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Polypharmacy is common in frailty and multimorbidity. The STOPP/START criteria are evidence-based tools to improve prescribing safety in older adults. β STOPP: identify potentially inappropriate medications. β START: highlight beneficial medications that are often underprescribed.
| Medication | Reason to Stop |
|---|---|
| Digoxin | No benefit in heart failure with preserved systolic function. β οΈ Reduce dose if eGFR <30 ml/min to avoid toxicity. |
| Thiazide diuretics | Stop if recurrent hypoNa, hypoK, hyperCa, or recent gout. |
| Loop diuretics | Not for routine hypertension. Avoid for ankle oedema without HF/CKD/CLD β use compression instead. |
| Aldosterone antagonists (spironolactone, eplerenone) | Risk of hyperkalaemia if combined with ACEI/ARB without monitoring. |
| Verapamil / Diltiazem | May worsen heart failure with reduced EF. |
| Nicorandil | Discontinue if GI or mucosal ulceration occurs. |
| ACEIs or ARBs | Stop in persistent hyperkalaemia. Avoid dual blockade (ACEI+ARB) unless under specialist advice. |
| Aspirin | Avoid long-term doses >150 mg (β bleeding risk). Avoid without PPI if history of ulcer. Avoid with anticoagulant unless strong indication. |
| Antiplatelet + Anticoagulant | β bleeding risk in stable CAD/CVD/PAD without recent ACS/stent. |
| Warfarin / DOACs | First DVT: >6 months; First PE: >12 months β stop if no ongoing risk factors. |
| NSAIDs + Warfarin/DOAC | High risk of GI bleeding. |
| Dabigatran | Avoid if eGFR <30 ml/min β bleeding risk. |
| Rivaroxaban / Apixaban | Avoid if eGFR <15 ml/min β bleeding risk. |
| Systemic corticosteroids | Avoid for maintenance COPD (inhaled steroids safer). |
| Condition | Recommended Medication | Rationale |
|---|---|---|
| Heart failure | ACEI/ARB, beta-blocker, spironolactone (if HFrEF) | Improves survival, reduces hospitalisation. |
| Atrial fibrillation | Anticoagulant (warfarin/DOAC) if CHAβDSβ-VASc β₯2 | Reduces stroke risk. |
| Post-MI / IHD | Statin, ACEI, beta-blocker, antiplatelet (if not contraindicated) | Secondary prevention. |
| Diabetes + proteinuria | ACEI/ARB | Renal protection. |
| Osteoporosis / fragility fracture | Bisphosphonate + calcium/Vit D | Fracture risk reduction. |
| Long-term steroids | Bisphosphonate prophylaxis | Prevent steroid-induced osteoporosis. |
| Hypertension + diabetes/CKD | ACEI/ARB | Renal & CV protection. |
| Vaccinations | Influenza, pneumococcal, shingles | Reduce infection burden in frail adults. |
| Depression | Antidepressant therapy (if persistent symptoms) | Improves mood, function, QoL. |
| Constipation | Laxative if regular opioid use | Prevent faecal impaction. |
| Falls risk | Vitamin D/calcium | Bone health, muscle strength (esp. care homes). |
π‘ Take-home: Safe prescribing in geriatrics = balance between stopping harm and starting benefit. Think of STOPP/START as your structured checklist during a CGA medication review.