STOPP START Tool to Support Medication Review

Older people are known to be at greater risk of adverse effects from their medicines due to age related
changes in pharmacokinetics and pharmacodynamics. Therefore, as a result of increasing age and frailty,
some treatments may cause more harm than benefit.

Polypharmacy and inappropriate prescribing are well known risk factors for adverse drug reactions (ADRs),
1
which commonly cause negative health outcomes in older people.

There is a growing body of evidence showing that some drugs are associated with more adverse reactions
2,3
and hospital admissions in the elderly . Hence, reviewing these medications contributes to reduce
problematic polypharmacy and address inappropriate prescribing in this group of patients.
4
NICE guidance on Medication Optimisation recommends using a screening tool – for example the
STOPP/START tool in older people – to identify potential inappropriate medication (STOPP criteria) and
potential prescribing omissions (START criteria) for those on multiple medicines or with long term conditions.

This document is an adaptation of the

STOPP START medication review screening tool

(STOPP-Screening Tool of Older Persons Prescriptions START -Screening
Tool to Alert doctors to Right i.e. appropriate, indicated Treatments)
Which consists of various criteria devised to identify potentially inappropriate medicines in older people.
These criteria are based on an up-to-date literature review and consensus validation among a European
1,5
panel of experts in geriatric pharmacotherapy .

Clinical guidelines and recommendations usually focus on starting treatments and/or managing single
conditions without taking into consideration or addressing, for instance, how the ratio benefit/risk changes as
the patient ages, or when it may be appropriate to stop or reduce the dose of a medication (particularly those
ones used for preventing conditions).

The tool was validated in patients aged 65 and over but physicians must use their clinical judgement when
deciding if a person is “elderly” in terms of using the toolkit and also consider other drug interactions or
contra-indications not listed here.

The final decision to stop the drug should be weighed against the daily symptomatic benefit or prevention of
rapid worsening of symptoms.

Where there is any doubt with the above information please check that it is in line with manufacturers
recommendations, published literature or changes in national and local guidance. All Bristol, North
Somerset and South Gloucestershire guidance can be found at http://www.bnssgformulary.nhs.uk/

South Gloucestershire version adapted by Raquel Iniesta, Care Homes Pharmacist South Gloucestershire Clinical
Commissioning Group. Permission obtained to adapt from STOPP/START Tool V9 – Dr D O’Mahony
(denis.omahony@ucc.ie). Acknowledgements also to NHS Wirral CCG STOPP/START Toolkit March 2015 (adapted
with permission), Midlands & Lancashire CSU, NHS Cumbria STOPP/START Toolkit Feb 2013 & Leicestershire
Medicines Strategy Group Nov 2014.

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Approved by BNSSG DTC 18 January 2017. Review January 2019 unless guidance changes.
STOP Circumstances to review Reason to review
medications
(age ≥ 65
years)
α-blockers (i.e. Long-term urinary catheter in situ No longer indicated for the relief of benign prostatic hyperplasia (BPH)
alfuzosin, >2 months symptoms (i.e. urinary retention)
doxazosin,
tamsulosin) Males with frequent incontinence Risk of urinary frequency and worsening of incontinence
and 5-alfa
reductase Hypotension/ Postural
inhibitors (i.e. hypotension
finasteride,
dutasteride) Please note that some α- blockers
e.g. doxazosin are also used to treat
hypertension
Anti-anginal Consider reducing, particularly if
medication mobility has decreased with less
need for medication

Caution: Nitrates are potent Risk of unwanted effects such as flushing headache, hypotension,
coronary vasodilators postural hypotension

