GC079 (supp-2)stopp-start-v3
STOPP/START version 3 (GC079 supplement 2) is an updated evidence-based set of explicit criteria for potentially inappropriate prescribing (STOPP) and potential prescribing omissions (START) in older adults, designed to optimize medication appropriateness in people aged 65 and over.
STOPP/START Version 3: Screening Tool for Potentially Inappropriate Prescribing in Older People
This document is the complete criteria list for STOPP/START version 3 — the most current European consensus-based tool for identifying Potentially Inappropriate Medications (PIMs) and Potential Prescribing Omissions (PPOs) in patients aged ≥ 65 years. It is a supplementary resource to GC 079 (Prescribing in Older People), and its content is directly testable in summative exams.
Why does this matter?
Older adults with multimorbidity take many drugs (polypharmacy). Each additional drug increases the risk of adverse drug reactions (ADRs) exponentially. STOPP identifies drugs that should not be prescribed in certain clinical contexts (things to STOP). START identifies drugs that should be prescribed but are commonly omitted (things to START). Together, they form a systematic medication review checklist.
Key exam framing: STOPP = drugs that are potentially inappropriate and should be stopped or avoided. START = drugs that are indicated but are often inappropriately omitted. Both apply to patients ≥ 65 years old. Version 3 (2023) expanded significantly from version 2 (2015). [1]
STOPP Criteria: Drugs to STOP (Potentially Inappropriate Prescriptions)
These are the UNIVERSAL PRINCIPLES that apply to every drug in every older patient. They are the most commonly examined because they test prescribing fundamentals. [1]
| Criterion | Rule | Why It Matters |
|---|---|---|
| A1 | Any drug prescribed without a clinical indication | Every medication must have a documented reason. Older patients accumulate drugs over time; at each review, ask "why is this drug still here?" |
| A2 | Any drug prescribed beyond the recommended duration, where treatment duration is well defined | Classic examples: PPIs beyond 8 weeks for uncomplicated peptic ulcer, antibiotics beyond the recommended course, benzodiazepines beyond 4 weeks |
| A3 | Any duplicate drug class prescription for daily regular use (e.g. two concurrent NSAIDs, SSRIs, loop diuretics, ACEIs, anticoagulants, antipsychotics, opioids) | Doubling drugs in the same class doesn't double efficacy but does double toxicity. The rule is: optimize monotherapy within a class before adding a new agent |
Exam Trap: Duplicate Drug Classes
A common exam question gives a patient on both ramipril AND lisinopril (two ACEIs), or on both codeine AND tramadol (two opioids). This violates A3. Students often miss this because they don't think of these as "duplicates" since they have different names. The key is to recognize the DRUG CLASS, not just the drug name.
This is the largest and highest-yield STOPP section with 21 criteria. Cardiovascular drugs are the most commonly prescribed in older adults and the most commonly tested.
| # | Criterion | Rationale (First Principles) |
|---|---|---|
| B1 | Digoxin for HF with normal systolic ventricular function | Digoxin works by increasing contractility (positive inotrope via Na+/K+-ATPase inhibition). If systolic function is normal (i.e. HFpEF), there's nothing to "boost" — no evidence of benefit, only risk of toxicity |
| B2 | Verapamil or diltiazem with NYHA III/IV HF | Non-dihydropyridine CCBs are negative inotropes. In already-failing hearts (HFrEF), they worsen cardiac output → clinical deterioration |
| B3 | Beta-blocker + verapamil or diltiazem | Both slow AV conduction. Combined → risk of complete heart block |
| B4 | Ventricular rate-limiting drugs (BB, verapamil, diltiazem, digoxin) with bradycardia < 50/min, type II or complete heart block | These drugs slow the heart further → asystole risk |
| B5 | Beta-blocker as monotherapy for uncomplicated hypertension | BBs are no longer first-line for isolated HTN (NICE, ESC guidelines). No firm efficacy evidence. First-line: ACEi/ARB, CCB (dihydropyridine), or thiazide |
| B6 | Amiodarone as first-line antiarrhythmic for SVT | Amiodarone has severe long-term toxicity (thyroid, pulmonary fibrosis, hepatotoxicity, corneal deposits). Use BB, digoxin, verapamil, or diltiazem first |
| B7 | Loop diuretic as first-line for HTN (without concurrent HF) | Loop diuretics are poor antihypertensives on their own. Thiazides are preferred for BP. Loops are for volume overload |
