Final list of statements included in PIM-Check
| PIM-Check: Potentially Inappropriate Medication checklist for Patients in Internal Medicine | |
| This tool is designed for quick detection of underprescription: UP, overprescription: OP, drug interaction: DDI or other kind of potentially inappropriate medications (eg, therapeutic adaptations, treatment re-evaluations, improper drug use): OTH, that may be dangerous for patients hospitalised in internal medicine (excluding pregnant women and patients with low life expectancy or requiring palliative care). It is organised by major physiological systems and pathologies. This is not a replacement for a clinical and biological evaluation by a clinician. The proposals are only applicable in the event there is no patient-specific contraindication. This tool was validated using a Delphi method including 40 international experts from Belgium, France, Québec and Switzerland. Some drugs listed may not be available in each country. | |
| CARDIOLOGY | |
| Heart failure | |
| 1 UP | Start ACEI or ARB Prescribe or continue long-term ACEI treatment in patients with HF (or ARB in case of intolerance) |
| 2 UP | Start beta-blocker treatment Prescribe or continue long-term beta-blocker treatment* in patients with HF |
| 3 UP | Start aldosterone antagonist when LVEF≤35% despite optimal treatment Consider prescribing an aldosterone antagonist in HF patients with LVEF≤35% despite treatment with ACEI, or ARB and beta-blocker at the recommended or maximum tolerated doses |
| 4 OP | Drugs that may exacerbate HF Avoid prescribing drugs* that may exacerbate HF, drugs that are rich in sodium** and antiarrhythmics (except for digoxin and amiodarone) in HF patients |
| Dyslipidaemia and hypolipidemics | |
| 5 UP | Dyslipidaemia and high cardiovascular risk: start statins Prescribe or continue treatment with statins in patients with a high cardiovascular risk or adapt lifestyle and dietary measures and the treatment intensity based on that risk (moderate, high or very high) |
| 6 UP | Dyslipidaemia, hypercholesterolaemia: start statins as a first-line treatment Prescribe statins as a first-line treatment in case of mixed dyslipidaemia or hypercholesterolaemia when pharmacological treatment is necessary* |
| 7 DDI | Statins and DDI Evaluate the risk of DDIs and adapt the treatment if statins are introduced or if treatment is modified in patients receiving statins |
| 8 OP | Avoid combining statins and fibrates Avoid combining statins and fibrates and prohibit the statin/gemfibrozil combination |
| Stable ischaemic heart disease | |
| 9 UP | Start beta-blocker treatment Prescribe or continue beta-blocker treatment in patients with ischaemic heart disease |
| 10 UP | Start low-dose aspirin Prescribe or continue treatment with low-dose aspirin in patients suffering from ischaemic heart disease (when there is no contraindication*) |
| 11 UP | Start statins Prescribe or continue statins in patients suffering from stable ischaemic heart disease |
| Secondary prevention of acute STEMI or NSTEMI | |
| 12 Other | Start lifestyle and diet modifications Encourage patients having undergone a STEMI or NSTEMI to participate in a secondary prevention programme, specifically aiming to adapt their diet, control their weight, engage in physical activity, stop smoking and improve compliance with treatment |
| 13 UP | Start beta-blocker treatment Prescribe or continue long-term beta-blocker treatment after a STEMI or NSTEMI |
| 14 UP | Dual antiplatelet therapy? Prescribe or continue treatment by dual antiplatelet therapy for up to 12 months after a STEMI or NSTEMI, followed by long-term antiplatelet monotherapy (first-line treatment = low-dose aspirin) |
| 15 UP | Start statins Prescribe or continue statins after STEMI or NSTEMI |
| 16 UP | Start ACEI or ARB Prescribe or continue treatment with ACEI for at least 30 days following a STEMI or NSTEMI and then, on a long-term basis, in particular in the presence of an aggravating factor* (or an ARB in case of intolerance) |
| High blood pressure | |
| 17 UP | Start antihypertensive drug treatment Begin antihypertensive drug treatment with a first-line drug* alone or in combination if pharmacological treatment of BP is necessary**. Combine it with lifestyle and diet modifications*** |
| 18 Other | Favour ACEI or ARB in patients with diabetes/CKD/HF/STEMI/NSTEMI and HBP Favour an ACEI or ARB combined or without another first-line antihypertensive drug to treat high BP in patients with diabetes or in patients with microalbuminuria/proteinuria, CKD, HF or history of STEMI or NSTEMI |