Nicorandil and present ulceration Nicorandil can cause serious skin, mucosal, and eye ulceration,
including gastrointestinal ulcers which may progress to perforation,
haemorrhage, fistula, or abscess.
Stop nicorandil treatment if ulceration occurs—consider the need for
alternative treatment or specialist advice if angina symptoms worsen
https://www.gov.uk/drug-safety-update/nicorandil-ikorel-now-second-line-
treatment-for-angina-risk-of-ulcer-complications
Antibiotics Long term prophylactic antibiotics Risk of adverse effects, including development of resistance.
Review for UTI are not routinely Antibiotic prescribing guidance available at:
recommended (including http://www.bnssgformulary.nhs.uk/includes/documents/Antimicrobial%20Rx%20Guidel
catheterised patients). ines%20for%20BNSSG%202015%20version%203%20final..pdf
To reduce recurrence first advise simple measures including hydration
and cranberry products.
Prophylactic antibiotics should be reviewed after 6 months and stopping
should be considered.
Patients should be reviewed at regular intervals to assess the
C. difficile infection risk/benefits in relation to C. difficile infection.

Discontinue all antibiotics other than those prescribed for CDI

Clostridium difficile in the Community Guideline available at:
http://www.bnssgformulary.nhs.uk/includes/documents/Treatment%20of%20CDIv
4.pdf
Anticholinergics To treat extra-pyramidal side- Elderly patients are more likely to experience adverse effects
effects of antipsychotic (including confusion, delirium, constipation, urinary retention, dry
Minimise use medications mouth/eyes, sedation, falls and cognitive impairment)
wherever
possible and Patients with dementia, chronic
review efficacy constipation, glaucoma or Risk of worsening respective condition.
and tolerance prostatic enlargement.
regularly. Anticholinergic drugs directly oppose the action of AChEIs and adversely
6
To reduce muscarinic side effects affects the course of dementia .
(e.g. Hyoscine, of acetylcholinesterase inhibitors
Tolterodine (AChEIs). Refer to Appendix1 for Anticholinergic Cognitive Burden Scale.
Oxybutynin,
Solifenacin, BNSSG joint formulary – Bladder and Urinary disorders
Trospium, http://www.bnssgformulary.nhs.uk/1-Bladder-and-urinary-disorders
Procyclidine, NICE CG171 Urinary Incontinence in Women
Trihexyphenidyl) https://www.nice.org.uk/guidance/cg171
Antidiarrhoeal For treatment of diarrhoea of Risk of delayed diagnosis, may exacerbate constipation with overflow
drugs (co- unknown cause diarrhoea, may precipitate toxic mega colon in inflammatory bowel
phenotrope, N.B. Please be aware of C. disease, may delay recovery in unrecognised gastroenteritis
loperamide or difficile in undiagnosed
codeine diarrhoea Risk of colitis and toxic mega colon if Clostridium difficile
phosphate) For the treatment of severe
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Approved by BNSSG DTC 18 January 2017. Review January 2019 unless guidance changes.
 infective gastroenteritis Risk of exacerbation or protraction of infection

Antipsychotics ˃1 month use as long-term Confusion, postural hypotension, extrapyramidal side effects, falls
hypnotic (check notes for
duration)
NB. Reduce ˃1 month use in parkinsonism Risk of worsening extrapyramidal symptoms
slowly
monitoring
effect
If fallen in last 3 months May cause gait dyspraxia, parkinsonism
Risk of gait disturbances, dehydration, prolonged sedation, cognitive
decline, falls, stroke and death.

>3 months treatment of Priority groups for review: care home patients (more frail and BPSD
behavioural and psychological more common than in general population) vascular dementia patients
symptoms of dementia patients and dementia patients with a history of cardiovascular disease,
(BPSD) and stable symptoms cerebrovascular disease or vascular risk factors.
(review ongoing need)
Benefits are limited over longer periods (>12 weeks)

Guidance from Alzheimer’s society is available online at

https://www.alzheimers.org.uk/site/scripts/services_info.php?serviceID=173
NICE guidelines:
http://pathways.nice.org.uk/pathways/dementia
Antihistamines First generation antihistamines Risk of sedation and anti-cholinergic side effects
(cyclizine, cholrphenamine,
promethazine).