| B8 | Loop diuretic for dependent ankle oedema without evidence of HF/liver failure/nephrotic syndrome/renal failure | Dependent oedema in elderly is often gravitational (venous insufficiency). Treatment: leg elevation + compression stockings, NOT diuretics |
| B9 | Thiazide diuretic with significant hypoK+ ( < 3.0), hypoNa+ ( < 130), hyperCa2+ (corrected > 2.65), or history of gout | Thiazides cause all four of these: K+ wasting, dilutional hyponatraemia, calcium retention (they reduce urinary Ca excretion), and hyperuricaemia |
| B10 | Loop diuretic for HTN with concurrent urinary incontinence | Loop diuretics increase urine volume → worsen incontinence |
| B11 | Centrally-acting antihypertensives (methyldopa, clonidine, moxonidine) | Poorly tolerated in elderly: sedation, depression, orthostatic hypotension, rebound hypertension on withdrawal |
| B12 | ACEi or ARB with hyperK+ > 5.5 mmol/L | ACEi/ARBs reduce aldosterone → reduce K+ excretion → dangerous hyperkalaemia |
| B13 | Aldosterone antagonists (spironolactone, eplerenone) + K+-conserving drugs (ACEi, ARB, amiloride, triamterene) WITHOUT monitoring serum K+ | Combined, these cause severe hyperkalaemia > 6.0. K+ must be checked at least every 6 months |
| B14 | PDE5 inhibitors (sildenafil, tadalafil) in severe HF with SBP < 90 or with concurrent nitrates | PDE5 inhibitors are vasodilators. With nitrates (also vasodilators) → profound hypotension → cardiovascular collapse. This is a classic pharmacology exam question |
| B15 | Drugs that prolong QTc in patients with known QTc prolongation (M > 450ms, F > 470ms) | Long QTc → risk of Torsades de Pointes → VF → death. Offending drugs: quinolones, macrolides, ondansetron, citalopram > 20mg/day, escitalopram > 10mg/day, TCAs, lithium, haloperidol, digoxin, class IA/III antiarrhythmics, phenothiazines, mirabegron |
| B16 | Statins for primary CV prevention in persons ≥ 85 with established frailty and life expectancy < 3 years | Statins take years to show primary prevention benefit. In frail elderly with limited life expectancy, risk > benefit. Note: secondary prevention statins are still appropriate |
| B17 | Long-term systemic NSAIDs with known coronary/cerebral/peripheral vascular disease | NSAIDs are prothrombotic (COX-2 inhibition reduces prostacyclin, a vasodilator and antiaggregant). Increased risk of MI and stroke |
| B18 | Long-term antipsychotics with known vascular disease | Antipsychotics also increase thrombosis risk |
| B19 | NSAIDs or systemic corticosteroids with HF requiring loop diuretics | NSAIDs cause Na+/water retention and reduce prostaglandin-mediated renal blood flow → worsen HF. Corticosteroids cause Na+ retention |
| B20 | Antihypertensive drugs in severe symptomatic aortic stenosis | In AS, cardiac output is fixed (obstruction). Reducing afterload causes severe hypotension/syncope because the ventricle cannot compensate |
| B21 | Digoxin as first-line for long-term (> 3 months) rate control in AF | Recent evidence: long-term digoxin associated with increased mortality. Cardio-selective beta-blockers are preferred first-line for rate control in AF |
High Yield: Key CV STOPP Points for Exams
- B3 (BB + non-DHP CCB → heart block) is a classic pharmacology MCQ.
- B14 (PDE5i + nitrates → cardiovascular collapse) appears in almost every exam cycle.
- B15 (QTc prolongation drug list) — memorize the offenders.
- B21 (Don't use digoxin first-line for AF rate control) is a newer and frequently tested criterion. [1]
This section (16 criteria) tests your understanding of when anticoagulants, antiplatelets, and their combinations are inappropriate.
| # | Criterion | Rationale |
|---|---|---|
| C1 | Long-term aspirin > 100mg/day | Higher doses increase bleeding without improving efficacy. Low-dose (75–100mg) is standard |
| C2 | Antiplatelets/anticoagulants with significant risk of major bleeding (uncontrolled severe HTN, bleeding diathesis, recent spontaneous bleeding) | Common sense but commonly tested: bleeding risk must be weighed |
| C3 | Aspirin + clopidogrel as long-term secondary stroke prevention > 4 weeks (unless coronary stent in past 12 months, ACS, or high-grade symptomatic carotid stenosis) | DAPT after stroke beyond 4 weeks: no added benefit over clopidogrel alone, just more bleeding |
| C4 | Antiplatelet + anticoagulant in chronic AF (unless recent stent or angiographically proven > 50% coronary stenosis) | If a patient is on an anticoagulant for AF, adding aspirin doesn't help — it just increases bleeding |
