[Detecting inappropriate medication in older people: the revised STOPP/START criteria]. / Onjuist geneesmiddelgebruik bij ouderen opsporen. De herziene STOPP- en START-criteria.

The use of potentially inappropriate medications (PIMs) by older people and potential prescribing omissions (PPOs) represent a serious problem. It increases the risk of adverse drug reactions (ADRs), however it is susceptible to influence in a substantial number of cases. Use of the STOPP/START criteria developed in Ireland to optimise pharmacotherapy of older people reduces the number of ADRs and medication errors. Licensing of new drugs, the increased number of potentially inappropriate drugs, and the availability of new literature were grounds for an update of the first version of the STOPP/START criteria which was published in 2008. In order to develop a screening tool with a broader application, a consensus panel of experts in the field of pharmacotherapy of older people was selected from 14 European countries for the second version of the STOPP/START criteria, including two from the Netherlands. The translation of the second version of the STOPP/START criteria has been adapted to the situation in the Netherlands, partly by omitting drugs that are not licensed in the Netherlands.

[Detection of inappropriate medication use in the elderly; will the STOPP and START criteria become the new Dutch standards?]. / Detectie van ongeschikt medicatiegebruik bij ouderen: worden de STOPP- en START-criteria de nieuwe standaard?

Many drugs that can be prescribed safely and effectively to younger patients are potentially inappropriate for the elderly as a result of physiological changes and increased comorbidity. A screening tool can be useful for detecting potentially inappropriate medication use in the elderly. When analysing medication use in the elderly, both overtreatment and undertreatment should be assessed. In Ireland, a screening method called the STOPP and START criteria has been developed; these provide 'handles' for the detection of potential overtreatment and undertreatment. The STOPP and START criteria, therefore, seem to be more fitting to the Dutch situation than the widely used Beers' criteria. In the new Dutch multidisciplinary guideline, 'Polypharmacy in the elderly' the use of the STOPP and START criteria is advised. In this article, we present a translation of the STOPP and START criteria which has been adapted for Dutch practice.

[Multidisciplinary guideline 'Recognition and treatment of chronic pain in vulnerable elderly people']. / Multidisciplinaire richtlijn 'Herkenning en behandeling van chronische pijn bij kwetsbare ouderen'.

Chronic pain in vulnerable elderly people is still poorly recognized and treated, both at home and in hospitals and care and nursing homes. Vulnerable elderly people experience and express pain differently to relatively healthy adults, especially when they suffer from cognitive impairment or specific conditions. Determining the nature and severity of the pain requires the use of pain assessment instruments that have been validated for use in vulnerable elderly people. Effective treatment of pain demands careful diagnosis and pharmacological and non-pharmacological interventions that have proven effectiveness in vulnerable elderly people. The combination of multiple morbidity and poly-pharmacy increases the chance of side-effects and complications. In addition, the pharmacokinetic and pharmacodynamic characteristics of many drugs are different in vulnerable elderly people. The advice is to start with a lower dose of pain medication and gradually build up a level on the basis of pain relief and side-effects ('start low, go slow!').

[Interaction between clopidogrel and proton pump inhibitors]. / Interactie tussen clopidogrel en protonpompremmers.

The drug interaction between proton pump inhibitors and clopidogrel has been the subject of much study in recent years. Contradictory results regarding the effect of proton pump inhibitors on platelet reactivity and on clinical outcome in clopidogrel-treated patients have been reported in literature. Concomitant use of omeprazole and clopidogrel was found to decrease the exposure (AUC) to clopidogrel's active metabolite by 50% and to sharply increase platelet reactivity, as a result of inhibition by omeprazole of CYP2C19, a cytochrome P450 (CYP) enzyme. Pantoprazole has a much weaker effect on clopidogrel's pharmacokinetics and on platelet reactivity during concomitant use. The influence of the other proton pump inhibitors when used simultaneously with clopidogrel has not yet been investigated in adequately randomized studies. Regulatory agencies state that the combination of clopidogrel and the CYP2C19 inhibitors omeprazole and esomeprazole should be avoided. To date, there is no conclusive evidence of a clinically-relevant interaction between any of the proton pump inhibitors and clopidogrel.

[Correct use of methotrexate]. / Correct gebruik van methotrexaat.

Insufficient knowledge about the correct dosage and potential implications of overdose have played an important role in recent accidents involving methotrexate (MTX). Therefore, it is important that the prescribing physician as well as the pharmacist and pharmacist's assistant have sufficient knowledge of the usual dosages, precautionary measures, side-effects, interactions and contraindications of MTX, to ensure a correct dosing regimen is prescribed. For nearly all indications, MTX is prescribed in a weekly dose of 5-30 mg and preferably in combination with 5 mg folic acid twice a week on a day that MTX is not used. The toxic dose of MTX lies very close to the effective MTX dose. It is therefore important to look out for signs of toxicity.

[Methotrexate: safe if prescribed correctly]. / Methotrexaat veilig, mits juist voorgeschreven.

Methotrexate (MTX) is an effective medicine that can be safely used for the treatment of rheumatic arthritis and severe cases of psoriasis. For nearly all indications MTX is prescribed as a weekly dose. As a result of prescription errors, miscommunication, failing pharmacovigilance and lack of knowledge, fatal incidents have occurred due to prescriptions for a dosage once daily instead of once weekly. To prevent such incidences in the future, a balanced automatic pharmacovigilance, clear instructions for the use of MTX on the prescription and good patient information are needed.