If fallen in past 3 months

Prolonged use
Aspirin Dose ˃150mg / day, restart at Risk of bleeding; no evidence of increased efficacy
75mg if still indicated

With a concurrent bleeding High risk of bleeding

disorder

Risk of gastrointestinal bleeding Risk of bleeding

(e.g. peptic ulcer disease) without
histamine H2 receptor antagonist
or PPI

Primary prevention of CVD Guidance for antiplatelet prescribing for primary and secondary
prevention of CVD: http://cks.nice.org.uk/antiplatelet-treatment
If being used as monotherapy for
stroke prevention in AF Guidance at:
https://www.nice.org.uk/guidance/cg180
Benzodiazepin ˃1 month use of long-acting Risk of prolonged sedation, confusion, impaired balance, falls
es – reduce benzodiazepines, eg.
slowly & chlordiazepoxide, oxazepam,
monitor effect diazepam, flurazepam, Benzodiazepines and Z drug withdrawal and insomnia guidelines
nitrazepam available at: http://cks.nice.org.uk/insomnia

Regular and prolonged use In older people in particular, the magnitude of the beneficial effect of
hypnotics may not justify the increased risk of adverse effects (such as
cognitive impairment and increased risk of falls).
If fallen in last 3 months
The severity of withdrawal symptoms will depend on the degree of
dependence. Abrupt discontinuation should be avoided. Reduce
slowly and monitor effect.
Beta-blocker In combination with verapamil Risk of symptomatic heart block
(Reduce
gradually to In those with diabetes mellitus
avoid rebound and frequent hypoglycaemic
effect) episodes Risk of masking hypoglycaemic symptoms
Beta-blocker In patients with asthma Risk of bronchospasm
(non-
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Approved by BNSSG DTC 18 January 2017. Review January 2019 unless guidance changes.
cardioselective)
Bisphosphonates Unable to sit upright / patient Instruction for administration of medication if not followed causes
(oral) experiencing swallowing increased risk of serious upper GI disorder
difficulties / compliance issues

Low risk of fractures

A fracture occurred while on

treatment

After 5 years of treatment with oral For BNSSG osteoporosis drug holidays guidance: currently being
medications or 3 years after updated
parenteral (zoledronate) Bisphosphonates accumulate in bone during treatment, and when
stopped there is some residual protection against fractures. The length
of this varies according to duration of therapy and which agent is being
administered. Review recommended after 5years with alendronate,
risendronate or ibandronate and after 3 years for zoledronate.
BP lowering Consider need for and intensity of Limited evidence supporting tight BP control in the older frail group
drugs treatment in light of CVD risk, life
expectancy and ADR risk Seek specialist advice for patients with advanced heart failure as can
Stop one at a decompensate rapidly off medication
time, If fallen in past 3 months and
maintaining hypotension/postural hypotension Risk of syncope or falls
the dose of the present
others without
change. Postural Hypotension (abnormal Risk of falls
Restart them if decrease in blood pressure of at
BP least 20 mm Hg systolic and 10
11
increases : mm Hg diastolic within three
- Diastolic minutes of standing upright)
>90mm
Hg Withhold ACE inhibitors/ ARBs Can be restarted when patient has improved (e.g. 24-48h of eating and
- Systolic > with severe risk of dehydration drinking normally)
150mm (e.g. vomiting/ diarroea) https://www.thinkkidneys.nhs.uk/
Hg
(160mm
Hg if no
organ
damage)
Calcium If ankle oedema present This may be an adverse effect of the Calcium Channel Blocker see
Channel UKMI QA322 3_ankle oedema with CCBs (www.sps.nhs.uk)
Blocker

Verapamil and diltiazem should They may further depress cardiac function and cause clinically
usually be avoided in heart failure. significant deterioration.

