Polypharmacy is common in frailty and multimorbidity. The STOPP/START criteria are evidence-based tools to improve prescribing safety in older adults. ✅ STOPP: identify potentially inappropriate medications. ✅ START: highlight beneficial medications that are often underprescribed.

⚠️ Issues in Prescribing

💊 Overprescribing: Excess dose/duration (e.g. long-term NSAIDs).
❌ Misprescribing: Wrong drug choice (e.g. verapamil in HF).
⬇️ Underprescribing: Missing beneficial drugs (e.g. bisphosphonates in steroid users).

⚕️ Caution When Stopping Medications

Some drugs require careful tapering or monitoring before discontinuation:

ACE inhibitors & diuretics in heart failure → withdrawal may precipitate decompensation.
Antiarrhythmics (amiodarone, digoxin, beta-blockers, CCBs) → risk of rhythm instability.
Anticonvulsants → risk of seizure recurrence.
Psychotropics (antidepressants, antipsychotics, mood stabilisers) → withdrawal syndromes.
Antimuscarinics for Parkinson’s → can worsen motor symptoms.
Corticosteroids, DMARDs, immunosuppressants → risk of adrenal crisis or flare.

🛑 Common Medications to Stop (STOPP Examples)

Medication	Reason to Stop
Digoxin	No benefit in heart failure with preserved systolic function. ⚠️ Reduce dose if eGFR <30 ml/min to avoid toxicity.
Thiazide diuretics	Stop if recurrent hypoNa, hypoK, hyperCa, or recent gout.
Loop diuretics	Not for routine hypertension. Avoid for ankle oedema without HF/CKD/CLD → use compression instead.
Aldosterone antagonists (spironolactone, eplerenone)	Risk of hyperkalaemia if combined with ACEI/ARB without monitoring.
Verapamil / Diltiazem	May worsen heart failure with reduced EF.
Nicorandil	Discontinue if GI or mucosal ulceration occurs.
ACEIs or ARBs	Stop in persistent hyperkalaemia. Avoid dual blockade (ACEI+ARB) unless under specialist advice.
Aspirin	Avoid long-term doses >150 mg (↑ bleeding risk). Avoid without PPI if history of ulcer. Avoid with anticoagulant unless strong indication.
Antiplatelet + Anticoagulant	↑ bleeding risk in stable CAD/CVD/PAD without recent ACS/stent.
Warfarin / DOACs	First DVT: >6 months; First PE: >12 months → stop if no ongoing risk factors.
NSAIDs + Warfarin/DOAC	High risk of GI bleeding.
Dabigatran	Avoid if eGFR <30 ml/min → bleeding risk.
Rivaroxaban / Apixaban	Avoid if eGFR <15 ml/min → bleeding risk.
Systemic corticosteroids	Avoid for maintenance COPD (inhaled steroids safer).

✅ START Criteria – Medications to Consider Starting

Condition	Recommended Medication	Rationale
Heart failure	ACEI/ARB, beta-blocker, spironolactone (if HFrEF)	Improves survival, reduces hospitalisation.
Atrial fibrillation	Anticoagulant (warfarin/DOAC) if CHA₂DS₂-VASc ≥2	Reduces stroke risk.
Post-MI / IHD	Statin, ACEI, beta-blocker, antiplatelet (if not contraindicated)	Secondary prevention.
Diabetes + proteinuria	ACEI/ARB	Renal protection.
Osteoporosis / fragility fracture	Bisphosphonate + calcium/Vit D	Fracture risk reduction.
Long-term steroids	Bisphosphonate prophylaxis	Prevent steroid-induced osteoporosis.
Hypertension + diabetes/CKD	ACEI/ARB	Renal & CV protection.
Vaccinations	Influenza, pneumococcal, shingles	Reduce infection burden in frail adults.
Depression	Antidepressant therapy (if persistent symptoms)	Improves mood, function, QoL.
Constipation	Laxative if regular opioid use	Prevent faecal impaction.
Falls risk	Vitamin D/calcium	Bone health, muscle strength (esp. care homes).

Drugs to Avoid in Older patients.

