Stopp Start Toolkit
Stopp Start Toolkit
Stopp Start Toolkit
Supporting
Medication Review
STOPP:
Screening Tool of Older People’s
Potentially
Inappropriate Prescriptions
START:
Screening Tool to Alert Doctors to
Right
(i.e. appropriate, indicated)
Treatments
Contents
Introduction
References
It is commonly agreed that older people are at greater risk of adverse effects from their
medicines due to age related changes in their major organs which in turn alter
pharmacokinetics and pharmacodynamics. They also often have multiple co-morbidities
leading to drug-drug interactions or cautions and contraindications to preferred treatments.
These patients however are often excluded from drug trials making it difficult for a clinician
to weigh up the benefits versus risks, let alone explain them to the patient. Furthermore,
although with increasing age a patient can move from benefiting from a treatment to being
at significant risk from it, there can be difficulty in stopping medication for the fear of being
accused of ageism.
This document is based on the STOPP START Tool, a medication review tool designed to
identify medication where the risks outweigh the benefits in the elderly and vice versa.
Eighteen experts in geriatric pharmacotherapy initially contributed to suggesting and then
rating the criteria. The STOPP criteria were evaluated (along with Beer’s criteria3) against
hospital admissions. One third of the patients with "potentially inappropriate prescriptions"
according to STOPP criteria presented with an associated adverse drug event.
All recommendations from the STOPP START Tool are included here, and where space
allows local and national guidance.
The recommendations are grouped according to British National Formulary chapters4 with
the STOPP items coloured red and the START items on the coloured green. The rationale
for the intervention is given in italics.
The tool was validated in patients aged 65 and over but there is still a place for clinical
judgement in deciding whether a person is "elderly" in terms of the potential effects of
medication.
Colour Key
1
Medication to consider starting in patients over 65 from the START Tool
STOPP
Diphenoxylate (co-phenotrope), loperamide or codeine phosphate
for treatment of diarrhoea of unknown cause
Prochlorperazine or metoclopramide
Fibre supplement
for chronic, symptomatic diverticular disease with constipation
MUST Tool
Review need for enteral nutrition. Assess patient according to MUST Tool:
www.bapen.org.uk/pdfs/must/must_full.pdf
Re-Feeding Syndrome
http://www.nice.org.uk/nicemedia/live/10950/29460/29460.pdf
Cardiovascular System BNF Section 2
STOPP
Digoxin
Beta-blocker
in combination with verapamil
o risk of symptomatic heart block
Aspirin
at dose >150 mg/day; restart at 75mg if still indicated
Warfarin
after 6 months of treatment for first, uncomplicated deep venous thrombosis
o no proven added benefit beyond 6 months
after 12 months of treatment for first uncomplicated pulmonary embolus
o no proven benefit beyond 12 months
with concurrent bleeding disorder
Clopidogrel
with concurrent bleeding disorder
o high risk of bleeding
Dipyridamole
as monotherapy for cardiovascular secondary prevention, unless intolerant to aspirin and
clopidogrel (secondary prevention TIA)
o no evidence for efficacy
with concurrent bleeding disorder
o high risk of bleeding
immediate release tablets
START
Cardiovascular System BNF Section 2
Warfarin
Aspirin
in the presence of chronic atrial fibrillation, where warfarin is contraindicated, but not aspirin
Aspirin or clopidogrel
with a documented history of atherosclerotic coronary, cerebral or peripheral vascular
disease in patients with sinus rhythm
following an acute myocardial infarction
Antihypertensive
therapy where systolic blood pressure consistently >160 mmHg
Statin
therapy with a documented history of coronary, cerebral or peripheral vascular disease
Beta-blocker
with chronic stable angina
following an episode of ACS if no contra-indications
Statin Therapy
The current NHS East Lancashire Medicines Management Board Lipid Modification Prescribing
Guidelines are available from the Medicines Management intranet pages 6. These guidelines do not
specify degree of independence or life expectancy - the decision to start a statin is between the
clinician and patient.
Simvastatin 40 mg is the treatment of choice in most scenarios. Dose and choice of statin should no
longer be based on target cholesterol, except in diabetes.
