Drug Assessment: Beers Criteria (2023) & STOPP/START Criteria (v3, 2023)

Drugs Identified from the Prescription

1. IVF IONS (IV Fluids / Electrolytes)

• STOPP: Hypotonic saline in hyponatremia can worsen it - avoid if patient is hyponatremic.
• START: If patient is dehydrated or hypovolemic, IV fluids are appropriate.

2. Inj XONE 1g (Ceftriaxone)

• No specific STOPP criterion for ceftriaxone itself.
• STOPP Section J (antibiotics): Antibiotics should be used only for confirmed or strongly suspected bacterial infections at appropriate doses.

• Avoid in patients with severe hyperbilirubinemia or hypoalbuminemia (displaces bilirubin)
• Dose adjustment needed if concomitant hepatic AND renal impairment
• Caution: Can cause biliary sludge/pseudolithiasis in elderly
• Monitor for C. difficile colitis (older adults are at higher risk)

3. Inj METROGYL (Metronidazole)

• No direct STOPP criterion for metronidazole as a standalone drug.
• Drug-Drug Interaction (STOPP): Metronidazole + warfarin = significant INR potentiation - flag if anticoagulants are also prescribed.

• Prolonged use (>10-14 days) can cause peripheral neuropathy
• Causes disulfiram-like reaction with alcohol
• Reduce dose in severe hepatic impairment

4. Inj PAN 40mg (Pantoprazole - Proton Pump Inhibitor)

• PPIs (including pantoprazole) are listed under "Use with Caution" (Table 4) and in the PIMs table if used long-term without indication.
• Specifically: Avoid use for >8 weeks unless for high-risk patients (e.g., on oral corticosteroids/NSAIDs, Barrett's esophagitis, hypersecretory conditions, severe esophagitis, or demonstrated need for maintenance therapy).
• Reason: Risk of Clostridioides difficile infection, bone loss/fractures, and hypomagnesemia with prolonged use.

• STOPP: PPI at full therapeutic dose for >8 weeks for peptic ulcer disease or esophagitis without a documented review of indication.
• START: PPIs are appropriately indicated alongside ASA/NSAIDs or anticoagulants (gastroprotection) - see aspirin section below.

5. Inj EMESET 4mg (Ondansetron - 5-HT3 Antagonist)

• ⚠️ QTc prolongation risk in the elderly is a concern - ondansetron can prolong the QT interval (dose-dependent)
• The Rosen's Emergency Medicine textbook specifically notes: "Ondansetron has been associated with QTc interval prolongation, which could be concerning in older patients who are already taking QTc-prolonging medications" - this is a nuanced consideration
• Avoid doses >16mg IV in a single dose in elderly patients (FDA guidance)
• Check baseline ECG/QTc if patient is on other QT-prolonging drugs
• Preferred over promethazine (which IS on the Beers list) for nausea in elderly

6. Inj HEPARIN 4000 IU (Unfractionated Heparin)

• The 2023 Beers Criteria includes a dedicated anticoagulant box.
• Unfractionated heparin is not listed as outright inappropriate, but older adults are at elevated bleeding risk with anticoagulants.
• Low-molecular-weight heparins (LMWH) are preferred over unfractionated heparin in most settings due to more predictable dosing and lower risk of heparin-induced thrombocytopenia (HIT).

• STOPP Section H (anticoagulants/antiplatelets): Anticoagulants should not be prescribed without a clear documented indication (e.g., VTE treatment/prevention, AF, mechanical heart valve).
• Monitor closely for bleeding complications.

• Clear documented indication
• aPTT or anti-Xa monitoring if therapeutic
• Platelet count monitoring for HIT (check on days 4-14)
• Consider switching to LMWH (enoxaparin) for longer-term use - safer in elderly

7. Cap ECOSPRIN GOLD 20 (Aspirin 75mg + Atorvastatin 20mg)

7a. Aspirin (component)

• "Avoid initiating aspirin for PRIMARY prevention of cardiovascular disease in older adults" - High evidence, Strong recommendation.
• Aspirin is APPROPRIATE for secondary prevention in patients with established CVD (prior MI, stroke, PAD, stent, etc.)
• The 2023 update explicitly states: "Consider deprescribing aspirin in older adults already taking it for primary prevention."
• Reason: Increased bleeding risk (GI, intracranial) outweighs cardiovascular benefit for primary prevention in older adults.

• STOPP: Aspirin for primary prevention in patients ≥65 without established cardiovascular disease.
• START: Aspirin or antiplatelet therapy IS indicated for established CVD/atherosclerotic disease.

7b. Atorvastatin 20mg (component)

• STOPP: Statins should be stopped in patients with life expectancy <1 year or receiving palliative/end-of-life care.
• START: Statins are indicated in patients with established CVD or with high cardiovascular risk.

8. T. GLYCOMET SR 500 (Metformin)

• Avoid if eGFR <30 mL/min/1.73m² (risk of lactic acidosis)
• Use with caution if eGFR 30-45 mL/min/1.73m²
• Note: Metformin is NOT on the general PIM list - it is in fact the preferred first-line oral hypoglycemic in elderly diabetics due to low hypoglycemia risk.

• STOPP: Metformin in severe renal impairment (eGFR <30).
• START: Metformin is the preferred first-line agent for Type 2 DM in older adults (START criteria).

• eGFR >45 - full dose appropriate
• eGFR 30-45 - use with caution, reduce dose
• eGFR <30 - CONTRAINDICATED, must stop
• Hold peri-procedure if contrast agent used (risk of acute kidney injury → lactic acidosis)

9. T. TELMA 40 (Telmisartan - ARB)

• START: ACE inhibitors or ARBs are indicated in patients with hypertension, heart failure with reduced ejection fraction (HFrEF), or diabetic nephropathy - telmisartan would be a START-appropriate drug.
• STOPP: ARBs should be stopped if causing significant hyperkalemia (K⁺ >6.0 mmol/L) or worsening renal function in a patient with bilateral renal artery stenosis.
• STOPP: Do not combine ACE inhibitor + ARB (dual RAAS blockade) - increases risk of hypotension, renal impairment, and hyperkalemia.

• Blood pressure (risk of orthostatic hypotension → falls in elderly)
• Serum potassium (hyperkalemia risk, especially with heparin or K-sparing diuretics)
• Renal function (creatinine/eGFR)
• Not to be combined with ACEi

Summary Table

Key Clinical Actions Recommended

1. Check renal function (eGFR/creatinine) before continuing Metformin - mandatory
2. Clarify aspirin indication - secondary vs primary prevention - stop if primary prevention only
3. Reassess pantoprazole at 8 weeks to determine if continued PPI therapy is indicated
4. ECG to check QTc before/during ondansetron use, especially if on other QT-prolonging agents
5. Monitor platelet count (days 4-14) if heparin is continued for >4 days (HIT risk)
6. Monitor K⁺ with telmisartan + heparin combination (both can cause hyperkalemia)
7. Orthostatic BP check in elderly patient on telmisartan - fall prevention
8. Avoid dual RAAS blockade - do not add ACEi to telmisartan

Note: The STOPP/START criteria are particularly relevant for this patient given the combination of antidiabetic, antihypertensive, and anticoagulant/antiplatelet therapy. Patient age and renal function are the two most critical variables that determine appropriateness of this entire regimen.