| 19 UP | Resistant high BP Seek a secondary cause of high BP and then optionally add an aldosterone antagonist*, amiloride or an alpha 1 blocker in case of true resistant HTN** |
| 20 OP | Drugs that can exacerbate high BP Exercise caution in using drugs that may increase BP* or that are rich in sodium** in patients with high BP |
| 21 OP | Avoid loop diuretic as a first-line treatment Do not prescribe a loop diuretic as a first-line treatment to treat high BP |
| Non-cardioembolic stroke and transient ischaemic attacks | |
| 22 UP | Start statins Prescribe statins in patients with non-cardioembolic and non-haemorrhagic TIA or stroke |
| 23 UP | Start antiplatelet therapy Prescribe a preventive antiplatelet therapy* in patients with non-cardioembolic and non-haemorrhagic TIA or stroke |
| Arrhythmias, atrial fibrillation and antiarrhythmics | |
| 24 Other | Adjust digoxin dose Reduce or adjust digoxin dose depending on the digoxin serum levels in elderly patients or patients with renal failure; favour an alternative when possible |
| 25 DDI | Digoxin and DDIs Evaluate the risk of DDIs and adapt treatment in case new treatment is introduced in a patient receiving digoxin (in particular with Pgp inhibitors) |
| 26 UP | Start oral anticoagulation Prescribe or continue oral anticoagulation* in patients suffering from non-valvular AF whose CHA2DS2-VASc** is≥1. In case of treatment with VKA, adapt the doses to obtain an INR between 2 and 3 |
| ANGIOLOGY/HAEMOSTASIS | |
| Oral anticoagulants | |
| 27 Other | Anticoagulation: start patient education Provide patient education for patients receiving oral anticoagulation (or the caregiver) |
| 28 Other | Anticoagulation: prevent the inappropriate administration of anticoagulant Verify the appropriateness of the administration for an oral anticoagulant taken by a patient (dosage, frequency and time of administration) with the indication, the usual treatment and the prescribed molecule (in particular for DOACs: the number of doses/day and the administration conditions) |
| 29 Other | VKAs: Vitamin K1 administration Favour the OR in case of VKA overdose requiring the administration of Vitamin K1. Favour low doses (1–5 mg) when there is VKA overdose with no bleeding or minor bleeding but requiring the administration of Vitamin K1 |
| 30 OP | Switching from VKA to DOAC Consider a DOAC switch in patients who were already treated with VKA only if the INR is not kept in the target zone despite monitoring and correct observance or in case of intolerance. Continue VKA treatment if the latter is effective and well tolerated |
| 31 Other | Anticoagulation and renal function Evaluate renal function* and adjust the doses to the CrCl if a DOAC is introduced in a patient. Favour VKA treatment if the CrCl is<30 mL/min |
| 32 DDI | Anticoagulation and DDIs Evaluate the risk of DDIs* and adapt the treatment if a new drug is introduced in patients receiving an oral anticoagulant |
| Deep vein thrombosis, pulmonary embolism, venus thromboembolism | |
| 33 UP | DVT/PE: start anticoagulation Prescribe or continue anticoagulation for at least 3 months* in case of proximal DVT and/or PE. In case of treatment with VKA, adapt the doses to obtain an INR between 2 and 3 |
| 34 UP | Idiopathic VTE: start anticoagulation Prescribe or continue anticoagulation for at least 3 months or long term with annual re-evaluation in case of idiopathic VTE or with a major persistent risk factor* |
| 35 UP | DVT/PE/VTE: start prophylactic anticoagulation Prescribe prophylactic anticoagulation* in patients who are hospitalised for acute medical affection for an anticipated duration of>3 days and with a high risk of thrombosis** and/or in patients who are hospitalised for surgical procedure with a moderate or high risk of thrombosis |
| PNEUMOLOGY | |
| Chronic respiratory diseases | |
| 36 Other | New inhalation drug delivery device: start patient education Provide individualised patient education (or caregiver) if a new inhalation drug delivery device is prescribed and ensure that it is used properly |
| 37 Other | Use of the holding chamber Favour the use of a holding chamber for the administration of products in a metered-dose inhaler in the event of worsening chronic respiratory disease or poor hand-lung coordination |
| 38 Other | ICS mode of administration Favour taking ICS before meals and rinse out the mouth and gargle or brush teeth after inhalation |
| 39 Other | Caution with non-cardioselective beta-blocker Favour a cardioselective beta-blocker* when it is indicated in patients with asthma or COPD |