Maximum dose of simvastatin is 20mg at night when given with concomitant amlodipine, verapamil,
diltiazem, amiodarone
http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON180637
http://www.nice.org.uk/CG36
Respiratory System BNF Section 3
STOPP
Theophylline
Systemic corticosteroids
instead of inhaled corticosteroids for maintenance therapy in moderate-severe COPD
o unnecessary exposure to long-term side-effects of systemic steroids
Nebulised ipratropium
Prescribing as required (prn) in addition to regular
o Can lead to exceeding licensed dosage and therefore exacerbate side effects
with glaucoma
o may exacerbate glaucoma
Adapted masks can be used to reduce direct optical exposure to
ipratropium
Carbocisteine
if no benefit after 4 weeks
o unnecessary if no benefit shown
Antibiotics
Review i/v antibiotics after 48 hours and switch to oral if possible
o Cultures and sensitivities may be available by this point; if i/v antibiotics continue
beyond 48 hours review daily
START
Respiratory System BNF Section 3
Beta-2 agonist or anticholinergic (antimuscarinic)
in patients at high risk of osteoporosis due to long term treatment with steroids
-cyanosis
-polycythaemia
-peripheral oedema
Theophylline
Only offer theophylline after trials of short- and long- acting bronchodilators or to people who cannot
use inhaled therapy.
Local guidance available on intranet
Home page: Policies and procedures>Guidelines>Medicines and prescribing>Aminophylline loading
and maintenance dosing
Oral Corticosteroids
Maintenance use of oral corticosteroid therapy in COPD is not normally recommended.
Some people with advanced COPD may need maintenance oral corticosteroids if treatment cannot be
stopped after an exacerbation. Keep the dose as low as possible, monitor for osteoporosis and offer
prophylaxis.
Central Nervous System & Psychotropic Drugs BNF Section 4
STOPP
Tricyclic antidepressants (TCAs)
with dementia
with glaucoma
o pro-arrhythmic effects
with constipation
Benzodiazepines
NB. In cases where a patient has been on benzodiazepine for a prolonged period they should be
withdrawn very slowly**
if long-term (i.e. > 1 month) and long-acting (e.g. chlordiazepoxide, oxazepam, nitrazepam) and
benzodiazepines with long-acting metabolites (e.g. diazepam)
Antipsychotics (Neuroleptics)
Anticholinergics
to treat extra-pyramidal side-effects of neuroleptic medications
o risk of anticholinergic toxicity, including confusion and urinary retention
with a history of clinically significant hyponatraemia (<130 mmol/L within the previous 2
months)
o SSRIs can cause/worsen hyponatraemia
Opioids
Use of long-term strong opiates as first line therapy for mild-moderate pain
Section 4
Levodopa
in idiopathic Parkinson’s disease with definite functional impairment and resultant disability
o specialist initiation only, refer where necessary
Antidepressant
drug in the presence of moderate-severe depressive symptoms lasting at least three months
Laxatives
In patients taking opioids
o Prevent constipation
The first step in mild depression is not routinely to prescribe e.g. offer CBT
**Welsh MeReC
Gives guidance on stopping benzodiazepines, antidepressants and antipsychotics available at
www.wemerec.org.
Glibenclamide or chlorpropamide
with Type 2 diabetes mellitus
o risk of prolonged hypoglycaemia
Beta-blockers
in those with diabetes mellitus and frequent hypoglycaemic episodes i.e. > 1 episode per month
o risk of masking hypoglycaemic symptoms
Oestrogens
with a history of breast cancer or venous thromboembolism
o increased risk of recurrence
without progestogen in patients with intact uterus
o risk of endometrial cancer
Pioglitazone
in patients with heart failure or at risk of heart failure
o increased incidence of heart failure with pioglitazone
Metformin
in patients with eGFR<30
o risk of acidosis; use metformin with caution if eGFR <45
START
Endocrine System BNF Section 6
Metformin
with type 2 diabetes +/- metabolic syndrome (in the absence of renal impairment - eGFR <50mL/
minute)
Antiplatelet therapy
in diabetes mellitus if one or more co-existing major cardiovascular risk factors present
(hypertension, hypercholesterolaemia, smoking history)
Statin therapy
in diabetes mellitus if one or more co-existing major cardiovascular risk factor present
http://www.nice.org.uk/Search.do?searchText=cg87&newsearch=true#/search/?reload
Available from the Medicines Management intranet pages6. See cardiovascular section of this
guidance.