Caution with Digoxin and Digoxin levels ↑↑

Betablockers Enhanced hypotensive effect with Betablockers
- Asystole, severe hypotension and heart failure with
verapamile+betablockers – avoid
- Possible severe hypotension and heart failure with nifedipine

With chronic constipation May exacerbate constipation

Dihydropyridines- CAUTION: Reflex tachycardia/ cardiopression

Avoid Nifedipine in CHD/CHF
Carbocisteine If no benefit after 4 weeks Unnecessary if no benefit shown

>1.5g/day Over recommended maintenance dose

Risk factors for peptic ulceration May disrupt the gastric mucosa barrier (consider gastro-protection)
Clopidogrel With concurrent bleeding disorder High risk of bleeding

Aspirin/ Clopidogrel combination

Ensure reviewed as per cardiology advice (usually indicated for a max
of 12 months after ACS only)
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Approved by BNSSG DTC 18 January 2017. Review January 2019 unless guidance changes.
 BNSSG guidelines for co-prescribing anticoagulants and antiplatelets
in primary care:
www.bnssgformulary.nhs.uk/includes/documents/Combination%20doc%20271
213.pdf
BNSSG Guidelines for prescribing antiplatelets:
www.bnssgformulary.nhs.uk/includes/documents/Guidelines%20for%20the%2
0Prescribing%20of%20Antiplatelets%20update%20Nov%202012%20081112S
B.pdf
Corticosteroids Oral instead of inhaled Unnecessary exposure to long-term side effects of systemic steroids.
corticosteroids for maintenance
(Withdraw therapy in moderate-severe Risk of major systemic corticosteroids side effects
gradually if: use COPD
>3 weeks, >40mg Ensure use of steroids aligned with COPD GOLD guideline:
prednisolone/day) www.bnssgformulary.nhs.uk/includes/documents/
COPD%20guidelines%20-April%2016%20v6.pdf

Guidance at http://cks.nice.org.uk/corticosteroids-oral
Long term use (>3 weeks)
Digoxin At doses ˃125 microgram per day Risk of toxicity increased (e.g. nausea, diarrhoea, arrhythmias)
with impaired renal function
(eGFR ˂50ml/minute)

With hypokalemia

Pulse persistently below 60bpm

Dipyridamole With concurrent bleeding disorder High risk of bleeding

As monotherapy for No evidence for efficacy except in ischaemic stroke.

cardiovascular secondary https://www.nice.org.uk/guidance/TA210/chapter/1-guidance
prevention
Antiplatelet prescribing guidelines: http://cks.nice.org.uk/antiplatelet-
treatment#!management
Diuretics Dependent ankle oedema and no No benefit; compression hosiery more appropriate. Consider
signs of heart failure medication causes, e.g. CCBs.

As first line monotherapy for Safer, more effective alternatives available

hypertension

Thiazides with history of gout Risk of exacerbating gout

Advise patient to stop during Restart when well (after 24-48h of eating and drinking normally)
intercurrent illness https://www.thinkkidneys.nhs.uk/
Domperidone Indications except See MHRA warning issued
nausea/vomiting https://www.gov.uk/drug-safety-update/domperidone-risks-of-cardiac-side-
Long term Underlying Cardiac effects
conditions, impaired cardiac
conduction, Duration of treatment:
co-prescribed other medications • The maximum treatment duration should not usually exceed one
known to prolong QT interval or week
potent CYP3A4 inhibitors or with • Patients currently receiving long-term treatment with domperidone
severe hepatic impairment should be reassessed at a routine appointment to advise on treatment
continuation, dose change, or cessation

