Unifying Concepts

STOPP/START Criteria for Potentially Inappropriate Prescribing in Older People

Adverse drug reactions (ADRs) in older people currently represent a serious and growing public health problem. Polypharmacy and inappropriate prescribing (IP) are wellknown risk factors for ADRs, which commonly cause adverse clinical outcomes in older people IP encompasses potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs). STOPP/START criteria for potential IP in older people recognise the dual nature of IP by including a list of PIMs (STOPP criteria) and PPOs (START criteria).

Proposed criteria rejected by the expert panel for inclusion in STOPP/START version 2 using Delphi consensus

Rejected new STOPP criteria

  • Diuretic for treatment of hypertension with concurrent urinary incontinence (may exacerbate incontinence)
  • SSRIs with concurrent bleeding diathesis, prescription of anticoagulants or antiplatelet agents (increased risk of bleeding in general), active peptic ulcer disease or concurrent NSAID prescription (risk of gastrointestinal bleeding)
  • SSRIs in patients with previous history of major non-traumatic bleeding or in combination with drugs that may promote peptic ulceration, e.g. NSAIDs (increased risk of recurrent major bleeding)
  • Aspirin, clopidogrel, dipyridamole, vitamin K antagonists, direct thrombin inhibitors or factor Xa inhibitors with concurrent high bleeding risk, i.e. HAS-BLED score ≥3; HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history, labile INRs, elderly (age > 65 years), drugs that promote bleeding/alcohol)
  • Antidepressants of any kind in patients with recurrent falls

Rejected new START criteria

  • Memantine for moderate–severe Alzheimer’s disease
  • Dopamine agonist (e.g. ropinirole or pramipexole) for Restless Legs Syndrome once iron deficiency has been excluded
  • Statin therapy in diabetes mellitus, unless the patient is at end of life or more appropriate for palliation
  • Phosphodiesterase type-5 inhibitor with persistent erectile dysfunction

SSRI, selective serotonin reuptake inhibitor; NSAID, non-steroidal anti-inflammatory drug.



  1. O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2 [published correction appears in Age Ageing. 2018 May 1;47(3):489]. Age Ageing. 2015;44(2):213–218. [Medline]
  2. O’Mahony D. STOPP/START criteria for potentially inappropriate medications/potential prescribing omissions in older people: origin and progress [published online ahead of print, 2019 Nov 30]. Expert Rev Clin Pharmacol. 2019;1–8. [Medline]


Created Jan 8, 2020.

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