Urogenital System BNF Section 7
STOPP
Bladder antimuscarinic drugs
with dementia
o risk of increased confusion, agitation
with chronic glaucoma
o risk of acute exacerbation of glaucoma
with chronic constipation
o risk of exacerbation of constipation
with chronic prostatism
o risk of urinary retention
Alpha-blockers
in males with frequent incontinence i.e. one or more episodes of incontinence daily
o risk of urinary frequency and worsening of incontinence
with long-term urinary catheter in situ i.e. more than 2 months
o drug not indicated
There is evidence to support the use of pelvic floor muscle training and bladder training
ahead of medication (see table below).
Stress Mixed Urge UI First
UI UI or OAB pregnancy
Pelvic floor * * *
muscle training
Bladder * *
training
Antimuscarinic
* *
treatment
Immediate release oxybutynin should be offered to women with overactive bladder syndrome
(OAB) or mixed urinary incontinence (UI) if bladder training has been effective. There is no
evidence of clinically significant differences between the antimuscarinic drugs.
Musculoskeletal System BNF Chapter 10
STOPP
Non-steroidal anti-inflammatory drug (NSAID)
with history of peptic ulcer disease or gastrointestinal bleeding, unless with concurrent H 2
receptor antagonist, PPI
o risk of peptic ulcer relapse
with moderate-severe hypertension (moderate: 160/100mmHg – 179/109mmHg; severe:
≥180/110mmHg)
o risk of exacerbation of hypertension
with heart failure
o risk of exacerbation of heart failure
with warfarin
o risk of gastrointestinal bleeding
with chronic renal failure - eGFR 20-50mL/minute
o risk of deterioration in renal function
Long-term use of NSAID (>3 months) for relief of mild joint pain in osteoarthritis
o simple analgesics preferable and usually as effective for pain relief
Long-term NSAID or colchicine for chronic treatment of gout where there is no contraindication to allopurinol
o allopurinol first choice prophylactic drug in gout
Long-term corticosteroids (>3 months) as monotherapy for rheumatoid arthritis or osteoarthritis
o risk of major systemic corticosteroid side-effects
Cyclo-oxygenase-2 selective inhibitors, diclofenac and ibuprofen in cardiovascular
disease
o Increased risk of thrombotic events
Musculoskeletal System BNF Chapter 10
START
Disease-modifying anti-rheumatic drug (DMARD)
with active moderate-severe rheumatoid disease lasting > 12 weeks
Bisphosphonates
in patients taking maintenance oral corticosteroid therapy. Ensure there are no absorption
interactions with e.g. Calcium. Counsel patient on the correct way to take a
bisphosphonate
In primary prevention, women aged 75 and over do not require a DEXA scan before starting
alendronic acid if they have two or more clinical risk factors or indicators of low BMD; for secondary
prevention this is reduced to one or more.
For treatments other than alendronic acid a DEXA scan is required because the treatments are only
indicated at certain T scores; unless, in secondary prevention, the clinician considers it inappropriate
or unfeasible.
Wound Management
The current NHS ELMMB Joint Wound Care Formulary is available from the Medicines
Management intranet pages6.
If after using a silver product for 1-2 weeks, no improvement in the wound is seen, then a full
reassessment of the wound and patient should be undertaken.
Vitamin D deficiency
Local guidance available on East Lancashire Medicines Management Board website
http://www.elmmb.nhs.uk
References
2. Task Force on Medicines Partnership. Room for Review. A guide to medication review: the
agenda for patients, practitioners and managers. Medicines Partnership. London. 2002
3. Beers MH. Explicit Criteria for Determining Potentially Inappropriate Medication Use by
Elderly. An Update. Arch Intern Med. 1997;157:1531-1536
December 2012