Ipratropium Prescribing as required (prn) in Can lead to exceeding licensed dosage and therefore exacerbate side
(nebulised) addition to regular prescribing effects
With glaucoma May exacerbate glaucoma
Laxatives – For patients with intestinal Risk of bowel perforation
stimulant (e.g. obstruction
bisacodyl,
senna) If >1 laxative: Do not stop BNSSG joint formulary – Constipation and bowel cleansing
abruptly. http://www.bnssgformulary.nhs.uk/2-Constipation-and-bowel-cleansing
Reduce stimulant first and monitor
effect
Metformin Renal impairment: Increased risk of lactic acidosis
Review dose if eGFR <45 ml/min Guidance NG28, T2 diabetes in adults: management
Avoid if eGFR˂30ml/minute https://www.nice.org.uk/guidance/ng28
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Approved by BNSSG DTC 18 January 2017. Review January 2019 unless guidance changes.
 Advise patient to stop during Restart when well (after 24-48h of eating and drinking normally)
intercurrent illness https://www.thinkkidneys.nhs.uk/
Metoclopramide Long term use Licensed for a max of 5 days (does not apply to off label use in
palliative care). https://www.gov.uk/drug-safety-update/metoclopramide-risk-
of-neurological-adverse-effects
The risks of neurological effects such as extrapyramidal disorders and
tardive dyskinesia outweigh the benefits in long term or high dose
Parkinson’s disease treatment.
(domperidone more suitable but
note contra-indications in cardiac Metoclopramide readily crosses the blood brain barrier, causing
disease and severe liver disease) central effects such as sedation and dystonic reactions.
NSAID (oral) Moderate severe hypertension Risk of exacerbation of hypertension
(moderate 160/100mm Hg -
179/109mm Hg; severe:
˃180/110mm Hg

CVD risk>20%, previous CVD Risk of exacerbation and cardiovascular ADRs

events, heart failure.

Age>65, on ACEI/ARBs and/or

diuretics (“triple whammy”), CKD Risk of deterioration in renal function and renal ADRs
(GFR ˂60ml/min) or heart failure).

GI ulcer, warfarin or new Gastro-intestinal ADRs (e.g. bleeding)

anticoagulants, steroids, SSRIs, If NSAIDs are essential: Consider gastro-protection with a PPI in those
high alcohol use with GI risk factors

On long-term NSAID and Allopurinol first choice prophylactic in gout

colchicine for chronic treatment of
gout when there is no C/I to
allopurinol

Long-term NSAIDs as Simple analgesics preferable (paracetamol and topical NSAIDs should
monotherapy (˃3 month for be considered ahead of systemic NSAIDs or COX-2 inhibitors)
arthritis)

Cox-2 inhibitors and diclofenac in Increased risk of thrombotic events

cardiovascular disease
Ibuprofen (at total daily dose
above 1200mg per day) in Increased risk of thrombotic events
cardiovascular disease

Advise patient to stop during Restart when well (after 24-48h of eating and drinking normally)
intercurrent illness https://www.thinkkidneys.nhs.uk/
Oestrogen With history of breast cancer or Increased risk of reoccurrence
(systemic) venous thromboembolism
Without progesterone in patients Risk of endometrial cancer
with intact uterus
Omega-3 fatty Prescribed for secondary Review as per
acids prevention of MI -MI: cardiac rehabilitation and prevention of further CVD
http://www.nice.org.uk/guidance/cg172/resources/guidance-mi-secondary-
Primary or Secondary prevention prevention-pdf
of CVD -CVD:risk assessment and reduction, including lipid modification
For CVD prevention in patients https://www.nice.org.uk/guidance/cg181
with CKD and/or Diabetes (type 1
and 2) There is no evidence to support that omega‑3 fatty acid compounds
help to prevent CVD
Opioids (all Long-term use of powerful opiates WHO analgesic ladder not observed
type) (e.g. morphine, fentanyl) as first Cognitive impairment and respiratory depression, dependency
line therapy for mild-moderate www.bnssgformulary.nhs.uk/LocalGuidelines/ChronicPainGuidelines
pain

Regular prescription >2 weeks in Risk of severe constipation

chronic constipation without
concurrent use of laxatives

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Approved by BNSSG DTC 18 January 2017. Review January 2019 unless guidance changes.
 Long-term in dementia unless for Exacerbation of cognitive impairment
palliative care or management of
chronic pain