| C5 | Antiplatelet + anticoagulant in stable vascular disease | Same principle: dual therapy = more bleeding, no benefit in stable disease |
| C6 | Ticlopidine in any circumstance | Obsolete drug: clopidogrel and prasugrel have better evidence, fewer side effects |
| C7 | Antiplatelets as alternatives to anticoagulants for stroke prevention in AF | Aspirin does NOT prevent stroke in AF. Only anticoagulants work |
| C8 | Anticoagulants for first provoked DVT > 6 months (without thrombophilia) | Standard duration for provoked DVT: 3–6 months. Beyond that, no proven benefit |
| C9 | Anticoagulants for first PE > 12 months (without thrombophilia) | Standard duration for provoked PE: 6–12 months |
| C10 | NSAIDs + anticoagulants | Both increase bleeding risk independently; combined → major GI bleeding |
| C11 | Vitamin K antagonists (warfarin) as first-line for AF (unless metallic valve, moderate-severe mitral stenosis, or eGFR < 15) | DOACs are preferred over warfarin for AF — equally efficacious and safer. Exceptions: mechanical valves, significant mitral stenosis, severe CKD (eGFR < 15) |
| C12 | SSRIs + anticoagulants with previous major haemorrhage | SSRIs have antiplatelet effects (they deplete serotonin from platelets, impairing aggregation). Combined with anticoagulants in someone who already bled → very high risk |
| C13 | Dabigatran + diltiazem or verapamil | These increase dabigatran plasma levels → increased bleeding |
| C14 | DOACs + P-glycoprotein (P-gp) inhibitors (amiodarone, azithromycin, carvedilol, cyclosporin, itraconazole, ketoconazole, macrolides, quinine, verapamil, ticagrelor) | All DOACs are P-gp substrates. P-gp inhibitors increase DOAC levels → bleeding. This is a HIGH-YIELD drug interaction question |
| C15 | Systemic oestrogens/androgens with previous VTE | Oestrogens are prothrombotic; androgens increase erythropoiesis and blood viscosity |
| C16 | Aspirin for primary CV prevention | NO evidence of benefit for primary prevention; only for secondary prevention. This aligns with Beers 2023 [3] |
Aspirin: Primary vs. Secondary Prevention
C16: Aspirin for primary prevention is NOT recommended in older adults. This is a major paradigm shift that is commonly tested. Aspirin is only indicated for SECONDARY prevention (i.e., patient already has established CVD). The AGS Beers Criteria 2023 also strongly recommends against initiating aspirin for primary prevention. [1][3]
This is the second largest STOPP section with 25 criteria. It tests anticholinergic burden, sedative prescribing, and dementia-related inappropriate prescribing.
| # | Key Criteria | Rationale |
|---|---|---|
| D1 | TCAs in patients with dementia, narrow-angle glaucoma, cardiac conduction abnormalities, prostatism, constipation, recent falls, urinary retention, or orthostatic hypotension | TCAs have potent anticholinergic effects → worsen ALL of these conditions |
| D2 | TCAs as first-line for depression | SSRIs/SNRIs are safer first-line. TCAs have more ADRs (anticholinergic, cardiac, sedation) |
| D3 | SNRIs (venlafaxine, duloxetine) with severe HTN (SBP > 180 ± DBP > 105) | SNRIs inhibit noradrenaline reuptake → can worsen hypertension |
| D4 | Anticholinergic antipsychotics with BPH/LUTS/urinary retention | Anticholinergic effects → urinary retention (detrusor relaxation + sphincter contraction) |
| D5 | Antipsychotics for BPSD unchanged for > 3 months without review | Long-term antipsychotic use in dementia → increased mortality, CV events, EPS. Regular review is mandatory |
| D6 | SSRIs with significant hypoNa+ ( < 130) | SSRIs cause SIADH → hyponatraemia. Very common in elderly |
| D7 | SSRIs with current/recent significant bleeding | SSRIs have antiplatelet effects (serotonin depletion from platelets) |
| D8 | Benzodiazepines ≥ 4 weeks | No indication for long-term use. Risks: prolonged sedation, confusion, falls, dependence. Must taper gradually (withdrawal syndrome if stopped abruptly) |
| D9 | Benzodiazepines for agitation/psychosis in dementia | No evidence of efficacy for BPSD |
| D10 | Benzodiazepines for insomnia ≥ 2 weeks | Falls, fractures, dependency |
| D11 | Z-drugs (zolpidem, zopiclone, zaleplon) for insomnia ≥ 2 weeks | Same risks as benzodiazepines for falls and fractures. Often falsely perceived as "safer" |
| D12 | Antipsychotics (other than clozapine or quetiapine) in Parkinsonism or DLB | Most antipsychotics block D2 → worsen Parkinsonism. Clozapine and quetiapine are exceptions (low D2 affinity in nigrostriatal pathway) |
