Inappropriate prescribing

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Inappropriate prescribing is a common healthcare issue as it is associated with increased morbidity and ineffectual use of resources. There is evidence for increased hospitalisation and mortality[1]. The term is usually used where the use of a certain medication does not have a clear evidence-based indication. While interpretation of the evidence base can vary, the use of objective criteria for inappropriate prescribing, such as Beer's criteria or the inappropriate prescribing in the elderly tool (IPET) in the elderly is associated in research studies with the risk of adverse drug reactions (ADR)s.

The most important message is that the increased risk is best correlated with polypharmacy. Thus the art of appropriate prescribing is often an issue of minimising the number of drugs.

However, major issues arise:

  1. Interventions utilising Beer's criteria or IPET have failed to show convincingly reduced mortality or resource use[2].
  2. Neither tool is easy to apply in clinical practice and indeed the resources consumed in utilising them in unselected populations is likely to be a factor in the inconsistent resource utilisation data.
  3. Any tool will reflect the knowledge base when it is developed. Ideally, it needs to consider:
    • Generalisation with changes in practice
      • Tools developed that emphasise tricyclic toxicity may not be appropriate for SSRIs
    • Under-utilisation of appropriate drugs
      • ACE inhibitor underdosage
    • Drug-drug interactions
    • Duplication
    • Knowledge that is out of date
      • IPET refers to caution with beta blockers in heart failure - true but specific beta blockers are good in heart failure

Some drugs whose use in the elderly causes concern

(The idea of this list is that it may allow you to double check, - many drugs on the list will be used for specific indications when no easy alternative available)

  • Duplicate prescriptions with in a class of drugs

Antiarrythmics

Antibiotics

Anticholinergics

Antidepressants

Antihistamines (sedative)

Bronchodilators

CNS disease

Diuretics

Hypoglycaemics

Hypotensives/Antianginals/Antiplatelets

Indigestion

  • Cimetidine relative to alternatives
  • High salt antacids in heart failure
  • PPIs at full dose for more than 8 weeks

NSAIDs

Laxatives

Minerals

Sedatives

Steroids

References

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