Recurrent Falls Risk of drowsiness, postural hypotension, vertigo

Pioglitazone Heart failure and elderly patients Increased risk of fracture, bladder cancer and heart failure
(glitazones)
Phenothiazines With Parkinsonism Risk of exacerbating Parkinsonism.
(e.g.
Prochlorperazine)
Quinine Long term use https://www.gov.uk/drug-safety-update/quinine-not-to-be-used-routinely-for-
nocturnal-leg-cramps
SSRIs If sodium less than 130 in past 2 SSRIs can cause/worsen hyponatraemia
months

Citalopram & escitalopram – risk Don’t use in patients with congenital long QT syndrome or known pre-
of QT prolongation existing QT interval prolongation
In combination with other drugs known to prolong the QT intervals
Citalopram >20mg/day BNSSG guidance:
http://www.bnssgformulary.nhs.uk/includes/documents/Citalopram%20dose%2
Escitalopram >10mg/day 0reduction%20flow%20chart%20based%20on%20advice%20from%20the%20
MHRA%20version5.pdf
High risk of gastrointestinal bleeding Can increase risk of bleeding
Statins Indications of shortened life In the absence of a recent acute coronary syndrome or
10
expectancy , unless there is an cerebrovascular event, the discontinuation of a statin toward the end
acute vascular syndrome of life is reasonable
www.medicinesresources.nhs.uk/GetDocument.aspx?pageId=797557

In patients displaying symptoms Risk of myopathy and rhabdomyolysis. Check creatinine kinase if
of muscle weakness and pain patient presents with muscular symptoms.

Consider review in light of Risks may outweigh potential benefits

comorbidities, polypharmacy,
general frailty, life expectancy, NICE CG181: Cardiovascular disease
patient preference and ADR risk https://www.nice.org.uk/guidance/CG181
Sulfonylureas With Type 2 diabetes Risk of prolonged hypoglycaemia
(particularly
Glibenclamide
or
Chlorpropamide)
Theophylline Monotherapy for COPD Safer, more effective alternatives, risk of adverse effects due to
narrow therapeutic index

http://www.bnssgformulary.nhs.uk/includes/documents/
COPD%20guidelines%20-April%2016%20v6.pdf
Tricyclic Dementia Risk of worsening cognitive impairment
antidepressant
s
NB. Withdraw Glaucoma May exacerbate glaucoma if untreated
gradually over
at least 4
weeks –
monitor effect
Cardiac conductive abnormalities Pro-arrhythmic effects

Constipation May worsen constipation

Combination with opiate or Risk of severe constipation

calcium channel blocker

Prostatism or history of urinary Risk of urinary retention

retention

Patients taking dosulepin Increased cardiac risk & toxicity in overdose

Ulcer healing PPI and H2RAs: dose for PUD > Earlier discontinuation or dose reduction for maintenance/prophylactic
drugs 8 weeks treatment of PUD, oesophagitis or GORD indicated.
(withdraw gradually to prevent Increased risk of C. difficile infection, pneumonia, bone fractures,
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Approved by BNSSG DTC 18 January 2017. Review January 2019 unless guidance changes.
 rebound hypersecretion of gastric hyponatremia and hypomagnesemia
acid) www.sps.nhs.uk/articles/clostridium-difficile-infection-is-use-of-proton-pump-
inhibitors-a-risk-factor-2/

GORD and dyspepsia in adults: investigation&management:

www.nice.org.uk/guidance/CG184/

clopidogrel+ [es]omeprazole MHRA Drug Safety Update 2010 advises that concurrent use should
be discouraged due to reduced antiplatelet effect, see www.gov.uk/drug-
safety-update/clopidogrel-and-proton-pump-inhibitors-interaction-updated-
advice
Vasodilator With persistent postural Risk of syncope and falls
drugs (e.g. hypotension i.e. recurrent > 20
hydralazine, mmHG drop in Sys BP
minoxidil)
st
Warfarin For 1 uncomplicated DVT or PE At 3 months, assess the risks and benefits of continuing treatment,
for longer than 3months taking into account the patient's risk of VTE recurrence and whether
they are at increased risk of bleeding. (www.nice.org.uk/guidance/cg144)

