Bastiaan Sallevelt

66 CHAPTER 2.2 Table 1. Main barriers and facilitators that affected clarity of the elements action, condition and explanation of STOPP/START recommendations. Barriers Example a (clarity rating, %) ACTION Lack of explicit drug (class) STOPP D7/8. Anticholinergics / antimuscarinics… (17%) › ‘e.g.’ represents a non-limitative list and is therefore inconclusive STOPP B10. Centrally-acting antihypertensives (e.g. methyldopa, clonidine, moxonidine, rilmenidine, guanfacine) … (33%) › Use of adjectives that need further investigation to allow use STOPP D14. First-generation antihistamines… (17%) START H1. High potency opioids… (17%) Lack of drug deprescribing schedules while considered necessary STOPP K2. Neuroleptic drugs… (17%) Starting dose and target dose not mentioned START C2. Angiotensin Converting Enzyme (ACE) inhibitor with systolic heart failure… (67%) Lack of directions how and what to monitor after starting a drug START E1. Disease-modifying antirheumatic drug (DMARD)… (25%) CONDITION General - Patient population for whom recommendations would not apply was not (clearly / unambiguously) defined › In patients with a strong indication for a potentially inappropriate drug, it may be harmful to stop it › In patients with potential omissions, warnings for important contra indications are lacking / not clearly defined STOPP B5. …as first-line antiarrhythmic therapy in supraventricular tachyarrhythmias (33%) START A2. …where Vitamin K antagonists or direct thrombin inhibitors or factor Xa inhibitors are contraindicated (33%) Medication – see also action › Ambiguous adjectives were used › Description of drug therapy (substance / dosage) not specific enough STOPP D2. …as first-line antidepressant treatment (33%) START E7. …in patients taking methotrexate (33%) Disease - Clinical interpretation of ‘disease (state)’ for defining population needed STOPP D1. …with dementia, narrow angle glaucoma, cardiac conduction abnormalities, prostatism, or prior history of urinary retention (33%) START A5. …with a documented history of coronary, cerebral or peripheral vascular disease (33%)