Fréquence des erreurs médicamenteuses

Les critères de Beers ont été publiés en 1991, puis révisés en 1997, en 2003, et en 2012. Ils pointent des risques de prescriptions inappropriées chez la personne âgée, en séparant
-    une première liste de médicaments toujours dangereux chez la personne âgée, et à toujours éviter indépendamment du terrain et de la maladie (exemple : amiodarone, indométacine, méprobamate, anticholinergiques et antihistaminiques type hydroxyzine, prométazine (...), benzodiazépines à longue durée d’action types diazepam, clorazépate (...), ou encore laxatifs stimulants : bisacodyl (...)
-     et une seconde liste de médicaments à éviter dans des contextes de pathologie particulières : par exemple dans les Troubles de l’hémostase ou les traitements par anticoagulants : NE PAS PRESCRIRE aspirine, AINS, dipyridamole, ticlodipine, clopidogrel ;  en cas d’Arythmie : NE PAS PRESCRIRE antidépresseurs tricycliques (imipramine, doxépine,amitriptyline) ou encore en cas d’adénome prostatique: NE PAS PRESCRIRE antihistaminiques anticholinergiques, relaxants musculaires, oxybutynine, flavoxate (...)
-    Le total de la révision de 2012 fait tout de même 14 pages de tableaux écrits en petits caractères
Depuis, la littérature ne cesse de pointer les limites de cette aide : médicaments qui ont disparu, changement d’analyse sur le niveau de risque, et surtout absence de prise en compte des interactions médicamenteuses, de risque de potentialisation d’effets, et du risque de ne pas prescrire à la bonne dose, ou de ne pas prescrire du tout (omission). Finalement, c’est une liste surtout intéressante pour la recherche mais pas tellement pour les docteurs. Cet état de a poussé les Européens à développer une nouvelle liste, plus pratique, organisée par grand systèmes physiologiques, avec une attention particulière sur la prévention des chutes iatrogènes, sur les mesusages des opiacés, sur le risque de potentialisation d’effets entre médicaments, sur la prévention des erreurs les plus graves absolument à éviter.
Screening tool of older People’s potentially inappropriate prescriptions (STOPP)
The following prescriptions are potentially inappropriate in persons aged_65 years of age
Cardiovascular system
Digoxin at a long-term dose>125mg/day with impaired renal functiona (increased risk of toxicity)
Loop diuretic for dependent ankle oedema only i.e. no clinical signs of heart failure (no evidence of efficacy, compression hosiery usually more appropriate)
Loop diuretic as first-line monotherapy for hypertension (safer, more effective alternatives available)
Thiazide diuretic with a history of gout (may exacerbate gout)
Non-cardioselective betablocker with chronic obstructive pulmonary disease (COPD) (risk of bronchospasm)
Betablocker in combination with verapamil (risk of symptomatic heart block)
Use of diltiazem or verapamil with NYHA Class III or IV heart failure (may worsen heart failure)
Calcium channel blockers with chronic constipation (may exacerbate constipation)
Use of aspirin and warfarin in combination without histamine H2 receptor antagonist (except cimetidine because of interaction with warfarin) or proton pump inhibitor (high risk of gastro-intestinal bleeding)
Dipyridamole as monotherapy for cardiovascular secondary prevention (no evidence for efficacy)
Aspirin with a past history of peptic ulcer disease without histamine H2 receptor antagonist or Proton Pump Inhibitor (risk of bleeding)
Aspirin at dose>150 mg/day (increased bleeding risk, no evidence for increased efficacy)
Aspirin with no history of coronary, cerebral or peripheral arterial symptoms or occlusive arterial event (not indicated)
Aspirin to treat dizziness not clearly attributable to cerebrovascular disease (not indicated)
Warfarin for first, uncomplicated deep venous thrombosis for longer than 6 months duration (no proven added benefit)
Warfarin for first uncomplicated pulmonary embolus for longer than 12 months duration (no proven benefit)
Aspirin, clopidogrel, dipyridamole or warfarin with concurrent bleeding disorder (high risk of bleeding)
Central nervous system and psychotropic drugs
Tricyclic antidepressants (TCA’s) with dementia (risk of worsening cognitive impairment)
TCA’s with glaucoma (likely to exacerbate glaucoma)
TCA’s with cardiac conductive abnormalities (pro-arrhythmic effects)
TCA’s with constipation (likely to worsen constipation)
TCA’s with an opiate or calcium channel blocker (risk of severe constipation)