Frequently Asked Questions about anticoagulation with Warfarin for GPs:

http://www.bnssgformulary.nhs.uk/includes/documents/BNSSG%20%20Anticoag
Bleeding disorders, peptic ulcer, ulation%20question%20and%20answers%20v5%20July%202013.pdf
severe hypertension, severe renal
impairment

Hepatic impairment with impaired Increased risk of bleeding as a result of impaired ability to produce
clotting ability and raised INR clotting factors
Any regular E.g. Two concurrent opiates, Optimisation of monotherapy within a single drug class prior to
duplicate drug multiple NSAIDs, multiple considering a new drug class
class diuretics.
prescription Two or more anticholinergics
(antimuscarinics)
Increased risk of side-effects including confusion falls and death

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 START medications (age ≥ Circumstances
65 years)
ACE Inhibitor Chronic heart failure
Following acute myocardial infarction
Diabetes with nephropathy (e.g.overt urinalysis proteinuria or microalbuminuria
(˃30mg / 24 hours) ± serum biochemical renal impairment)
Antidepressants In presence of moderate to severe depressive symptoms lasting at least three
months
SSRIs are in general better tolerated in patients with dementia and depression
Antihypertensive Systolic blood pressure consistently ˃160mm Hg

Antipsychotic medication Patients with a co-morbid mental illness (e.g. schizophrenia, persistent
delusional disorder, psychotic depression or bipolar affective disorder) should
11
not have this medication reduced without specialist advice
Aspirin Documented history of atherosclerotic coronary, cerebral or peripheral vascular
disease in patients with sinus rhythm
Following an acute MI
Beta-blocker (oral) With chronic stable angina

Beta-agonist (inhaled) For BNSSG COPD guidance:

http://www.bnssgformulary.nhs.uk/includes/documents/COPD%20guidelines%20April%20
16%20v6.pdf
Review patients with mild, moderate or severe COPD at least once a year, and
very severe COPD at least twice a year as per NICE guidance -
http://www.nice.org.uk/guidance/cg101

Bisphosphonates In patients taking maintenance oral corticosteroid therapy with previous fragility
fractures or incident fractures during glucocorticoid therapy. Ensure there are no
absorption interactions e.g. Calcium. Counsel patient on the correct way to take
a bisphosphonate.
Calcium and vitamin D In patients with known osteoporosis (radiological evidence or previous fragility
fracture) or acquired dorsal kyphosis
BNSSG guidelines for treatment of vitamin D deficiency in adults in Primary
Care: www.bnssgformulary.nhs.uk/includes/documents/
BNSSG%20CCG%20Vitamin_D_Prescribing_Guidelines%20Jan16.pdf

Clopidogrel For ischaemic stroke or PVD as per http://www.nice.org.uk/guidance/ta210

DMARD With active moderate-severe rheumatoid disease lasting ˃12 weeks

Fibre supplement For chronic symptomatic diverticular disease with constipation

Laxatives In patients taking opioids - to prevent constipation

Ulcer healing drugs (PPI, For severe reflux or peptic stricture requiring dilatation
H2RA)
The risk of bleeding is increased when low-dose aspirin is combined with other
drugs that can increase the risk of bleeding. If these drugs are used
(clopidogrel+[es]omeprazole concurrently with low-dose aspirin, consider the need for gastro-protection with
should be avoided due to a proton pump inhibitor (such as omeprazole) or a histamine antagonist (such
reduced antiplatelet effect) as ranitidine). More information available at
http://cks.nice.org.uk/antiplatelettreatment#!prescribinginfosub

Drugs that can increase the risk of bleeding include:

- Antiplatelet drugs (such as clopidogrel, prasugrel, or ticagrelor).
- Nonsteroidal anti-inflammatory drugs (NSAIDs) (for example ibuprofen).
- Oral and parenteral anticoagulants (for example warfarin or heparin). Low
dose aspirin and oral anticoagulants are usually co-prescribed on the advice of
a specialist. Close monitoring is required.
- SSRIs (such as fluoxetine), venlafaxine, or duloxetine. Consider alternatives
that may be safer, such as trazodone, mianserin, mirtazapine, or reboxetine.
- Other drugs known to increase gastrointestinal bleeding (for example
corticosteroids).

Statins NICE CG181 ( https://www.nice.org.uk/guidance/CG181 )

For older people (≥85) statins may be of benefit in reducing the risk of non-fatal
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Approved by BNSSG DTC 18 January 2017. Review January 2019 unless guidance changes.
 myocardial infarction. Be aware of factors that may make treatment
inappropriate (comorbidities, polypharmacy, general frailty, life expectancy
(evidence shows that benefits of statins are seen at the earliest after 2 years of
therapy), patient preference and ADR risk)

Primary prevention of CVD when 10% or greater 10-year risk of developing

CVD. (Estimate the level of risk using the QRISK2 assessment tool)

Adults with T1 diabetes who are older than 40 years or have had diabetes for
more than 10 years or have established nephropathy or have other CVD risk
factors

CKD and Secondary prevention of CVD (documented history of coronary,

cerebral or peripheral vascular disease)
Anticoagulation (warfarin or Chronic atrial fibrillation as per http://www.nice.org.uk/guidance/cg180
a NOAC) Following diagnosis of DVT and PE if benefit outweighs the risk of treatment
For BNSSG guidelines: http://www.bnssgformulary.nhs.uk/Local-Guidelines/

References
1. Gallagher P, Ryan C, O’Connor M, Byrne S, O’Sullivan D, O’Mahony D. STOPP (Screening Tool of Older Persons’
Prescriptions)/START (Screening Tool to Alert Doctors to Right Treatment) criteria for potentially inappropriate
prescribing in older people: version 2. Age and Ageing 2014; O: 1-6
2. Howard R et al. Which drugs cause preventable admissions to hospital? A systematic review. Br J Clin Pharmacol
2006; 63:2; 136-147
3. Pirmohamed M et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18,820
patients. BMJ 2004; 329; 15-17
4. NICE Guidance – Medicines Optimisation: the safe and effective use of medicines to enable the best possible
outcomes, published March 2015
5. Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D. STOPP (Screening Tool of Older Persons’
Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment): Consensus Validation. Int J Clin
Pharmacol Ther 2008; 46(2): 72 – 83. PMID 18218287
6. Lu CJ et al. Chronic exposure to anticholinergic medications adversely affects the course of Alzheimer disease.
Am J Geriatr Psychiatry. 2003 Jul-Aug; 11 (4):458-61
7. STOPP START medication toolkit supporting medication review, NHS Cumbria, February 2013
8. STOPP START tool, Leicestershire Medicines Strategy Group, Feb 2014
9. STOPP START tool, Wirral Clinical Commissioning Group, March 2015
10. NHS Scotland. Polypharmacy guidance. Oct 2012. Available at:
http://www.central.knowledge.scot.nhs.uk/upload/Polypharmacy%20full%20guidance%20v2.pdf
11. All Wales Medicines Strategy Group. Polypharmacy: Guidance for prescribing in Frail Adults. July 2014.
12. Scottish Government and NHS Education for Scotland. Polypharmacy Guidance. Available online:
http://www.polypharmacy.scot.nhs.uk/ ( Last visited August/2016)

th
Approved by BNSSG DTC 18 January 2017. Review January 2019 unless guidance changes.
APPENDIX
1

*AEC- Anticholinergic effect on cognition.

th
Approved by BNSSG DTC 18 January 2017. Review January 2019 unless guidance changes.