| D13 | Anticholinergics (biperiden, orphenadrine, procyclidine, trihexyphenidyl) for EPS of antipsychotics | Risk of anticholinergic toxicity. Better approach: reduce antipsychotic dose or switch to a less extrapyramidal agent |
| D14 | Potent anticholinergics in delirium or dementia | Anticholinergics worsen cognitive impairment. List: TCAs, chlorpromazine, clozapine, thioridazine, diphenhydramine, chlorpheniramine, tolterodine, oxybutynin, hyoscine, procyclidine, benzatropine, tizanidine |
| D15 | Antipsychotics for BPSD > 12 weeks unless severe and non-pharmacological Rx failed | Increased risk of stroke and MI |
| D16 | Antipsychotics as hypnotics (unless for psychosis/BPSD) | Not indicated for sleep; increased confusion, hypotension, EPS, falls |
| D17 | Acetylcholinesterase inhibitors (AChEI) with persistent bradycardia < 60, heart block, or recurrent unexplained syncope | AChEIs increase vagal tone → slow AV conduction → worsened bradycardia/syncope |
| D18 | AChEIs with concurrent drugs causing bradycardia (BB, digoxin, diltiazem, verapamil) | Additive bradycardia effect |
| D19 | Memantine with known seizure disorder | Memantine (NMDA antagonist) can lower seizure threshold |
| D20 | Nootropics in dementia (Ginkgo, piracetam, modafinil, omega-3, panax ginseng, creatine, etc.) | No evidence of efficacy. Waste of money and risk of interactions |
| D21 | Phenothiazines as first-line for psychosis/BPSD | Sedative, anticholinergic. Exceptions: prochlorperazine for nausea/vertigo, chlorpromazine for persistent hiccoughs, levomepromazine as antiemetic in palliative care |
| D22 | Levodopa/dopamine agonists for benign essential tremor | No evidence of efficacy. Essential tremor responds to propranolol (see START D7) |
| D23 | Levodopa/dopamine agonists for drug-induced Parkinsonism | This is a prescribing cascade — the correct action is to stop the offending drug, not add more drugs |
| D24 | First-generation antihistamines as first-line for allergy/pruritus | Sedating, anticholinergic. Second-generation (cetirizine, loratadine, fexofenadine) are safer |
| D25 | First-generation antihistamines for insomnia | High side-effect profile. Z-drugs safer for short-term use if absolutely needed |
Anticholinergic Burden: The Recurring Theme
The concept of anticholinergic burden runs through almost every section of STOPP. Examiners love asking about it. Anticholinergic effects include: dry mouth, constipation, urinary retention, blurred vision, tachycardia, cognitive impairment, delirium, and falls. In elderly patients, these effects are amplified because of reduced hepatic/renal clearance and baseline cognitive vulnerability. D14 lists the key offenders — memorize this list. [1]
These criteria are about drugs that become dangerous below specific eGFR thresholds. The thresholds are directly testable. [1]
| Drug | eGFR Threshold | Risk |
|---|---|---|
| Digoxin ≥ 125µg/day long-term | < 30 | Digoxin toxicity (renally excreted) |
| Dabigatran | < 30 | Bleeding (80% renally excreted) |
| Factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) | < 15 | Bleeding |
| NSAIDs | < 50 | Deterioration in renal function (prostaglandin-mediated renal blood flow) |
| Colchicine | < 10 | Colchicine toxicity (bone marrow suppression, neuromyopathy) |
| Metformin | < 30 | Lactic acidosis (impaired renal clearance of metformin) |
| MRA (spironolactone, eplerenone) | < 30 | Dangerous hyperkalaemia |
| Nitrofurantoin | < 45 | Nitrofurantoin toxicity (pulmonary, hepatic, neuropathic); also ineffective as drug not concentrated in urine |
| Bisphosphonates | < 30 | Acute renal failure |
| Methotrexate | < 30 | Methotrexate toxicity (pancytopenia, mucositis) |
eGFR Thresholds: Memory Aid
30 is the magic number for most: digoxin, dabigatran, metformin, MRA, bisphosphonates, methotrexate all share the < 30 cutoff.
Exceptions:
- NSAIDs: < 50 (more conservative because NSAIDs directly damage kidneys)
- Nitrofurantoin: < 45
- Factor Xa inhibitors: < 15 (they have less renal clearance than dabigatran)
- Colchicine: < 10 (very low threshold) [1]
| # | Criterion | Rationale |
|---|---|---|
| F1 | Prochlorperazine or metoclopramide with Parkinsonism | Both are dopamine antagonists → worsen Parkinsonian symptoms. Use domperidone instead (doesn't cross BBB well) |
| F2 | PPI at full dose for uncomplicated PUD > 8 weeks | After healing, step down to half dose or H2 antagonist, or discontinue. PPI overuse → hypomagnesaemia, C. difficile, osteoporotic fractures, CKD |
