Appendix 1

STOPP: Screening Tool of Older Peoples potentially inappropriate Prescriptions. The following
drug prescriptions are potentially inappropriate in persons aged 65 years of age

A. Cardiovascular System
1. Digoxin at a long-term dose > 125g/day with impaired renal function (increased risk of toxicity).
2. Loop diuretic for dependent ankle oedema only i.e. no clinical signs of heart failure (no evidence of
efficacy, compression hosiery usually more appropriate).
3. Loop diuretic as first-line monotherapy for hypertension (safer, more effective alternatives
available).
4. Thiazide diuretic with a history of gout (may exacerbate gout).
5. Beta-blocker with Chronic Obstructive Pulmonary Disease (COPD) (risk of increased
bronchospasm).
6. Beta-blocker in combination with verapamil (risk of symptomatic heart block).
7. Use of diltiazem or verapamil with NYHA Class III or IV heart failure (may worsen heart failure).
8. Calcium channel blockers with chronic constipation (may exacerbate constipation).
9. Use of aspirin and warfarin in combination without histamine H2 receptor antagonist (except
cimetidine because of interaction with warfarin) or proton pump inhibitor (high risk of gastrointestinal
bleeding).
10. Dipyridamole as monotherapy for cardiovascular secondary prevention (no evidence for efficacy).
11. Aspirin with a past history of peptic ulcer disease without histamine H2 receptor antagonist or
Proton Pump Inhibitor (risk of bleeding).
12.Aspirin at dose > 150mg day (increased bleeding risk, no evidence for increased efficacy).
13. Aspirin with no history of coronary, cerebral or peripheral vascular symptoms or occlusive event
(not indicated).
14. Aspirin to treat dizziness not clearly attributable to cerebrovascular disease (not indicated).
15. Warfarin for first, uncomplicated deep venous thrombosis for longer than 6 months duration (no
proven added benefit).
16. Warfarin for first uncomplicated pulmonary embolus for longer than 12 months duration (no
proven benefit).
17. Aspirin, clopidogrel, dipyridamole or warfarin with concurrent bleeding disorder (high risk of
bleeding).
estimated GFR <50ml/min.

B. Central Nervous System and Psychotropic Drugs.

1. Tricyclic antidepressants (TCAs) with dementia (risk of worsening cognitive impairment).
2. TCAs with glaucoma (likely to exacerbate glaucoma).
3. TCAs with cardiac conductive abnormalities (pro-arrhythmic effects).

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4. TCAs with constipation (likely to worsen constipation).
Appendix 1 cont.

5. TCAs with an opiate or calcium channel blocker (risk of severe constipation).

6. TCAs with prostatism or prior history of urinary retention (risk of urinary retention).
7. Long-term (i.e. > 1 month), long-acting benzodiazepines e.g. chlordiazepoxide, fluazepam,
nitrazepam, chlorazepate and benzodiazepines with long-acting metabolites e.g. diazepam (risk of
prolonged sedation, confusion, impaired balance, falls).
8. Long-term (i.e. > 1 month) neuroleptics as long-term hypnotics (risk of confusion, hypotension,
extra-pyramidal side effects, falls).
9. Long-term neuroleptics ( > 1 month) in those with parkinsonism (likely to worsen extra-pyramidal
symptoms)
10. Phenothiazines in patients with epilepsy (may lower seizure threshold).
11. Anticholinergics to treat extra-pyramidal side-effects of neuroleptic medications (risk of
anticholinergic toxicity).
12. Selective serotonin re-uptake inhibitors (SSRIs) with a history of clinically significant
hyponatraemia (non-iatrogenic hyponatraemia <130mmol/l within the previous 2 months).
13. Prolonged use (> 1 week) of first generation antihistamines i.e. diphenydramine, chlorpheniramine,
cyclizine, promethazine ( risk of sedation and anti-cholinergic side effects).

C. Gastrointestinal System
1. Diphenoxylate, loperamide or codeine phosphate for treatment of diarrhoea of unknown cause (risk
of delayed diagnosis, may exacerbate constipation with overflow diarrhoea, may precipitate toxic
megacolon in inflammatory bowel disease, may delay recovery in unrecognised gastroenteritis).
2. Diphenoxylate, loperamide or codeine phosphate for treatment of severe infective gastroenteritis i.e.
bloody diarrhoea, high fever or severe systemic toxicity (risk of exacerbation or protraction of
infection)
3. Prochlorperazine (Stemetil) or metoclopramide with Parkinsonism (risk of exacerbating
Parkinsonism).
4. PPI for peptic ulcer disease at full therapeutic dosage for > 8 weeks (dose reduction or earlier
discontinuation indicated).
5. Anticholinergic antispasmodic drugs with chronic constipation (risk of exacerbation of constipation).

