Potentially Inappropriate Medications in the Elderly: a French Consensus Panel List
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Eur J Clin Pharmacol (2007) 63:725–731 DOI 10.1007/s00228-007-0324-2 SPECIAL ARTICLE Potentially inappropriate medications in the elderly: a French consensus panel list Marie-Laure Laroche & Jean-Pierre Charmes & Louis Merle Received: 15 February 2007 /Accepted: 9 May 2007 / Published online: 7 June 2007 # Springer-Verlag 2007 Abstract Results The final list proposed 36 criteria applicable to Objective To evaluate drug-related problems in the elderly, people≥75 years of age. Twenty-nine medications or various lists of potentially inappropriate medications have medication classes applied to all patients, and five criteria been published in North America. Unfortunately, these lists involved medications that should be avoided in specific are hardly applicable in France. The purpose of this study medical conditions. Twenty-five medications or medication was to establish a list of inappropriate medications for classes were considered with an unfavourable benefit/risk French elderly using the Delphi method. ratio, one with a questionable efficacy and eight with both Method A two-round Delphi method was used to converge unfavourable benefit/risk ratio and questionable efficacy. to an agreement between a pool of 15 experts from various Conclusion This expert consensus should provide prescrib- parts of France and from different backgrounds (five ers with an epidemiological tool, a guideline and a list of geriatricians, five pharmacologists, two pharmacists, two alternative therapies. general practitioners, one pharmacoepidemiologist). In round one, they were sent a questionnaire based on a literature review listing medications and clinical situations. Keywords Inappropriate medications . Elderly . They were asked to comment on the potential inappropri- Delphi method . France ateness of the criteria proposed using a 5-point Likert scale (from strong agreement to strong disagreement) and to Abbreviations suggest therapeutic alternatives and new criteria. In round NSAID nonsteroidal antiinflammatory drug two, the experts confirmed or cancelled their previous SNRI serotonin and noradrenaline reuptake inhibitor answers from the synthesis of the responses of round one. SSRI selective serotonin reuptake inhibitor After round two, a final list of potentially inappropriate IMs inappropriate medications drugs was established. Introduction : M.-L. Laroche L. Merle (*) Drug-related problems are a major public health issue, Department of Pharmacology-Toxicology, especially as many adverse drug reactions are considered Centre of Pharmacovigilance, University Hospital Dupuytren, 87042 Limoges, France preventable. Among these adverse effects, those linked to e-mail: [email protected] unsuitable medications are of particular interest. These M.-L. Laroche drugs named IMs have an unfavourable benefit-to-risk ratio e-mail: [email protected] when safer or equally effective alternatives are available. Therefore, IMs appear as a risk factor for preventable drug- J.-P. Charmes related illnesses. Identifying these medications is of Department of Geriatrics, Hospital Rebeyrol, 87042 Limoges, France paramount importance when treating the elderly, who often e-mail: [email protected] receive many drugs. 726 Eur J Clin Pharmacol (2007) 63:725–731 A way to establish a list of IMs in the elderly is the use of Methods an expert consensus to develop explicit criteria when clinical information is lacking. Explicit criteria have already been The Delphi method, developed by the Rand Corporation in proposed in the United States and Canada. In 1991, Beers the 1950s, is a research method allowing a consensus et al. developed the first list of criteria for determining IM use opinion to be reached among experts, using questionnaires, in nursing home residents [1]. In 1997, this criteria list was through an iterative process known as rounds [10]. We used expanded so as to include drugs whose risk may outweigh two rounds in our study. The responses from the first round their benefit in all patients older than 65 years, whatever were collected and analysed; a revised questionnaire based their dwelling place [2]. A last updating of the Beers criteria on the results of this analysis was then submitted to the was published by Fick et al. in 2003 [3]. In Canada, McLeod same experts to converge to an agreement from the average et al. proposed another IM list because of a disagreement responses. with some medications identified by Beers [4]. The Canadian The study was organised in six phases: (a) creation of the explicit criteria identified medications in the context of preliminary questionnaire of IMs from a literature review, drug–drug and drug–disease interactions. In these