| F3 | Constipating drugs (antimuscarinics, oral iron, opioids, verapamil, aluminium antacids) with chronic constipation | Use non-constipating alternatives when available |
| F4 | Oral iron > 200mg elemental/day | No enhanced absorption above this dose; only more GI side effects. Once daily or alternate-day dosing is now preferred |
| F5 | Corticosteroids with history of PUD/erosive oesophagitis without PPI | Steroids don't directly cause ulcers but impair healing and increase recurrence risk. Co-prescribe PPI |
| F6 | Antiplatelets or anticoagulants with GAVE | GAVE ("watermelon stomach") is a vascular ectasia causing chronic GI bleeding → antiplatelet/anticoagulant → catastrophic bleeding |
| F7 | Antipsychotics with dysphagia | Antipsychotics cause dystonia, EPS → impaired swallowing → aspiration pneumonia |
| F8 | Megestrol acetate to increase appetite | Increased thrombosis and death risk, unproven efficacy. Common in geriatric cachexia — don't use |
| # | Criterion | Rationale |
|---|---|---|
| G1 | Theophylline monotherapy for COPD | Narrow therapeutic index, many drug interactions. Use LAMA/LABA instead |
| G2 | Systemic corticosteroids as maintenance for moderate-severe COPD | Use INHALED corticosteroids. Systemic steroids for COPD maintenance → diabetes, osteoporosis, immunosuppression, myopathy |
| G3 | LAMA (tiotropium etc.) with narrow-angle glaucoma or bladder outflow obstruction | Antimuscarinic: pupil dilation → acute angle closure; detrusor relaxation → urinary retention |
| G4 | Benzodiazepines with acute/chronic respiratory failure (pO2 < 8.0 kPa ± pCO2 > 6.5 kPa) | Benzodiazepines suppress respiratory drive → worsened CO2 retention → death |
| # | Criterion | Rationale |
|---|---|---|
| H1 | Non-selective NSAIDs with history of PUD/GI bleeding without PPI | Must co-prescribe PPI. Or use COX-2 selective agent |
| H2 | NSAIDs with severe HTN (SBP > 170, DBP > 100) | NSAIDs cause Na+/water retention and inhibit renal prostaglandins → worsen HTN |
| H3 | Long-term NSAID > 3 months for OA pain where paracetamol not tried | Step-wise: try paracetamol first. It's safer and often equally effective |
| H4 | Long-term corticosteroids > 3 months as monotherapy for RA | Must use DMARDs as backbone. Steroids alone → osteoporosis, diabetes, infections |
| H5 | Corticosteroids for OA (other than periodic intra-articular injections) | OA is not an inflammatory disease in the same way as RA. Systemic steroids are not appropriate |
| H6 | Long-term NSAID/colchicine > 3 months for gout without trying XO inhibitor | Allopurinol/febuxostat are first-choice prophylaxis for gout. NSAIDs/colchicine are for acute flares, not long-term |
| H7 | NSAID + corticosteroid for any arthritis | Additive PUD risk |
| H8 | Oral bisphosphonates with upper GI disease (dysphagia, oesophagitis, gastritis, PUD) | Bisphosphonates cause oesophageal ulceration/stricture. Use IV bisphosphonate or denosumab |
| H9 | Long-term opioids for OA | No evidence of efficacy for OA pain; increased risk of falls, constipation, dependence, delirium |
| # | Criterion | Rationale |
|---|---|---|
| I1 | Systemic antimuscarinics (oxybutynin, tolterodine, trospium) with dementia/cognitive impairment | Anticholinergic → worsened cognition. Use mirabegron (beta-3 agonist) instead |
| I2 | Antimuscarinics with narrow-angle glaucoma | Pupil dilation → acute angle closure |
| I3 | Antimuscarinics for LUTS/BPH with high post-void residual > 200ml | Risk of urinary retention |
| I4 | Antimuscarinics with constipation | Reduce gut motility → worsen constipation |
| I5 | Alpha-1 blockers (other than silodosin) with symptomatic orthostatic hypotension/syncope | Alpha-1 blockers cause vasodilation → worsen postural hypotension. Silodosin is more uroselective and has less vascular effect |
| I6 | Mirabegron in labile/severe HTN | Beta-3 agonist → can raise blood pressure |
| I7 | Duloxetine with urinary urgency/urge incontinence | Duloxetine is for STRESS incontinence (increases urethral sphincter tone via NA/5-HT). Not for urgency/urge |
| I8 | Antibiotics for asymptomatic bacteriuria | No treatment needed unless pregnant or undergoing urological procedures. Treatment increases antibiotic resistance without clinical benefit |
| # | Criterion | Rationale |
|---|---|---|
| J1 | Long-acting sulphonylureas (glibenclamide, chlorpropamide, glimepiride) in T2DM | Prolonged half-life → prolonged hypoglycaemia in elderly (reduced renal clearance). Use short-acting agents (gliclazide) |
| J2 | Thiazolidinediones (TZDs) with HF | TZDs cause fluid retention → worsen HF |