D. Respiratory System.
1. Theophylline as monotherapy for COPD. (safer, more effective alternative; risk of adverse effects
due to narrow therapeutic index)
2. Systemic corticosteroids instead of inhaled corticosteroids for maintenance therapy in moderate-
severe COPD (unnecessary exposure to long-term side-effects of systemic steroids).
3. Nebulised ipratropium with glaucoma (may exacerbate glaucoma).

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 Appendix 1 cont.

E. Musculoskeletal System
1. Non-steroidal anti-inflammatory drug (NSAID) with history of peptic ulcer disease or
gastrointestinal bleeding, unless with concurrent histamine H2 receptor antagonist, PPI or misoprostol
(risk of peptic ulcer relapse).
2. NSAID with moderate-severe hypertension (moderate: 160/100mmHg 179/109mmHg; severe:
180/110mmHg) (risk of exacerbation of hypertension).
3. NSAID with heart failure (risk of exacerbation of heart failure).
4. Long-term use of NSAID (>3 months) for relief of mild joint pain in osteoarthtitis (simple analgesics
preferable and usually as effective for pain relief)
5. Warfarin and NSAID together (risk of gastrointestinal bleeding).
6. NSAID with chronic renal failure (risk of deterioration in renal function).
7. Long-term corticosteroids (>3 months) as monotherapy for rheumatoid arthrtitis or osterarthritis (risk
of major systemic corticosteroid side-effects).
8. Long-term NSAID or colchicine for chronic treatment of gout where there is no contraindication to
allopurinol (allopurinol first choice prophylactic drug in gout)
estimated GFR 20-50ml/min.

F. Urogenital System
1. Bladder antimuscarinic drugs with dementia (risk of increased confusion, agitation).
2. Antimuscarinic drugs with chronic glaucoma (risk of acute exacerbation of glaucoma).
3. Antimuscarinic drugs with chronic constipation (risk of exacerbation of constipation).
4. Antimuscarinic drugs with chronic prostatism (risk of urinary retention).
5. Alpha-blockers in males with frequent incontinence i.e. one or more episodes of incontinence daily
(risk of urinary frequency and worsening of incontinence).
6. Alpha-blockers with long-term urinary catheter in situ i.e. more than 2 months (drug not indicated).

G. Endocrine System
1. Glibenclamide or chlorpropamide with type 2 diabetes mellitus (risk of prolonged hypoglycaemia).
2. Beta-blockers in those with diabetes mellitus and frequent hypoglycaemic episodes i.e. 1 episode
per month (risk of masking hypoglycaemic symptoms).
3. Oestrogens with a history of breast cancer or venous thromboembolism (increased risk of
recurrence)
4. Oestrogens without progestogen in patients with intact uterus (risk of endometrial cancer).

H. Drugs that adversely affect those prone to falls ( 1 fall in past three months)
1. Benzodiazepines (sedative, may cause reduced sensorium, impair balance).
2. Neuroleptic drugs (may cause gait dyspraxia, Parkinsonism).
3. First generation antihistamines (sedative, may impair sensorium).

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 Appendix 1 cont.

4. Vasodilator drugs known to cause hypotension in those with persistent postural hypotension i.e.
recurrent > 20mmHg drop in systolic blood pressure (risk of syncope, falls).
5. Long-term opiates in those with recurrent falls (risk of drowsiness, postural hypotension, vertigo).

I. Analgesic Drugs
1. Use of long-term powerful opiates e.g. morphine or fentanyl as first line therapy for mild-moderate
pain (WHO analgesic ladder not observed).
2. Regular opiates for more than 2 weeks in those with chronic constipation without concurrent use of
laxatives (risk of severe constipation).
3. Long-term opiates in those with dementia unless indicted for palliative care or management of
moderate/severe chronic pain syndrome (risk of exacerbation of cognitive impairment).

J. Duplicate Drug Classes

Any duplicate drug class prescription e.g. two concurrent opiates, NSAIDs, SSRIs, loop diuretics,
ACE inhibitors (optimisation of monotherapy within a single drug class should be observed prior to
considering a new class of drug).

Appendix 2

Beers Criteria for Potentially Inappropriate Medication Use in Older Adults: Independent of
Diagnosis or Conditions [6]

Propoxyphene and combination products

Indomethacin
Pentazocine
Trimethobenzamide
Muscle relaxants and antispasmodics: methocarbamol, carisprodol, oxybutinin, chloroxazone,
metaxalone and cyclobenzaprine (do not consider extended release oxybutinin)
Flurazepam
Amitriptyline, chlordiazepoxideamitryptilline and perphenazineamitryptilline
Doxepin
Mepobramate
Doses of short-acting benzodiazepines: doses greater than lorazepam, 3 mg; oxazepam, 60 mg;
alprazolam, 2 mg; temezepam, 15 mg; triazolam 0.25mg.
Long-acting benzodiazepines: Chlordiazepoxide, chlordiazepoxideamitryptilline, clidinium
chlordiazepoxide, diazepam, quazepam, halazepam and chlorazepate
Disopyramide

