A new set of criteria for identifying potentially hazardous medications in elderly patients accurately predicted serious adverse drug events, a prospective study found.
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The chance of an avoidable adverse event occurring was significantly greater when medication use was evaluated with the criteria known as STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions), with an odds ratio of 1.847 (95% CI 1.506 to 2.264, P<0.001), according to Denis O'Mahony, MD and colleagues from University College Cork in Ireland.
In contrast, use of the traditional Beers criteria did not predict the risk of adverse medication-associated events (OR 1.276, 95% CI 0.945 to 1.722, P=0.11), the researchers reported in the June 13 issue of the Archives of Internal Medicine.
The Beers criteria, in use for two decades, are based on two lists of drugs that should not be used in older patients, specifically drugs that should be avoided in all older patients and those that should be avoided in patients with specific conditions.
These criteria have been criticized, however, and studies incorporating them have shown conflicting associations with adverse event outcomes.
The importance of being able to identify the use of potentially inappropriate medications in the elderly, according to the researchers, is that adverse drug events today represent the fifth leading cause of death among people in the U.S.
O'Mahony's group developed and validated the STOPP criteria, which focus on potentially inappropriate medications that are in wide use, incorporating drug interactions and duplications.
According to STOPP criteria, the most commonly used inappropriate medications were:
- Full therapeutic dosage of proton pump inhibitors for longer than eight weeks in patients with uncomplicated ulcers
- Aspirin in patients with no history of coronary, cerebral, or peripheral vascular symptoms or occlusive arterial events
The most common in the Beers set were:
- Short- to intermediate-term benzodiazepines in patients with a history of falls
- Long-term benzodiazepines and tricyclic antidepressants in patients with a history of depression
To compare the overall accuracy of the STOPP and Beers criteria, as well as the ability to identify adverse drug events that lead to hospitalization, the researchers prospectively evaluated 600 consecutive patients, ages 65 and older, admitted for treatment of an acute illness.
Patients' median age was 77, and more than half were women.
They had been prescribed a total of 4,523 medications for a median of seven per patient.
According to the STOPP criteria, 610 potentially inappropriate drugs had been prescribed in 56.2% of patients, compared with 235 potentially hazardous drugs in 28.8% of patients using the Beers criteria.
When the researchers looked at adverse events in the cohort, they identified 329 potentially serious events in 26.3% of patients, with 10.9% being the main cause of patients' hospitalization.
An additional 55.6% of the events were considered to have contributed significantly to the need for hospitalization.
A total of 51.7% of the adverse events related to drugs included in the STOPP criteria, compared with 20.4% for the Beers criteria (P<0.01).
In addition, among the 71.4% of the adverse events considered avoidable, 67.7% were included in the STOPP criteria compared with 28.5% in Beers criteria (P<0.001).
"The present study results indicate that STOPP criteria are more sensitive to [potentially inappropriate medications] that result in [adverse drug events] than Beers criteria and are therefore more clinically relevant," O'Mahony's group stated.
Limitations of the study included the lack of information on over-the-counter drug use and on the duration of use of potentially risky medications.
In the same issue of the Archives, Alessandro Morandi, MD, of Vanderbilt University in Nashville, Tenn., and colleagues reported on a prospective cohort study that looked at prescription of medications before and during hospital admission.
Among 120 patients (median age 68), the percentage of patients taking at least one potentially inappropriate medication rose from 66% at admission to 85% at discharge.
Morandi and colleagues also determined that half of these medications were first prescribed in the intensive care unit.
"While it is possible that these drug therapies may be appropriate when started during the course of an acute illness in the ICU (e.g., stress ulcer prophylaxis with H2 antagonists in mechanically ventilated patients), most should have been discontinued at ICU and/or hospital discharge," they stated.
In an invited commentary, Jeffrey L. Schnipper, MD, MPH, of Brigham and Women's Hospital in Boston, decried the current inadequacy of implementation of available tools for assessing medication safety.
Advances in safe medication use, Schnipper wrote, won't simply be a matter of new technology such as tools that can automatically alert clinicians of potentially inappropriate medications.
"Also required is process redesign that effectively incorporates these tools into work flow, monitors the impact on patient care, and allows for iterative refinement," he argued.
Furthermore, research should focus on "multifaceted interventions in real healthcare settings so that gains in medication safety can be widely and successfully spread," Schnipper concluded.
The STOPP study was supported by The Health Research Board of Ireland and Enterprise Ireland.
All authors and the editorialist had no financial disclosures.
The second study received support from several sources, including the Veterans Administration and the National Institutes of Health. Two contributors disclosed receiving honoraria from Pfizer, GlaxoSmithKline, Lilly, Hospira, and Aspect.
All authors and the editorialist had no financial disclosures.
The second study received support from several sources, including the Veterans Administration and the National Institutes of Health. Two contributors disclosed receiving honoraria from Pfizer, GlaxoSmithKline, Lilly, Hospira, and Aspect.
Primary source: Archives of Internal Medicine
Source reference:
Hamilton H, et al "Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients" Arch Intern Med 2011; 171: 1013-1019.
Additional source: Archives of Internal Medicine
Source reference:
Morandi A, et al "Inappropriate medications in elderly ICU survivors: where to intervene? Arch Intern Med 2011; 171: 1032-1034.
Additional source: Archives of Internal Medicine
Source reference:
Schnipper J "Medication safety: are we there yet?" Arch Intern Med 2011; 171: 1019-1020.