TCA’s with prostatism or prior history of urinary retention (risk of urinary retention)
Long-term (i.e. >1 month), long-acting benzodiazepines e.g. chlordiazepoxide, fluazepam, nitrazepam, chlorazepate and benzodiazepines with long-acting metabolites e.g. diazepam (risk of prolonged sedation, confusion, impaired balance, falls)
Long-term (i.e. >1 month) neuroleptics as long-term hypnotics (risk of confusion, hypotension, extrapyramidal side effects, falls)
Long-term neuroleptics (>1 month) in those with parkinsonism (likely to worsen extrapyramidal symptoms)
Phenothiazines in patients with epilepsy (may lower seizure threshold)
Anticholinergics to treat extrapyramidal side-effects of neuroleptic medications (risk of anticholinergic toxicity)
Selective serotonin re-uptake inhibitors (SSRI’s) with a history of clinically significant hyponatraemia (non-iatrogenic hyponatraemia<130 mmol/l within the previous 2 months)
Prolonged use (>1 week) of first generation antihistamines i.e. diphenydramine, chlorpheniramine, cyclizine, promethazine (risk of sedation and anticholinergic side effects)
Gastro-intestinal system
Diphenoxylate, loperamide or codeine phosphate for treatment of diarrhoea of unknown cause (risk of delayed diagnosis, may exacerbate constipation with overflow diarrhoea, may precipitate toxic megacolon in inflammatory bowel disease, may delay recovery in unrecognised gastroenteritis)
Diphenoxylate, loperamide or codeine phosphate for treatment of severe infective gastroenteritis i.e. bloody diarrhoea, high fever or severe systemic toxicity (risk of exacerbation or protraction of infection)
Prochlorperazine (Stemetil) or metoclopramide with Parkinsonism (risk of exacerbating Parkinsonism)
PPI for peptic ulcer disease at full therapeutic dosage for>8 weeks (earlier discontinuation or dose reduction for maintenance/prophylactic treatment of peptic ulcer disease, oesophagitis or GORD indicated)
Anticholinergic antispasmodic drugs with chronic constipation (risk of exacerbation of constipation)
Respiratory system
Theophylline as monotherapy for COPD (safer, more effective alternative; risk of adverse effects due to narrow therapeutic index)
Systemic corticosteroids instead of inhaled corticosteroids for maintenance therapy in moderate-severe COPD (unnecessary exposure to long-term side-effects of systemic steroids)
Nebulised ipratropium with glaucoma (may exacerbate glaucoma)
Musculoskeletal system
Non-steroidal anti-inflammatory drug (NSAID) with history of peptic ulcer disease or gastro-intestinal bleeding, unless with concurrent histamine H2 receptor
antagonist, PPI or misoprostol (risk of peptic ulcer relapse)
NSAID with moderate-severe hypertension (moderate: 160/100 mmHg – 179/109 mmHg; severe: _180/110 mmHg) (risk of exacerbation of hypertension)
NSAID with heart failure (risk of exacerbation of heart failure)
Long-term use of NSAID (>3 months) for relief of mild joint pain in osteoarthtitis (simple analgesics preferable and usually as effective for pain relief)
Warfarin and NSAID together (risk of gastro-intestinal bleeding)
NSAID with chronic renal failureb (risk of deterioration in renal function)
Long-term corticosteroids (>3 months) as monotherapy for rheumatoid arthrtitis or osterarthritis (risk of major systemic corticosteroid side-effects)
Long-term NSAID or colchicine for chronic treatment of gout where there is no contraindication to allopurinol (allopurinol first choice prophylactic drug in gout)
Urogenital system
Bladder antimuscarinic drugs with dementia (risk of increased confusion, agitation)
Bladder antimuscarinic drugs with chronic glaucoma (risk of acute exacerbation of glaucoma)
Bladder antimuscarinic drugs with chronic constipation (risk of exacerbation of constipation)
Bladder antimuscarinic drugs with chronic prostatism (risk of urinary retention)
Alphablockers in males with frequent incontinence i.e. one or more episodes of incontinence daily (risk of urinary frequency and worsening of incontinence)
Alphablockers with long-term urinary catheter in situ i.e. more than 2 months (drug not indicated)
Endocrine system
Glibenclamide or chlorpropamide with type 2 diabetes mellitus (risk of prolonged hypoglycaemia)
Betablockers in those with diabetes mellitus and frequent hypoglycaemic episodes i.e. _1 episode per month (risk of masking hypoglycaemic symptoms)
Oestrogens with a history of breast cancer or venous thromboembolism (increased risk of recurrence)
Oestrogens without progestogen in patients with intact uterus (risk of endometrial cancer)