| J3 | Non-selective beta-blockers in DM with frequent hypoglycaemia | Mask hypoglycaemic symptoms (tremor, tachycardia are adrenergic warnings). Sweating (cholinergic) is preserved |
| J4 | SGLT2i with symptomatic hypotension | SGLT2i cause osmotic diuresis and volume depletion → worsen hypotension |
| J5-J8 | Systemic oestrogens with breast cancer, VTE history, arterial disease, or without progestogen in intact uterus | Oestrogens: increase thrombosis, stimulate breast tissue, and cause endometrial hyperplasia/cancer without opposing progestogen |
| J9 | Levothyroxine in subclinical hypothyroidism (normal fT4, TSH < 10) | No evidence of benefit. Risk of iatrogenic thyrotoxicosis (AF, osteoporosis). Only treat if TSH ≥ 10 or symptomatic |
| J10 | Desmopressin for urinary incontinence/frequency | Causes water retention → hyponatraemia (can be life-threatening in elderly) |
This section is highly testable in the context of "an elderly patient who falls" — a classic exam scenario. [1]
| Drug Class | Mechanism of Increased Fall Risk |
|---|---|
| Benzodiazepines | Reduced sensorium, impaired balance |
| Antipsychotics | Parkinsonism, orthostatic hypotension |
| Vasodilators with persistent postural hypotension | Syncope (SBP drop ≥ 20 and/or DBP drop ≥ 10) |
| Z-drugs (zopiclone, zolpidem, zaleplon) | Protracted daytime sedation, ataxia |
| Anti-epileptics | Impaired sensorium, cerebellar dysfunction |
| First-generation antihistamines | Sedation |
| Opioids | Sedation, impaired sensorium |
| Antidepressants | Sedation (especially TCAs, mirtazapine) |
| Alpha blockers as antihypertensives | Orthostatic hypotension |
| Alpha blockers for BPH (except silodosin) | Orthostatic hypotension |
| Centrally acting antihypertensives | Sedation + orthostatic hypotension |
| Antimuscarinics for OAB/urge incontinence | Impaired sensorium |
Falls Assessment: Always Review Medications
When examining a patient who falls, Section K is your medication review checklist. Every drug class listed here should be actively looked for on the drug chart. If present in a patient with recurrent falls, consider stopping or switching. This connects directly to GC 054 (Frailty) and the Tinetti falls lecture. [1][4]
| # | Criterion | Rationale |
|---|---|---|
| L1 | Strong opioids as first-line for mild pain | Follow the WHO analgesic ladder: Step 1 (paracetamol/NSAID) → Step 2 (weak opioid) → Step 3 (strong opioid) |
| L2 | Regular opioids without concomitant laxative | ALL patients on regular opioids need a laxative. Constipation is inevitable and does not develop tolerance |
| L3 | Long-acting opioids without short-acting for breakthrough pain | Long-acting provides baseline coverage; short-acting for acute episodes. Missing the breakthrough → uncontrolled severe pain |
| L4 | Topical lidocaine patch for chronic OA pain | No evidence of efficacy for OA. Indicated only for localized neuropathic pain (e.g., post-herpetic neuralgia) |
| L5 | Gabapentinoids for non-neuropathic pain | Gabapentin/pregabalin only work for neuropathic pain. No evidence for nociceptive or mixed pain |
| L6 | Paracetamol ≥ 3g/24h in poor nutrition (BMI < 18) or chronic liver disease | Reduced glutathione stores → paracetamol hepatotoxicity at lower doses |
M1: Concomitant use of ≥ 2 drugs with antimuscarinic properties (e.g., bladder antispasmodics + TCAs, or first-gen antihistamines + antipsychotics). The cumulative anticholinergic burden causes delirium, falls, cognitive decline, constipation, urinary retention, and dry mouth. [1]
START Criteria: Drugs to START (Potential Prescribing Omissions)
Unless the patient is end-of-life with a palliative focus, these drugs SHOULD be initiated if there is no contraindication. [1]
- Where a drug is clearly indicated, appropriate, and not contraindicated, initiate it per formulary guidelines.
| # | Drug to Start | When to Start | Why |
|---|---|---|---|
| B1 | Antihypertensive | SBP > 140 and/or DBP > 90 (or > 150/90 if moderate-severe frailty) | Reduces stroke, MI, HF risk |
| B2 | Statin | Documented coronary/cerebral/peripheral vascular disease (secondary prevention) | Unless end-of-life or moderate-severe frailty |
| B3 | ACEi | Coronary artery disease | Cardioprotective (HOPE trial) |
| B4 | Beta-blocker | Symptomatic CAD | Anti-anginal |
| B5 | ACEi | HFrEF | Reduces mortality (cornerstone of HF therapy) |
| B6 | Cardio-selective BB (bisoprolol, nebivolol, metoprolol, carvedilol) | Stable HFrEF | Reduces mortality |
