DÄ internationalArchive31-32/2010Potentially Inappropriate Medications in the Elderly

Original article

Potentially Inappropriate Medications in the Elderly

The PRISCUS List

Dtsch Arztebl Int 2010; 107(31-32): 543-51; DOI: 10.3238/arztebl.2010.0543

Holt, S; Schmiedl, S; Thürmann, P A

Background: Certain drugs are classified as potentially inappropriate medications (PIM) for the elderly because they carry an increased risk of adverse drug events in this patient group. PIM lists from other countries are of limited usefulness in Germany because different drugs are on the market in each country and prescribing practices vary as well. Thus, a list of potentially inappropriate medications for the elderly was developed specifically for use in Germany.

Methods: A preliminary PIM list suitable for the German market was created on the basis of a selective literature search and a qualitative analysis of published international PIM lists. The final German PIM list was developed by means of a comprehensive, structured expert survey in two rounds (a so-called Delphi process).

Results: 83 drugs in a total of 18 drug classes were rated as potentially inappropriate for elderly patients. For 46 drugs, the experts came to no clear decision after the second Delphi round. For cases in which the administration of a PIM is clinically necessary, the final PRISCUS list contains recommendations for clinical practice, e.g. monitoring of laboratory values and dose adaptation. Therapeutic alternatives are also listed.

Conclusion: Potentially inappropriate medications carry the risk of causing adverse drug events in the elderly.
A drawback of using a Delphi process to generate a PIM list, as was done for the new German list, is that little scientific evidence is currently available for the evaluation of active substances, potential therapeutic alternatives, and indicated monitoring procedures. Thus, the validity and practicability of the PRISCUS list remain to be demonstrated (and the same holds for PIM lists already published in other countries). It should be used as a component of an overall concept for geriatric pharmacotherapy in which polypharmacy and interacting medications are avoided, and doses are regularly re-evaluated. 

LNSLNS

In Germany, the Federal Statistical Office (Statistisches Bundesamt) currently predicts a marked rise in the percentage of elderly people in the population, with the number of people over age 80 rising by more than 4 million, to approximately 10 million, by the year 2050 (e1). Multimorbidity is more common in advanced age (1) and leads inevitably to polypharmacy. According to an annual report of medical prescribing in Germany (Arzneiverordnungsreport), persons over age 60 participating in the German statutory health insurance system received an average of 3.1 defined daily doses (DDD) of medication as long-term treatment in the year 2008 (2). This age group was given 66% of all prescribed drugs, even though it accounts for only 26.8% of the population. Comparable figures have been published in the United Kingdom, Sweden, the Netherlands, Ireland, the USA, and other countries (3, e2e5). The more drugs a patient takes, the greater the risk of drug interactions and adverse effects (e6, e7). Aside from adverse effects in the narrow sense of the term, patients commonly suffer from adverse drug events (ADE), often because of multiple prescribing. In this article, we will make frequent use of the term “adverse drug events” and the abbreviation ADE.

Old age is commonly associated with multiple illnesses, as well as with altered pharmacokinetics and pharmacodynamics (4, e8, e9)—for example, delayed renal elimination of drugs and increased sensitivity to anticholinergic and sedating effects. Many drugs are thus inappropriate for elderly patients because of their pharmacological effects and/or potential adverse effects. Many types of ADE are difficult to distinguish from the manifestations of diseases that the patient already has or might develop, and many drugs can elevate the risk of complications, such as falls, that typically affect the elderly (e10). Medications whose risk of ADE exceeds their expected clinical benefit when they are given to elderly persons, and which can be replaced by better-tolerated alternatives, are called potentially inappropriate medications (PIM) (5). Efforts have been made recently in the USA, Canada, France, Ireland, and Norway (611) to identify PIM among the drugs that are available in each of these countries. The best known list of this type is the so-called Beers list (6). The medication recommendations for multimorbid elderly patients that have been published to date in countries outside Germany are variable in both form and content and often do not apply to the German situation because of differences in approved drugs, in prescribing behavior, and in therapeutic guidelines. Propoxyphene, for example, appears on international lists as a PIM but is not available as a medication in Germany.

