulation, and therapeutic massage)c,d | xg | |||
| Colchicine | |||||||
| Gout | Avoid the long-term use of colchicine for chornic treatment of gout where there is no contraindication to a xanthine-oxidase inhibitor e.g. allopurinol. | 4.83 (4.40;5.26)d | Paracetamolc,d; Dipyrone 500–1000 mg q6hr or q8hr,c,d; Non-pharmacological treatment (e.g., physiotherapy, acupuncture, thermotherapy, electrostimulation, and therapeutic massage)c,d | x | |||
| eGFR < 10 ml/min/1.73m2 or creatinine clearance <30 ml/min) | Risk of colchicine toxicity; Higher risk of gastrointestinal, neuromuscular, bone marrow adverse effects Toxicity. | 4.78 (4.44; 5.12) | Paracetamolc,d; Dipyrone 500–1000 mg q6hr or q8hr,c,d; Non-pharmacological treatment (e.g., physiotherapy, acupuncture, thermotherapy, electrostimulation, and therapeutic massage)c,d | xh | x | ||
| Corticosteroids | |||||||
| Rheumatoid arthrtitis | Long-term corticosteroids (> 3 months) as monotherapy for rheumatoid arthritis: Safer alternatives available; unnecessary exposure to systemic corticosteroid side-effects. | 4.89 (4.63; 5.15) | x | ||||
| Osteoarthritis | Safer alternatives available; unnecessary exposure to systemic corticosteroid side-effects. | 4.78 (4.27; 5.29) | x | ||||
| Osteoporosis c | long - term use of corticosteroids may increase bone loss and worsen osteoporosis. | 5.00 (5.00; 5.00)d | |||||
| Diabetes c | long - term corticosteroids may cause difficulty in controlling blood glucose level. | 4.83 (4.40; 5.26)d | |||||
| Delirium | Avoid in older adults with or at high risk of delirium because of the potential of worsening or inducing delirium. | 4.78 (4.27; 5.29) | x | ||||
| Opioids | |||||||
| History of falls or fractures | May cause ataxia. impaired psychomotor function. syncope. additional falls. | 4.56 (4.15; 4.96) | Paracetamolc,d; Dipyrone 500–1000 mg q6hr or q8hr,c,d; Non-pharmacological treatment (e.g., physiotherapy, acupuncture, thermotherapy, electrostimulation, and therapeutic massage)c,d | x | x | ||
| Pethidine/Meperidine | |||||||
| Delirium | Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. | 4.78 (4.27; 5.29) | Paracetamolc,d; Dipyrone 500–1000 mg q6hr or q8hr,c,d; Non-pharmacological treatment (e.g., physiotherapy, acupuncture, thermotherapy, electrostimulation, and therapeutic massage)c,d. Analgesics (dipyrone or paracetamol) in combination with weak opioids (tramadol or codeine)c,d. | x | x | ||
| Tramadol | |||||||
| Chronic seizures or epilepsy | Lowers seizure threshold. | 4.63 (4.19; 5.16) | Paracetamolc,d; Dipyrone 500–1000 mg q6hr or q8hr,c,d; Non-pharmacological treatment (e.g., physiotherapy, acupuncture, thermotherapy, electrostimulation, and therapeutic massage)c,d | x | x | ||
aConfidence interval; bNon-steroidal anti-inflammatory drugs; cSuggestions from experts; dItems validated only in the second round; eThe alternative therapies described in this table were validated by expert consensus (lower limit of confidence interval ≥ 4.0); dScreening Tool to Alert doctors to Right Treatment; eEuropean Union; f Non-COX-2 selective non-steroidal anti-inflammatory drug (NSAID) with history of peptic ulcer disease or gastrointestinal bleeding, unless with concurrent PPI or H2 antagonist (risk of peptic ulcer relapse; gMedications classified as anticholinergic drugs in the criteria; h Used the measure Creatinine Clearance <30 ml/min; iLong-term colchicine for treatment of gout where there is no contraindication to allopurinol. Allopurinol is first choice prophylactic drugs in gout; jAvoid the long-term use of Non-COX-2 selective non-steroidal anti-inflammatory (> 3 months).