| B7 | MRA (spironolactone, eplerenone) | HF without severe renal impairment (eGFR > 30) | Reduces mortality (RALES trial) |
| B8 | SGLT2i | Symptomatic HF ± reduced EF, regardless of diabetes | Major new addition in V3. DAPA-HF, EMPEROR trials |
| B9 | Sacubitril/valsartan | HFrEF with persistent symptoms despite optimal ACEi/ARB | PARADIGM-HF trial; replaces ACEi/ARB |
| B10 | Beta-blocker | Chronic AF with uncontrolled rate | Rate control |
| B11 | IV iron | Symptomatic HFrEF with iron deficiency | Improves exercise capacity and symptoms |
Heart Failure: The Four Pillars + New Additions
| # | Drug | Indication |
|---|---|---|
| C1 | Anticoagulant (VKA, DOAC) | Chronic or paroxysmal AF |
| C2 | Antiplatelet (aspirin/clopidogrel/prasugrel/ticagrelor) | Documented coronary, cerebral, or peripheral vascular disease |
| # | Drug | Indication |
|---|---|---|
| D1 | L-DOPA or dopamine agonist | Idiopathic PD with functional impairment |
| D2 | Non-TCA antidepressant | Major depression |
| D3 | AChEI (donepezil, rivastigmine, galantamine) | Mild-moderate Alzheimer's dementia |
| D4 | Rivastigmine | DLB or PD dementia |
| D5 | SSRI (or SNRI/pregabalin if SSRI contraindicated) | Persistent severe anxiety affecting function |
| D6 | Dopamine agonist (ropinirole, pramipexole, rotigotine) | Restless Legs Syndrome (after excluding iron deficiency and severe CKD) |
| D7 | Propranolol | Essential tremor with functional impairment |
| # | Drug | Indication |
|---|---|---|
| E1 | 1-alpha-hydroxycholecalciferol or calcitriol | Severe CKD (eGFR < 30) with hypocalcaemia + secondary hyperparathyroidism |
| E2 | Phosphate binder | Severe CKD (eGFR < 30) with persistent hyperphosphataemia > 1.76 mmol/L |
| E3 | EPO analogue | Severe CKD (eGFR < 30) with symptomatic anaemia not due to haematinic deficiency; target Hb 10–12 g/dL |
| E4 | ACEi/ARB | CKD with proteinuria > 300mg/24h |
| # | Drug | Indication |
|---|---|---|
| F1 | PPI | Severe GORD or peptic oesophageal stricture |
| F2 | PPI | Starting low-dose aspirin AND history of PUD/reflux oesophagitis |
| F3 | PPI | With short-term ( < 2 weeks) or longer-term ( > 2 weeks) NSAID use |
| F4 | Fibre supplements | Diverticulosis with constipation |
| F5 | Osmotic laxative (lactulose, macrogol, sorbitol) | Chronic persistent idiopathic/secondary constipation |
| F6 | Probiotics with antibiotics | Prevention of C. difficile diarrhoea (if not immunocompromised/severely debilitated) |
| F7 | H. pylori eradication | HP-associated active PUD |
| # | Drug | Indication |
|---|---|---|
| G1 | LAMA or LABA | Symptomatic COPD (GOLD 1–2) and chronic asthma |
| G2 | Regular ICS | Moderate-severe asthma or COPD (GOLD 3–4, FEV1 < 50%) with repeated exacerbations |
| G3 | Home continuous O2 | Chronic hypoxaemia (pO2 < 8.0 kPa / 60 mmHg, SaO2 < 89%) |
| # | Drug | Indication |
|---|---|---|
| H1 | DMARD | Chronic active disabling RA |
| H2 | Bisphosphonate + vit D + calcium | Long-term systemic corticosteroid therapy (prevent steroid-induced osteoporosis) |
| H3 | Vitamin D | Known osteoporosis, previous fragility fracture, or T-score ≤ -2.5 |
| H4 | Anti-resorptive or anabolic therapy (bisphosphonate, teriparatide, denosumab) | Documented osteoporosis (T-score ≤ -2.5) or previous fragility fracture |
| H5 | Vitamin D supplement | Confirmed 25-OH-D deficiency ( < 50 nmol/L) in housebound, falls-prone, or osteopenic patients |
| H6 | Anti-resorptive after stopping ≥ 2 doses of denosumab | Rebound bone loss and vertebral fracture risk after denosumab discontinuation |
| H7 | Anti-resorptive after stopping teriparatide/abaloparatide | Bone gains from anabolic therapy are lost without consolidation therapy |
| H8 | XO inhibitor (allopurinol, febuxostat) | Recurrent gout |
| H9 | Folic acid | With methotrexate |
Denosumab Discontinuation: Critical New Criterion
H6: After stopping denosumab (at least 2 missed doses), anti-resorptive therapy MUST be given. Denosumab suppresses RANKL-mediated osteoclast activity. When stopped, there is a massive rebound increase in bone resorption, rapid BMD loss, and increased risk of multiple vertebral fractures. This is new in V3 and is increasingly tested. [1][6]
| # | Drug | Indication |
|---|---|---|
| I1 | Selective alpha-1 blocker (tamsulosin, silodosin) | LUTS/BPH where surgery not indicated |
| I2 | 5-alpha reductase inhibitor (finasteride, dutasteride) | LUTS/BPH where surgery not indicated |
| I3 | Topical vaginal oestrogen | Symptomatic atrophic vaginitis |
| I4 | Topical vaginal oestrogen | Recurrent UTIs in women |
| I5 | PDE5 inhibitor | Persistent erectile dysfunction causing distress |
