The New PRISCUS List

Used Judiciously, a Valuable Aid in Deciding When to Start and Withdraw Medications

Editorial accompanying the article: “Potentially inadequate medications in the elderly: PRISCUS 2.0—first update of the PRISCUS list” by Nina-Kristin Mann et al. in this issue of Deutsches Ärzteblatt International

The following pages of this issue of Deutsches Ärzteblatt International contain the long-awaited update of the well-known PRISCUS list, presented by the team led by Petra Thürmann of Witten/Herdecke University. The new version is called PRISCUS 2.0 and lists substances that are potentially inappropriate medications (PIM) for the elderly (1).

Deprescribing can be difficult

Multimedication, especially in patients of advanced age, has recently been a prominent topic in research publications and in medical training courses on applied pharmacotherapy. However, discontinuation (“deprescription”) of accustomed or long-used medications is plainly not easy for either physicians or their patients. Even specific recommendations such as the Canadian “Deprescribing guidelines for the elderly” (2) have had little effect to date.

One of the reasons for this may be that not many controlled studies have been carried out, so that there is little external evidence on the clinically relevant consequence of a reduction in multimedication. Valid controls are essential in such research, however, because reduction or modification of medication can result in adverse effects such as pharmacodynamically explicable withdrawal symptoms or psychological insecurity on the part of patients, e.g., anxiety that vital treatment is being withheld on grounds of cost (3).

A PIM list can therefore be very helpful in daily practice, highlighting the potential dangers of multimedication and providing a basis for explanation of the risks to one’s patients. Prominent examples are drugs that increase the danger of falls or cloud the patient’s perceptions.

The PRISCUS 2.0 process

The first PRISCUS list for the German drug market was compiled over a decade ago (4) and was ripe for revision.

Almost 60 experts from the fields of clinical practice and academic medicine took part in a three-stage Delphi process to assess the evidence on whether substances identified as potentially problematic in the elderly should really be classified as clinically relevant PIM. The focus was on prescription data from statutory health insurance funds in Germany and Austria, yielding a realistic portrayal of daily prescription practice.

The evaluations were based on a systematic literature search and on systematic reviews conducted specifically for the purpose of the PRISCUS 2.0 project.

New data, new classifications

PRISCUS 2.0 classifies 187 substances as PIM, an increase of 133 over the original PRISCUS list. This expansion seems astounding at first sight, but is largely explained by the fact that in some classes of medications, e.g., the neuroleptics or the non-steroidal antirheumatic drugs, PRISCUS 2.0 evaluated substances individually to take account of possible differences among them. This also permitted, in contrast to the original PRISCUS list, between different compounds of a certain drug class.

For instance, proton pump inhibitors (PPI) and ibuprofen are not longer considered as PIM in general. Rather, the former are PIM only if the course of treatment lasts longer than 8 weeks, the latter only if the daily dosage exceeds 1200 mg or the treatment course is longer than 7 days without gastrointestinal PPI prophylaxis.

Another feature of PRISCUS 2.0 that is helpful for daily prescription practice is the provision of comments on specific drug-related risks that may arise from comorbidities and organ dysfunction.

With increasing frequency, physicians are routinely encountering the situation that a patient’s multimorbidity leads to them writing a large number of prescriptions, all of them indicated and in accordance with guidelines. Such patients have to take numerous different medications.

In cases where it is desirable to trim multimedication down to a manageable and pharmacologically reasonable level, PRISCUS 2.0 is a useful aid.

A valuable instrument for physicians

Drugs classified as PIM in the new PRISCUS 2.0 list should have the highest priority when considering whether medications should be deprescribed.

However, cancellation of a prescription should not be a reflex action, as indeed the authors of the study themselves point out. In individual cases, continued prescription of a PIM may very well be indispensable for the patient’s health and quality of life.

If tools such as PRISCUS 2.0 are used slavishly in the sense of algorithms, their acceptance will suffer. Such aids and lists are valuable instruments in deciding whether medications can be deprescribed in the context of each individual patient’s circumstances (5).

Conflict of interest statement

The author declares that no conflict of interest exists.

Manuscript received on 13 December 2022, revised version accepted on 13 December 2022.

Translated from the original German by David Roseveare.

Corresponding author
Prof. Dr. med. Bernd Mühlbauer
Institut für Pharmakologie
Klinikum Bremen Mitte, 28177 Bremen, Germany

Cite this as:
Muehlbauer B: The new PRISCUS List—used judiciously, a valuable aid in deciding when to start and withdraw medications.
Dtsch Arztebl Int 2023; 120: 1–2. DOI: 10.3238/arztebl.m2022.0408

References

1. Mann NK, Mathes T, Sönnichsen A, Pieper D, Klager E, Moussa M, Thürmann PA: Potentially inadequate medications in the elderly: PRISCUS 2.0—first update of the PRISCUS list. Dtsch Arztebl Int 2023; 120: 3–10

2. Farrell B, McCarthy L, Thompson W: Deprescribing guidelines for the elderly. https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ (last accessed on 13 December 2022).

3. Ludwig WD, Schuler J: Multimedikation: Warum ist eine Reduzierung von Medikamenten häufig so schwierig? Der Arzneimittelbrief 2018; 52: 23.

4. Holt S, Schmiedl S, Thürmann PA: Potentially inappropriate medications in the elderly: the PRISCUS list. Dtsch Arztebl Int 2010; 107: 543–51

5. Todd A, Jansen J, Colvin J, McLachlan AJ: The deprescribing rainbow: a conceptual framework highlighting the importance of patient context when stopping medication in older people. BMC Geriatr 2018; 18: 295. doi: 10.1186/s12877–018–0978-x. PMID: 30497404; PMCID: PMC6267905