Drug Class & Examples	Prescribing Concerns
🌼 First-generation (sedating) antihistamines Diphenhydramine, Chlorpheniramine, Promethazine, Cyproheptadine, Clemastine, Hydroxyzine, Doxylamine	Sedating and strongly anticholinergic → ↑ delirium, falls, urinary retention, dry mouth, constipation. Note: Diphenhydramine may be appropriate in severe allergic reactions.
💊 Antispasmodics Dicyclomine, Hyoscyamine, Propantheline, Oxybutynin (IR), Scopolamine, Belladonna alkaloids, Clidinium	Strong anticholinergic properties → delirium, urinary retention, constipation. Note: Hyoscyamine, scopolamine, and belladonna may be appropriate in palliative care (secretions).
📘 Tricyclic Antidepressants (TCAs) Amitriptyline, Doxepin, Imipramine, Nortriptyline	Avoid in elderly → sedating, strong anticholinergic, cause delirium, falls, constipation, orthostatic hypotension.
🧠 Anticholinergic Anti-Parkinson Agents Benztropine, Trihexyphenidyl	Avoid → sedation, anticholinergic toxicity. Better alternatives exist for Parkinson’s disease and EPS prevention.
💪 Muscle Relaxants Cyclobenzaprine, Methocarbamol, Carisoprodol, Metaxalone	Limited benefit in elderly. Cause sedation, delirium, and ↑ falls risk.
😴 Benzodiazepines Alprazolam, Lorazepam, Diazepam, Chlordiazepoxide, Clorazepate	Avoid for delirium, sleep disorders, agitation. ↑ risk of sedation and falls. Note: May be appropriate for alcohol/benzo withdrawal.
🌙 Non-benzodiazepine Hypnotics Zolpidem	Similar to benzodiazepines: ↑ sedation, delirium, falls, fractures. Avoid in elderly.
🧩 Antipsychotic Agents (Atypical & Conventional) Haloperidol, Thioridazine, Chlorpromazine, Olanzapine, Quetiapine, Risperidone	↑ Risk of stroke & death in elderly with dementia. Use only if non-drug measures fail and patient is at risk to self/others.
⬇️ Alpha-1 Blockers Doxazosin, Prazosin, Terazosin	Avoid as antihypertensives → high risk of orthostatic hypotension. Better agents available.
🩺 CNS-acting Alpha Agonists Clonidine, Methyldopa	Associated with bradycardia, hypotension, sedation, delirium, depression. Avoid methyldopa; use clonidine cautiously.
❤️ Cardiac Glycosides Digoxin (>0.125 mg/day)	Higher doses ↑ toxicity risk in elderly due to reduced renal clearance. No additional benefit at high doses.
💓 Antiarrhythmic Drugs Amiodarone, Flecainide, Procainamide, Sotalol, Quinidine, Disopyramide	Rate control often safer than rhythm control in elderly. Amiodarone → thyroid/lung toxicity, QT prolongation. Disopyramide → HF, anticholinergic.
💊 Non-COX Selective NSAIDs Aspirin (>325 mg/day), Ibuprofen, Naproxen, Piroxicam, Indomethacin	↑ GI bleeding, renal impairment, and HF exacerbation risk. If unavoidable, add PPI for gastroprotection.
🍬 Long-acting Sulfonylureas Chlorpropamide, Glyburide	↑ Risk of prolonged hypoglycaemia. Avoid in elderly.
🧪 Urinary Anti-infective Agent Nitrofurantoin	Avoid if CrCl <60 ml/min → ineffective & ↑ neuropathy, hepatotoxicity risk.

🌟 Teaching Pearls

STOPP = deprescribing where risk > benefit.
START = don’t undertreat common, reversible risks.
Always integrate into CGA & frailty review.
Document rationale, involve patient/carers in decision-making.
Review regularly: “right drug, right dose, right patient, right time.”

💡 Take-home: Safe prescribing in geriatrics = balance between stopping harm and starting benefit. Think of STOPP/START as your structured checklist during a CGA medication review.

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Polypharmacy and STOPP/START criteria