| J1 | ACEi/ARB in DM with renal disease (proteinuria > 30mg/24h), unless eGFR < 30 |
| # | Drug | Indication |
|---|---|---|
| K1 | High-potency opioids | Moderate-severe non-arthritis pain where simpler agents failed |
| K2 | Laxatives | With regular opioid use |
| K3 | Topical 5% lidocaine patch | Localized neuropathic pain (e.g., post-herpetic neuralgia) |
| # | Vaccine | Indication |
|---|---|---|
| L1 | Seasonal influenza vaccine | Annually |
| L2 | Pneumococcal vaccine | At least once per national guidelines |
| L3 | Varicella-zoster vaccine | Per national guidelines |
| L4 | SARS-CoV-2 vaccine | Per national guidelines |
Integration with Related Material
| Feature | STOPP/START V3 | Beers Criteria 2023 |
|---|---|---|
| Origin | European (Irish-led, Delphi consensus) | American (AGS) |
| Focus | Both PIMs and PPOs | PIMs only (no "START" equivalent) |
| Strengths | Includes prescribing omissions (START); organized by system | More comprehensive drug-specific lists; includes drug-drug and drug-disease interactions |
| Used in HKUMed GC slides | Yes, primary tool [1] | Yes, supplementary [2][3] |
| Aspirin for primary prevention | C16: STOPP | Also in Beers: avoid [3] |
- STOPP/START is the practical tool that operationalizes the principles taught in GC 079
- GC 079 emphasizes: medication review, deprescribing, polypharmacy reduction, avoiding prescribing cascades
- STOPP D23 (don't add levodopa for drug-induced Parkinsonism) is the textbook example of a prescribing cascade
- STOPP B16 (statins in frailty with < 3 year life expectancy), START B1 (higher BP threshold in frailty at 150/90)
- Section K (falls-risk drugs) directly links to frailty assessment and falls prevention
Active Recall - STOPP/START V3
High Yield Summary
-
STOPP/START V3
- is a systematic, evidence-based checklist for medication review in patients ≥ 65 years.
- STOPP identifies potentially inappropriate medications (PIMs) organized by system (A–M), while START identifies commonly omitted indicated drugs (PPOs) organized by system (A–L).
-
Top exam-relevant points
-
- Section A (STOPP): No drug without indication, no duplicate classes, no treatment beyond recommended duration 2. CV system: BB + non-DHP CCB = heart block; PDE5i + nitrates = collapse; digoxin NOT first-line for AF rate control; aspirin NOT for primary prevention 3. Coagulation: DOACs preferred over warfarin for AF (unless mechanical valve, MS, eGFR < 15); no antiplatelet + anticoagulant in stable disease 4. CNS: Anticholinergic burden is the central theme; BZDs max 4 weeks; antipsychotics in dementia need regular review; SSRIs cause hyponatraemia 5. Renal: eGFR < 30 = stop dabigatran, metformin, bisphosphonates, MRA, methotrexate; eGFR < 50 = stop NSAIDs 6. Falls (Section K): Review all FRIDs in every patient who falls 7. START highlights: Four pillars of HFrEF (ACEi/BB/MRA/SGLT2i), anticoagulation for AF, AChEI for Alzheimer's, vaccines for all 8. New V3 additions: SGLT2i for HF (START B8), anti-resorptive after denosumab discontinuation (START H6), aspirin not for primary prevention (STOPP C16), probiotics with antibiotics for C. diff prevention (START F6)
-
[1] Lecture slides: GC 079 (supp-2)STOPP-START-V3.pdf (all pages) [2] Lecture slides: GC 079 (supp-4)AGS Beers Criteria for potentially inappropriate med use_Pocket Guide_2023.pdf [3] AOS material: AOS - Geriatrics.pdf (p18, Beers Criteria aspirin section) [4] Lecture slides: GC 054. Frailty in the older people.pdf [5] Senior notes: Block A - Shortness of breath on exertion_ heart failure.pdf (HF pharmacotherapy) [6] Senior notes: Block A - Back pain in an elderly woman_ osteoporosis and related fractures.pdf (bisphosphonates, denosumab) [7] Lecture slides: GC 079. Prescribing in older people.pdf [8] Lecture slides: GC 054. Frailty in the older people.pdf
GC079 (supp-1)stopp-start Criteria For Potentially Inappropriate Prescribing In Older 2023
The 2023 STOPP/START criteria are evidence-based screening tools designed to identify potentially inappropriate medications (STOPP) and potential prescribing omissions (START) in adults aged 65 years and older to optimize pharmacotherapy and reduce adverse drug events.
GC079 (supp-3)ags Beers Criteria For Potentially Inappropriate Med Use: 2023
The 2023 AGS Beers Criteria is an evidence-based guideline identifying medications that are potentially inappropriate for older adults (≥65 years) due to unfavorable risk-benefit profiles, aimed at optimizing prescribing safety in geriatric care.