206 CHAPTER 3.1 3. Screening for over-treatment: this step involves evaluation of over-treatment according to STOPP criteria. All medications including those initiated in the prior step are evaluated based on the medical conditions and known biomedical parameters and symptoms or complaints. During this step, the newly initiated medications, including START criteria-based recommendations accepted during the previous step, could also appear as STOPP recommendations. For example, in the previous step an ACE inhibitor was started according to START rule A6. However, due to the presence of hyperkalaemia, STOPP rule B11 (“ACE Inhibitors or Angiotensin Receptor Blockers in patients with hyperkalaemia”) would then be triggered. The user decides whether these STOPP recommendations are relevant to the patient under review. If a recommendation is followed, the medication in question will then be removed from the recommended medications list. They will appear on the final report as ‘medication advised to be stopped’. All medications that could not be assigned to an appropriate medical condition and have therefore been allocated the ICD-10 code ‘R69’ are considered potential overtreatment. Moreover, the STOPP criteria addressing impaired renal function and combinations with certain medications (e.g. digoxin and eGFR <30ml/min) will be triggered here, based on either entered eGFR values or an ICD-10 diagnosis of renal insufficiency. In addition to stopping medications, the user could also decide to recommend a dose adjustment (both manually and based on STOPP criteria). 4. Medication-Disease Interactions (ADEs): this step encompasses the adjudication of clinical signs or symptoms entered which are based on the predefined list of symptoms and signs that may be attributable to medications or medical conditions. The software user, based on expert opinion, can assign symptoms and signs manually to medications and a drop-down menu with three possible actions appears: (A) The symptom/sign can be registered as ‘side effect’ of the concerning medication; (B) The medication can be either maintained, stopped or adjusted; (C) Adaptations to other drugs can be made including stopping, adjusting or starting new drugs. All assigned symptoms and signs will appear on the report linked to their possible causative medication. 5. Medication-Medication Interactions: during the fifth step, the medication list will be checked for drug-drug interactions based upon the incorporated or local interaction database (dependent on licensing) within the software. If an interaction is identified, the user can again choose to act upon or ignore the prompt. An explanation about the interaction is present to assist the software user in this decision process. When a drug-drug interaction is addressed, the software user must decide which medication to maintain, stop or adjust. Also, other drugs from the medication list can be adapted here and a new medication can be initiated, for instance to replace one of the interacting medications.
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