The creation of a specifically German list of potentially inappropriate medications that elderly persons should not take, or whose doses require special adjustment for elderly patients (6, 7), was made a goal of the German Health Ministry’s Drug Safety Initiative (Aktionsplan Arznei­mittel­therapie­sicherheit) for 2008/2009 (e11), on the recommendation of a council of experts for the evaluation of developments in health care (e12). The joint project was entitled PRISCUS (Latin for “old and venerable”). The PIM list that it created can be found in full at www.priscus.net (in German). This PIM list is described in the present article, and its potential uses are discussed.

Methods

The PRISCUS list was created in four steps:

(a) Qualitative analysis of selected PIM lists for elderly patients from other countriesTwo publications on the subject from the USA (6, 7), one from Canada (8), and one from France (9) were identified, qualitatively analyzed, and evaluated for applicability to the German drug market in terms of availability and prescribing frequency (e13).

(b) Literature searchThe literature was searched (in the Medline database PubMed and elsewhere) for publications on drug recommendations for the elderly and problems related to drugs commonly used by elderly patients. Particular attention was paid to publications that provided scientific evidence of an elevated risk of ADE and drug interactions for specific medications and medication classes taken by the elderly. The literature contains many different age thresholds for the definition of the elderly. The authors of the PRISCUS list established age 65 as the lower limit (10, 12).

(c) Development of a preliminary list of potentially inappropriate medications for elderly patients, specifically adapted to the German marketThe information obtained in steps (a) and (b) was used to create a preliminary PIM list containing 131 medications belonging to 24 different classes, with extensive accompanying information (eBox 1 (gif ppt), eTable 1 (gif ppt)). eBox 2 (gif ppt) contains a detailed description of steps (a) – (c).

(d) Generation of the final PRISCUS list by consultation of experts (modified Delphi process)As was done for the PIM lists that were published in other countries, the German PIM list was generated by expert consensus (eBox 3 (gif ppt)) on the basis of a literature review followed by consultation of experts in a modified Delphi process (13, e14, e15).

The Internet-based Delphi interrogation process consisted of two rounds and began in December 2008, when contact was made with more than 50 German-speaking experts, of whom 38 agreed in writing to participate in the project. These experts represented eight different specialties (geriatric medicine, clinical pharmacology, general practice, internal medicine, pain therapy, neurology, psychiatry, and pharmacy). The experts were identified with the aid of the specialty societies and the Drug Commission of the German Medical Association. Further potential participants were identified by personal communication.

The experts rated each potentially inappropriate medication on the five-point Likert scale (e16), which ranges from a score of 1 (drugs that can definitely be considered potentially inappropriate for elderly patients) to 5 (drugs whose risk for elderly patients is comparable to the risk for younger patients). A score of 3 is neutral (undecided). Furthermore, the experts were asked to propose monitoring parameters (e.g., laboratory values to be tested), dose adjustments, and alternative, predominantly pharmacological, treatment alternatives for each drug. They were also asked to list, for each drug, any comorbidities that would elevate the risk of adverse events.

After the first round of questioning, the mean Likert score and the corresponding 95% confidence interval (CI) were determined for each drug. Drugs for which the upper bound of the 95% CI was less than 3.0 were classed as PIM, while drugs for which the lower bound of the 95% CI was greater than 3.0 were classed as drugs whose risk is comparable in elderly and younger patients. Only the drugs whose 95% CI was on both sides of 3.0 were evaluated a further time by the experts in the second round of questioning (7, 10). The experts’ answers in the second round were evaluated by the same procedure. Drugs whose 95% CI remained on both sides of 3.0 in the second round were designated as “not unequivocally characterized.”

A number of medications were evaluated in separate categories of dosage, indication, or manner of drug release in the second round, on the basis of the experts’ recommendations. Statistical calculations were performed with the SPSS program, version 17 (SPSS Inc., Chicago, IL, USA).

Results

Twenty-five of the 38 experts (65.8%) participated in the first round of questioning, and 26 completed the second round. One expert participated only in the first round, two others only in the second round.

