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Inappropriate medicines list updated for first time in 15 years


Jolyon Attwooll


5/02/2024 4:20:37 PM

Authors of a recent study, specific to Australia, have identified 19 medications which may cause more harm than benefit among older people.

Messy assortment of medications
The list is designed for use as a decision support tool when assessing medication appropriateness in older people.

A list designed to stop older people being prescribed medications that could cause them harm has been updated for the first time in 15 years.
 
Since the release of the previous potentially inappropriate medicines (PIMs) list, authors of a new study published in the Internal Medicine Journal have noted changes to medications available in Australia since.
 
The list was compiled using the Delphi technique, which requires consensus from experts. Those involved in the study included 33 clinicians and researchers from various fields including geriatrics, general medicine, pharmacy, clinical pharmacology, general practice and epidemiology.
 
Of a total 130 medications or medication classes considered, including many that appear in international PIMs lists, 19 were deemed potentially inappropriate.
 
Of those 19, 16 were listed with possible alternative treatments, including some nonpharmacological possibilities.
 
PIMs are described in the article as ‘medicines with risks that may potentially outweigh their benefits and should be avoided if there are equally or more effective but lower-risk alternatives available’.
 
Corresponding author of the study, Dr Kate Wang of RMIT University, said the list is useful for Australian healthcare practitioners who look after people aged 65 and older.
 
Dr Wang found that PIMs lists from other countries are only ‘partially applicable’ in Australia due differences in availability, prescribing patterns, clinical guidelines and the healthcare system.
 
‘It’s important to note that all medications on this list provide clinical benefits, if used appropriately, and may be suitable for some people considering their allergies, interactions with other drugs, medication conditions, individual beliefs, clinical experiences, preferences and goals,’ she said.
 
Benzodiazepines, nonsteroidal anti-inflammatory drugs (NSAIDs) and tricyclic antidepressants, which appear in many PIMs lists internationally, are also included in the updated Australian version.
 
For Professor Mark Morgan, Chair of RACGP Expert Committee – Quality Care, the list is ‘a helpful and practical resource’.
 
In particular he drew attention to a table (see Table 2 in article) detailing the comorbidities which make each of the 19 medicines a high risk in the elderly.
 
However, he also notes one area where he believes more detail would be useful.
 
‘In the list of safer alternatives, paracetamol features frequently as an alternative to NSAIDs or opioids for analgesia,’ he told newsGP.
 
‘While this might be true from a safety perspective it should be noted that the evidence of efficacy of paracetamol for some painful conditions is limited.
 
‘Low back pain and osteoarthritis are examples where many patients don’t see a benefit from paracetamol.
 
‘I see this list of medicines as a helpful resource but it would be more helpful still if there was a layer of evidence-synthesis underpinning the various recommendations so we could trust they are based on the best available information, rather than just collected wisdom from multiple experts.
 
‘I hope there is opportunity to build on this initial work to ensure the alternatives that are suggested are the best available.’
 
The study notes that while medicines have ‘great potential for benefit in older people … some have high risks of medication-related harm, including severe adverse effects, drug–drug interactions, medication-related falls, hospitalisations and death’.
 
The study authors also cited research which suggests medication-related adverse effects contribute to 20% of unplanned hospital admissions.
 
Half of those are ‘potentially preventable’, they wrote.
 
Professor Morgan suggested computer decision support (CDSS) could have a useful role, noting his involvement as a clinical advisor to Primary Sense, a data extraction and clinical support tool which provides in-built medication alerts.
 
‘[CDSS] could play a role in alerting GPs who are about to prescribe one of these medicines to a patient that fits into one of the high-risk groups,’ he said.
 
‘Alerts need to be concise, relevant to the specific patient and offer alternative evidence-based strategies.’
 
Professor Morgan pointed to previous research he co-authored, published in the Australian Journal of General Practice in November 2022, which underscores the impact of CDSS.
 
We found that about 40% of the time, GPs responded to well-targeted alerts which suggests that computer decision support can be helpful at pulling relevant information together at the point of prescribing,’ he said.
 
Authors of the research published in the the Internal Medicine Journal emphasised the need for every patient to be considered individually.
 
‘The PIMs list is intended to be used as a decision support tool for clinicians when assessing medication appropriateness in older people and does not substitute individualised assessment of each patient presenting for clinical management,’ they wrote.
 
Details of the RACGP’s evidence-based non-drug therapies and strategies are published in HANDI (Handbook of Non-Drug Interventions) on the RACGP website.
 
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Dr Mark Raines   6/02/2024 1:31:42 PM

I don't use over half the drugs on this list for any patients not just the elderly.

A couple of questions come to mind.
If the most experts were over 59 year in quoted study would their consensus be different?
At least the experts suggest I can use celecoxib along with paracetamol.
Except you can always find a study which upsets your views, for example, this one suggested there is an increase in renal and cardiovascular badness with celecoxib.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6299466/

At the end of the day a shared decision may go, yes I can given you strategies and medication which will help with pain, help you move better and make life bearable, but there may be a X% risk you may need to go to hospital with heart/kidney/etc problems..........


Dr Stephen H   6/02/2024 3:21:46 PM

So as an anti-emetic we should prescribe ondansetron? I don't disagree from a safety and efficacy point of view, but maybe this should be PBS listed beyond the current very narrow list of indications (chemo/radiotherapy)


A.Prof Christopher David Hogan   6/02/2024 6:21:23 PM

These lists are of restricted relevance to General Practice.
The aim should be to advise that such medications are not first line drugs & should only be used with caution & explanation. To ban these drugs outright is not helpful.
Life is full of difficult choices & sometimes we have no option but to use such medications .
GPs deal regularly with complexity & uncertainty, more so than most other disciplines. How many GPs experienced in aged care were on the panel?
There is a limitation to guidelines that lies in the paucity of evidence supporting them.
There are over 400 guidelines for people with one condition.
A handful for people with 2 comorbidities but the only evidence for people with multiple co- morbidities is for deprescribing. It is not hard to find patients with over 10 multiple comorbidities.


Dr Michael Charles Rice   8/02/2024 9:49:14 PM

#AlwaysLearning, allways favouring safer options. But I'm hamstrung, by the PBS and by the Approved Product Information from TGA.

It's time we had a means for expanding PBS and TGA indications for safer alternatives, that doesn't rely on the medicine's Sponsor? Once out of patent, little is likely to change and genuine advances are few and far between.

Brief observations:
Prazosin is unrestricted on PBS but the proposed alternatives silodosin and tamsulosin require authorities.
I'd love better access to ondansetron
Not to mention quetiapine and risperidone and of course, PBS-funded yoga!
Melatonin would be good on PBS
As would be ANY alternative for oxybutinin!
Paracetamol's undoubtedly a safer alternative to NSAIDs: is it efficacious beyond placebo?
I'm all for avoiding tricyclics in the elderly: but I use them as analgesic adjuvants, not antidepressants. Perhaps some of those SSRIs and SNRIs need PBS indications updated?