various (b) recruitment of the experts, (c) mailing of the round-one cases, the explicit criteria were obtained through a literature questionnaire, (d) analysis of the answers and creation of the review and a questionnaire evaluated by national experts new questionnaire, (e) mailing of this round-two question- involved in geriatric care, clinical pharmacology, psycho- naire based on round-one synthesis and (f) final analysis. pharmacology, clinical pharmacy and ambulatory care. A preliminary questionnaire about IM in the elderly was These North American criteria are not adapted to the constructed from the Beers lists (1991, 1997, 2003), the European situation. Availability of drugs, clinical practice, Canadian criteria (1997), the criteria adapted to French socioeconomic levels and health system regulations are practice (2001), and the guidelines of the French Medicine different from those prevailing in the United States and Agency (Agence Française de Sécurité Sanitaire des Canada and are even different between European countries Produits de Santé, AFFSaPS) on medication prescribing in [5, 6]. Nevertheless, we think the discrepancies between the elderly (June 2005) [1–3, 4, 7, 11]. The questionnaire European countries are smaller than those that can be was composed of criteria that covered two categories: (a) identified when comparing North American and European medications or medication classes that should generally be practices. To our knowledge, up to now, no criteria for IMs avoided in the elderly as being either ineffective or prone to have been developed for European countries. induce a risk when a safer alternative is available and (b) In France, an IM list derived from the 1997 Beers criteria medications that should be avoided in specific medical was elaborated in 2001 by nine French experts (five geri- conditions. atricians, four pharmacologists) and used in three studies Fifteen experts were invited to participate. The panel was [7–9]. Most of the Beers criteria were included in this list, composed of five pharmacologists, one pharmacoepidemi- except drugs not available in France, drugs necessitating ologist, five geriatricians, two pharmacists (one from dose information and drugs that should not be used in the hospital and one from community practice) and two general elderly under specific medical conditions. Three criteria practitioners with clinical geriatric qualification (one from were added: concomitant use of two (or more) nonsteroidal urban and one from rural areas). They were all selected anti-inflammatory drugs, concomitant use of two (or more) from different geographic parts of France. All the experts psychotropic drugs from the same therapeutic class and use accepted and participated in all the rounds of the study. of any medications with anticholinergic properties other In April 2006, the round-one questionnaire was sent to than those listed by Beers. This list has some limits: lack the panel of experts together with information on how to fill of a consensus method, exclusion of some criteria (dose, in the forms. This preliminary questionnaire included 37 drugs in specific medical conditions), obsolescence of the criteria: 30 drugs or drug therapeutic classes independently list as a consequence of marketing and removal of drugs from the diagnoses and seven criteria linked to specific from the pharmaceutical market since 2001. Therefore, this medical conditions. Each criterion was to be evaluated by list is hardly usable in other pharmacoepidemiological the experts using a 5-point Likert scale [12]; a score of 1 studies or in public health intervention for minimising meant a strong agreement on the inappropriateness, 3 meant drug-related problems. Besides, none of these lists (neither an equivocal opinion and 5 meant a strong disagreement North American nor that presently used in France) about inappropriateness. Experts were also invited to suggest suggested any alternative drugs to replace inappropriate safer alternative therapeutics and to add other criteria. medications. The responses were used to create the second question- The aim of this study was to establish a list of IMs for naire. Items with a median score of 1 or 2 were retained in the French elderly population using the Delphi method and the IM list; items with a median score of 4 or 5 were ex- to propose safer, effective alternatives. cluded from the list. Items with a median score of 3 were Eur J Clin Pharmacol (2007) 63:725–731 727 resubmitted. A synthesis was elaborated, based on the ourable benefit-to-risk ratio and a questionable efficacy experts’ arguments and on the criteria suggested and then (Table 1). sent to the experts as round-two questionnaire. In August 2006, the round-two questionnaire was sent to the panel of experts. This second questionnaire also Discussion