Five of the 131 different drugs (active substances) under consideration were evaluated by the experts in the first round in two different categories based on the manner of drug release. Rapidly released nifedipine, for example, was unequivocally rated as a PIM, while sustained-release nifedipine was classified as a questionable PIM. Thus, 136 different drug evaluations emerged from the first round (Figure (gif ppt)). 17 drugs were judged to carry comparable risks for younger and older patients, and were thus classified as non-PIM. 61 drugs were considered by the experts to be potentially inappropriate for elderly patients.

For 58 drugs, an unambiguous expert evaluation was not obtained in the first round, and a further evaluation in the second round was needed. Nine of these drugs were evaluated in two different categories based on their dosage or indication, in accordance with the experts’ suggestions. The experts in the second round also suggested 10 new drugs for consideration as possible PIM. Thus, 77 different drugs were evaluated in the second round.

The experts in the second round of questioning evaluated 21 of the 77 drugs as potentially inappropriate for elderly patients. Forty-seven drugs could not be unambiguously classified even after the second round (eTable 2 (gif ppt)). One of these was prasugrel, which was then designated by the authors of the PRISCUS list as a PIM on the basis of the manufacturer’s recommendations (e17) (Figure).

Thus, at the end of two rounds of questioning, 83 drugs were judged to be potentially inappropriate for elderly patients (Table (gif ppt), eTable 3 (gif ppt)). Among them were two (nifedipine and tolterodine) that were only classified as PIM in their rapid-release formulation. For 9 drugs, upper dose limits were stated.

After evaluating many textual references to therapeutic alternatives and monitoring derived from the literature, the experts also provided comments, supplementary information, and more concrete statements. These are contained in the final PRISCUS list (short version in the Table; complete list at www.priscus.net [in German language]).

Sixty-four of the 83 drugs designated as PIM in the PRISCUS list are so designated in at least one of the PIM lists that have been published in other countries (69). Among the remaining 19 German PIM drugs that are not listed as PIM in any of the four foreign lists, 12 are not available on the market in at least one of the three countries to which these lists apply (e18); however, 7 are on the market in all three (the USA, Canada, and France). On the other hand, 124 drugs are designated as PIM in at least one of the four foreign lists (sometimes only in the presence of specific comorbidities) but do not appear on the German PRISCUS list. Seventy of these drugs are not on the German market. Thirty-seven of them did not appear on the preliminary PIM list for various reasons, including low frequency of prescription (dosulepine) or lack of scientific evidence (cimetidine). Of the 17 remaining drugs classified as PIM on foreign lists but not on the German list, 6 were designated as non-PIM, and 11 could not be unambiguously classified.

Discussion

The project described here created the first list of potentially inappropriate medications for elderly patients in the German-speaking countries. A specifically German list was needed because the French, American, and Canadian drug markets are only partly comparable with the market in Germany (5, 14, 15).

Of the 83 medications that were designated as potentially inappropriate in the final list, nearly three-quarters had already been classified as such in the first round of questioning. This implies that, for these drugs, solid scientific evidence indicates their potential unsuitability for elderly patients, and/or that better therapeutic alternatives exist. Some drugs, however, were not classified as potentially inappropriate until the second round of questioning, e.g., certain antiarrhythmic drugs (flecainide, sotalol). In these cases, there was doubt about the evidence for increased risk in elderly patients, and/or the lack of available alternatives. Forty-six drugs could not be unambiguously classified even after the second round. In the four PIM lists that were published in other countries (69), drugs that could not be unambigously classified were generally listed as suitable for use by the elderly.

The use and applications of the PRISCUS list

Drugs listed as potentially inappropriate in a PIM list with adequate scientific validity ought to be associated with a higher frequency of adverse drug events in the elderly (e19). An analysis of 18 epidemiological studies, mostly from the USA, ranging in size from 186 to 487 383 elderly patients, revealed that the use of drugs on the Beers list was associated with a higher risk of hospitalization, both for outpatients living at home and for residents of old age homes (12). A more recent study has revealed that the consumption of potentially inappropriate medication by elderly persons living at home is associated with a higher risk of falls (e10). Potentially inappropriate medication generally leads to higher costs because of more physician consultations and hospitalizations. In some of these studies, however, the methods used to eliminate confounding factors, such as comorbidites and co-medication, from the analysis were not beyond criticism (12, 15).

