or PPOs identified by version 1 and version 2 criteria (Thevelin et al., 2019). These investigators revealed a higher incidence of inappropriate prescribing with the application of version 2 criteria (40% vs. 23%; p < 0.001). The differences were attributed to a more than threefold increase in PIMs associated with fall risk–increasing drugs and a near doubling of PPOs associated with musculoskeletal or cardiovascular treatment. The SENATOR and OPERAM trials are two more recent large- scale investigations involving STOPP/START version 2 (Blum et al., 2021; O’Mahony et al., 2020). The SENATOR trial was a prospective, randomized, open-label study that enrolled 1,537 hospitalized older (mean age 78 years) patients with polypharmacy and multiple morbidities. The intervention group received standard care and the application of a software tool that applied STOPP/START V2 prescribing rules. None of the endpoints, including adverse drug reaction (ADR) incidence, mortality, readmission, healthcare utilization, or quality of life indicators, reached statistical significance; however, the authors cite poor prescriber adherence of approximately 15% as likely blunting the effect of the intervention. The OPERAM trial randomized more than 2,000 hospitalized older patients with multimorbidity and polypharmacy to standard care or intervention that included a medication optimization strategy that employed a clinical decision support process based on STOPP/START criteria. Eighty-six percent of patients in the intervention group had at least one instance of criteria-based inappropriate prescribing (mean 2.75 recommendations per patient). However, while there were numerically fewer primary and secondary outcomes in the intervention group, there was no statistically significant difference between groups in the hazard ratio for the primary outcome of rehospitalization within 12 months of enrollment, nor were there any differences in secondary outcomes, including first fall or death. The authors of the OPERAM trial cited limitations of no ongoing study interventions in the 12-month follow-up period and a high baseline 12-month mortality rate that may have diluted the magnitude of any intervention benefit. STOPPFrail Neither the AGS Beers nor the STOPP/START criteria addressed the matter of patients in hospice or other end-of-life care. To that end, Lavan and colleagues published the STOPPFrail criteria in 2017, which identified PIMs that would be good candidates for deprescribing, given greater harm than benefit or with negligible benefit in end-of-life care (Lavan et al., 2017). An update to these criteria was published in 2020, and it contained 25 recommendations in ten therapeutic categories covering cardiovascular, coagulation, central nervous, gastrointestinal, respiratory, musculoskeletal, urogenital, and endocrine systems (Curtin et al., 2020). Patients considered for these deprescribing recommendations should also meet three common criteria: Severe chronic disease and/or acute terminal illness and/or The process of stopping, substituting, or reducing a medication under the supervision of a healthcare professional to manage polypharmacy and improve outcomes encompasses the principles of deprescribing. This activity can be guided by AGS Beers and/or STOPP criteria. It could include discontinuing medications without an indication, high risk or potentially inappropriate medications, or selecting a medication with a more favorable safety profile. Examples of medications often targeted for deprescribing include proton pump inhibitors, sedatives, hypnotics, antihistamines, and skeletal muscle relaxants. Feldman and colleagues described a 50% reduction in target medication use by deploying a deprescribing protocol in 115 patients (mean age 76 years) in a transitional care unit (Feldman et al., 2019). Similar initiatives are well described across acute, subacute, and ambulatory care settings.
Some authors have observed that several differences between AGS Beers and STOPP/START criteria favor the latter, although the influence of author bias cannot be excluded (O’Mahony, 2020). STOPP/START criteria are organized by physiologic process, as opposed to drug/class categories, and are more explicit than the Beers criteria. Further, the Beers criteria fail to specifically identify PIMs that involve therapeutic duplications or therapies without indication, and there is no mention in the Beers criteria of medications that should be used for a particular indication or omission. Furthermore, small- and large-scale studies have demonstrated the applicability and value of STOPP/ START criteria to clinical practice and quality improvement research. A single-center study identified a 9.3% absolute risk reduction in adverse drug reactions within 7 to 10 days of hospitalization when STOPP/START version 1 criteria were applied upon admission, as opposed to standard care (O’Connor et al., 2016). Several investigators have conducted comparisons of AGS Beers and STOPP/START criteria. The CRIME study by Tosato and colleagues sought to evaluate adverse drug reaction and/or functional status decline outcomes in 871 hospitalized elderly patients when 2012 AGS Beers and a modified set of STOPP version 1 criterion were applied (Tosato et al., 2014). While the STOPP criteria appeared to identify one or both target outcomes more often, the combined use of STOPP and AGS Beers criteria was superior to either individual screening tool. Bahat and colleagues retrospectively applied 2012 AGS Beers to the more recent STOPP version 2 criteria to identify potentially inappropriate medications in 667 older patients admitted to an outpatient university hospital clinic (Bahat et al., 2017). Patients had a mean age of 77.6 years and were taking a mean of 6.1 ± 3.4 chronic medications. More PIMs were identified using STOPP version 2 than 2012 AGS Beers criteria (39.1% vs. 33.3%, respective; p < 0.001). A greater number of medications, conditions, and extent of functional impairment were better than age as a predictor of PIMs. dependency to maintain activities of daily living; at high risk for acute medical complications or deterioration; and expected death within 12 months. Regardless of the benefits that the AGS Beers and STOPP/ START criteria have added to the clinical care of elderly patients, they should not be employed in isolation. Until a robust trial evaluating comparative outcomes between these two screening tools finds a demonstrable incremental benefit of one over the other, clinicians may rely on one or both resources as one, but not the only, tool for evaluating and delivering optimal medication use for elderly patients.
DEPRESCRIBING
Self-Assessment Quiz Question #4 Which of the following best describes the principle of deprescribing? a. Making sure that an antibiotic prescription does not exceed a 10-day supply. b. Canceling all medications ordered by a patient’s former primary care provider. c. Refraining from prescribing medications because of a drug–allergy interaction concern. d. Discontinuing a medication whose risk of adverse effects is greater than the benefit.
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