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Digoxin (should not exceed 0.125 mg daily, except when treating atrial arrhythmias)
Short-acting dipyridamole.
Methyldopa and methyldopa-hydrochlorothiazide Cyclandelate
Reserpine at doses >0.25 mg
Chlorpropramide
Gastrointestinal antispasmodic drugs: dicyclomine, hyoscyamine, propantheline, belladonna alkaloids
and clinidiumchlordiazepoxide.
Anticholinergics and antihistamines: Chlorpheniramine, diphenhydramine, hydroxyzine,
cyproheptadine, promethazine, tripelennamine and dexchlorpheniramine
Diphenhydramine
Ergot mesyloids and cyclandelate
Ferrous sulphate >325 mg/day.
All barbiturates (except phemobarbital) except when used to control seizures.
Meperidine
Ticlopidine
Ketorolac
Amphetamines and anorexic agents

Appendix 2 cont.

Beers Criteria for Potentially Inappropriate Medication Use in Older Adults: Independent of
Diagnosis or Conditions [6]

Long-term use of full-dosage, longer half-life, non-COX selective NSAIDs: Naproxen, Oxaprozin and
piroxiam.
Daily fluoxetine
Long-term use of stimulant laxatives: bisacodyl, cascara sagrada, and Neoloid except in the presence of
opioid analgesic use.
Amiodarone
Orphenadrine
Guanethidine
Guanadrel
Cyclandelate
Isoxsurpine
Nitrofurantoin
Doxazosin
Methyltestosterone
Thiridazine
Mesoridazine
Short acting nifedipine

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Clonidine
Mineral oil
Cimetidine
Ethacrynic acid
Dessicated Thyroid
Amphetamines (excluding methylpheidate hydrochloride and anorexics)
Extrogens only (oral)

Appendix 2 cont.

2002 Criteria for Potentially Inappropriate Medication Use in Older Adults: Considering
Diagnoses or Conditions. [6]

Diagnosis Drug
Heart failure Disopyramide and high sodium content drugs
[e.g. sodium and sodium salts (alginate,
bicarbonate, biphosphate, citrate, phosphate,
salicylate and sulphate)]
Hypertension Phenylpropanolamine hydrochloride (removed
from the market in 2001), pseudoephedrine, diet
pills and amphetamines
Gastric or duodenal ulcers NSAIDS and aspirin (>325 mg)
Seizures or epilepsy Clozapine, chlorpromazine, thioridazine and
thiothixene
Blood-clotting disorders or
receiving anticoagulant therapy Aspirin, NSAIDs, dipryidamole, Ticlodipine and
clopidgrel
Bladder outflow obstruction Anticholinergics and antihistamines, GI
antispasmodic drugs, muscle relaxants,
oxybutinin, flavoxate, anticholinergics,
antidepressants, decongestants and tolteridine
Stress incontinence Alpha-blockers, anticholinergics, tricyclic
antidepressants (imipramine hydrochloride,
doxepin hydrochloride and amitryptilline
hydrochloride) and long-acting benzodiazepines
Arrhythmias Tricyclic antidepressants (imipramine
hydrochloride, doxepin hydrochloride and
amitryptilline hydrochloride)
Insomnia Decongestants, theophylline, methylphenidate,
MAOIs and amphetamines

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Parkinson disease Metoclopramide, conventional antipsychotics
and tacrine

Appendix 2 cont.

2002 Criteria for Potentially Inappropriate Medication Use in Older Adults: Considering
Diagnoses or Conditions cont.

Cognitive impairment Barbiturates, anticholinergics, antispasmodics,

muscle relaxants and CNS stimulants:
dextroamphetamine, methylphenidate,
methamphetamine and pemolin
Depression Long-term benzodiazepine use. Sympatholytic
agents: methyldopa, reserpine and guanethidine
Anorexia and malnutrition CNS stimulants: dextroamphetamine,
methylphenidate, methamphetamine, pemolin
and fluoxetine
Syncope or falls Short- to intermediate acting benzodiazepine and
tricyclic antidepressants (imipramine
hydrochloride, doxepin hydrochloride and
amitryptilline hydrochloride)
SIADH/hyponatraemia SSRIs: fluoxetine, citalopram, fluvoxamine,
paroxetine and sertraline
Seizure disorder Bupropion
Obesity Olanzapine
COPD Long-acting benzodiazepines: chlordiazepoxide,
chlordiazepoxideamitryptilline, clidinium
chlordiazepoxide, diazepam, quazepam,
halazepam and chlorazepate. b-blockers:
propanolol
Constipation Calcium channel blockers, anticholinergics,
tricyclic antidepressants (imipramine
hydrochloride, doxepin hydrochloride and
amitryptilline hydrochloride)

CNS = central nervous system; COPD = chronic obstructive pulmonary disease; GI = gastrointestinal;
MAOI = monoamine oxidase inhibitor; NSAID = non-steroidal anti-inflammatory drug; SIADH =
syndrome of inappropriate ADH (antidiuretic hormone); SSRI = selective serotonin reuptake inhibitor.
adverse drug events