The association between a particular, potentially inappropriate medication and the occurrence of adverse events is also, of course, a function of how often the medication is prescribed. Fialová et al. (14) compared the frequency of PIM in eight European countries: 41.1% of elderly persons in the Czech Republic, but only 5.8% in Denmark, received at least one potentially inappropriate medication according to the criteria of Beers (6, 7) and McLeod (8). Such marked differences across countries in the prevalence of PIM can be considered markers for the quality and safety of prescribing practices, even though the potential association of PIM with adverse events was not investigated in this study.

The complete PRISCUS drug recommendations are intended as a supportive aid for physicians and pharmacists (6). The list makes no claim of completeness, nor can it replace the individualized evaluation of benefits and risks for each patient (5, e19, e20). It is hoped that the PRISCUS list will raise awareness of the special difficulties of pharmacotherapy for the elderly. It may, in fact, be necessary to give a drug on the PIM list to an elderly patient if the suggested alternatives are poorly tolerated or if they interact with other drugs that the patient is taking. A list of this type also does not take full account of the problems of polypharmacy, which may lead to clinically relevant interactions, or of undermedication (16). Nonetheless, the PRISCUS list does cover certain important areas, e.g., it provides concrete suggestions for safe monitoring in case the prescription of a potentially inappropriate medication cannot be avoided. A further potential application is the development of preventive strategies and guidelines for multimormbid patients: thus, the PRISCUS list might be integrated into the existing geriatric guidelines for the German state of Hesse (e21), or into a standardized assessment protocol for primary care physicians (10), such as the STEP assessment (17). The list could also conceivably be integrated into electronic prescription systems.

Validity and limitations of the PRISCUS list

The group of 25 experts (26 in the second round) belonged to eight different specialties and thus possessed broad knowledge of pharmacotherapy for the elderly (e15). In view of the lack of methodologically high-quality studies on elderly patients (e12, e22, e23), the Delphi method has been acknowledged as an acceptable way to generate PIM lists (610), despite its limitations (7).

The subjectivity of assessment by expert consensus is evident in the differences in content between the PRISCUS list and the other PIM lists that were previously published abroad. The classification of a drug as potentially inappropriate for elderly patients finally depends, not just on the level of evidence for risk, but also on the available alternatives and on the need for treatment. Platelet-aggregation inhibitors, such as acetylsalicyic acid and clopidogrel, and oral anticoagulants, such as phenprocoumone, are not designated as potentially inappropriate, even though they are suspected of causing many adverse drug events in elderly patients (e6). It would scarcely be possible to designate these medications and classes of medications as potentially inappropriate for the elderly, as they are absolutely necessary for the proper treatment of many “typical” diseases of old age, such as stroke and atrial fibrillation. Their safe use requires proper treatment monitoring and dose adjustment.

Validation of the PRISCUS list will have to be performed in two steps. First, there must be a measurable correlation between the prescribing of the drugs listed in it and clinically relevant adverse events. Second, the consistent implementation of the instructions contained in it must demonstrably lead to a reduction of complications (e19). To accomplish these ends, the most common drug-associated and avoidable complications must be identified, and instruments must be developed that can be used in everyday clinical practice. The PRISCUS list suggests therapeutic alternatives; analogously, there are current efforts in the USA to create a “positive Beers list,” i.e., a list of drugs whose use in elderly patients is relatively beneficial (e24). The PRISCUS list will have to be updated regularly to take account of new drugs and new data (6).

Overview

The PRISCUS list was created for the German pharmaceuticals market on the basis of expert knowledge, in view of the lack of scientific data on the safety and efficacy of some drugs for the elderly and the resulting difficulty of making evidence-based recommendations for safe medication use in old age. Studies in multiple countries have shown that the use of potentially inappropriate medications, such as those on the PRISCUS list, elevates the risk of adverse events. The avoidance of such medications would presumably improve the safety of pharmacotherapy for the elderly. The PRISCUS list offers a great deal of practical advice and can help physicians make individualized therapeutic decisions for their patients. The complete PRISCUS list can be found on the Internet at www.priscus.net .

This project was supported by the German Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung, BMBF), project number 01ET0721.

Acknowledgements

The authors thank the following experts for their participation in the Delphi interrogation process: D. Adam (Ludwig-Maximilian University, Munich), A. Born (University of Bern, Switzerland), K. Ehrenthal (Hanau), H. Endres (University of Bochum), R. Erkwoh (HELIOS Hospital, Erfurt), J. Fritze (Frankfurt/Main), W.E. Haefeli (University of Heidelberg), S. Harder (University of Frankfurt am Main), J. Hauswaldt (Hannover Medical School), W. Hewer (Vinzenz von Paul Hospital gGmbH, Rottweil), U. Jaehde (University of Bonn), R. W. C. Janzen (Bad Homburg), P. Kaufmann-Kolle (Aqua Institute, Göttingen), W. Krahwinkel (HELIOS Hospital, Leisnig), U. Laufs (Saarland University Hospital, Bad Homburg), J. Lauterberg (University of Bonn), P. Mand (Hannover Medical School), E. Mann (Rankweil [Austria]), K. Mörike (Tübingen University Hospital), C. Muth (University of Frankfurt am Main), W. Niebling (University of Freiburg), G. Schmiemann (Hannover Medical School), J. Schulz (HELIOS Hospital Berlin Buch), C. C. Sieber und K. Becher (University of Erlangen-Nuremberg), S. Stehr-Zirngibl (University of Bochum), U. Thiem (University of Bochum), M. Zieschang (Alicepark Dialysis Center, Darmstadt). The authors also thank Prof. Dr. Trampisch and colleagues (Department of Medical Informatics, Biometry, and Epidemiology, Ruhr University, Bochum) for technical support. We also thank the Drug Commission of the German Medical Association, and particularly Dr. F. Aly.

Conflict of Interest Statement
Prof. Thürmann received payment for the performance of two clinical phase I trials from the Stada AG and Biotest AG companies, lecture honoraria from Bayer Vital and Biotest Pharma AG, and honoraria for belonging to the Data Safety Monitoring Boards of Ono Pharmaceuticals and Fresenius Kabi.
Dr. Schmiedl and Ms. Holt state that they have no conflict of interest as defined by the guidelines of the International Committee of Medical Journal Editors.

Manuscript submitted on 3 March 2010; revised version accepted on 2 June 2010.

Translated from the original German by Ethan Taub, M.D.

Corresponding author
Prof. Dr. med. Petra A. Thürmann
Klinische Pharmakologie
Private Universität Witten/Herdecke gGmbH
Philipp Klee-Institut für Klinische Pharmakologie
HELIOS Klinikum Wuppertal
Heusnerstr. 40
42283 Wuppertal, Germany

@For eReferences please refer to:
www.aerzteblatt-international.de/ref3110

eTables and eBoxes available at:
www.aerzteblatt-international.de/10m0543

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Klinische Pharmakologie, Private Universität Witten/Herdecke gGmbH:
Holt, Dr. med. Schmiedl, Prof. Dr. med. Thürmann
Philipp Klee-Institut für Klinische Pharmakologie, HELIOS Klinikum Wuppertal: Dr. med. Schmiedl, Prof. Dr. med. Thürmann
1.Akker M vd, Buntinx F, Knottnerus A: Comorbidity or multimorbidity: what’s in a name? A review of the literature. Eur J Gen Pract 1996; 2: 65–70.
2.Coca V, Nink K: Arzneimittelverordnungen nach Alter und Geschlecht. In: Schwabe U, Paffrath D (eds.): Arzneiverordnungsreport 2009. Heidelberg: Springer Medizin Verlag 2009; 901–14.
3.Milton JC, Hill-Smith I, Jackson SHD: Prescribing for older people. BMJ 2008; 336: 606–9. MEDLINE
4.Mangoni AA, Jackson SHD: Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. Br J Clin Pharmacol 2003; 57: 6–14. MEDLINE
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