| Asthma | |
| 40 UP | Asthma and long-term treatment: start ICS as a first-line treatment Prescribe, as a first-line treatment, low-dose ICS in patients with mild persistent asthma* requiring background treatment |
| 41 OP | Asthma and long-term treatment: avoid long-acting beta2-agonists as a first-line treatment or as monotherapy Do not prescribe as first-line treatment or as monotherapy a long-acting beta2-agonists to treat asthma |
| 42 UP | Asthma and long-term treatment: add long-acting beta2-agonists as a second-line treatments Add long-acting beta2-agonists (favoured) or increase the inhaled corticosteroid doses in patients with asthma for whom taking a low dose ofICS alone is not sufficient |
| Chronic obstructive pulmonary disorder | |
| 43 UP | COPD and long-term treatment: start a beta2-agonist or anticholinergics as a first-line treatment Prescribe an inhaled bronchodilator (β2-mimetic or anticholinergics) as a first-line pharmacological treatment for COPD |
| 44 OP | COPD and long-term treatment: avoid ICS as a first-line treatment or as a monotherapy Do not prescribe ICS as a first-line treatment and as a monotherapy to treat COPD |
| NEPHROLOGY | |
| Renal failure | |
| 45 Other | Adjust drug doses Adjust drug doses if a new treatment is introduced in a patient with renal failure or in case of a significant modification of renal function |
| 46 OP | RF: be careful with nephrotoxic drugs and or adjust doses of drugs that are excreted by the kidneys Avoid nephrotoxic drugs* and exercise caution in prescribing drugs that are excreted by the kidneys in chronic renal failure patients or patients having a pathology that may cause acute renal failure, or adjust doses and check renal function |
| 47 UP | Correct iron deficiency before starting ESA treatment Correct any iron deficiency before starting ESA treatment and then prescribe a sufficient iron supplement* in combination with ESA treatment |
| 48 UP | ESA and Hb target Prescribe, if needed and in collaboration with a nephrologist, an ESA in chronic renal failure patients with a Hb level<10 g/dL or bothersome symptoms, despite sufficient iron supplementation. The Hb target is approximately 11.5 g/dL (between 10 and 12 g/dL) while avoiding exceeding 12 g/dL |
| 49 UP | Calcium, vitamin D and/or phosphate-binding agents Continue or adjust calcium, vitamin D supplementation and/or phosphate-binding agents (to be taken with food) in chronic renal failure patients |
| 50 UP | Start ACEI or ARB Prescribe or continue treatment with ACEI or ARB in chronic renal failure patients with albuminuria* or chronic renal failure patients with diabetes and microalbuminuria** |
| Benign prostatic hyperplasia | |
| 51 OP | Drugs that may exacerbate BPH Avoid anticholinergic* or sympathomimetic drugs in patients with BPH or use with caution and under monitoring |
| GASTROENTEROLOGY | |
| Peptic ulcer disease and proton pump inhibitors | |
| 52 OP | Peptic ulcer disease prevention: PPI treatment started before hospitalisation Re-evaluate the continuation of PPI treatment that started more than 8 weeks before hospitalisation |
| 53 OP | PPI treatment started during hospitalisation Stop PPI treatment before patient discharge if that treatment started during hospitalisation to prevent bleeding |
| 54 OP | PPI re-evaluate treatment dose and duration Do not exceed a dose equivalent* to 20 mg/day of oral esomeprazole if empiric PPI treatment is started during hospitalisation and do not extend past 8 weeks without gastroenterologist opinion or endoscopic evaluation |
| 55 OP | PPI: prescription with no valid indication Do not prescribe a PPI to prevent lesions that are caused by taking NSAIDs, CS or aspirin alone in the absence of a risk factor* |
| 56 OP | Be careful with drugs that may exacerbate ulcer disease Avoid prescribing drugs that may cause digestive bleeding* in patients suffering from peptic ulcer disease or make sure that it is combined with a PPI |
| Hepatic impairment and cirrhosis | |
| 57 OP | Hepatic impairment and cirrhosis: avoid or adjust doses of hepatotoxic drugs or of drugs that are metabolised by the liver Avoid the use or adjust doses of potentially hepatotoxic drugs or of drugs that are metabolised by the liver* when started in patients with hepatic impairment |
| 58 UP | Hepatic encephalopathy: lactulose and lactitol Consider prescribing disaccharides that are not generally absorbable at high doses in patients suffering from hepatic encephalopathy |
| Diarrhoea | |
| 59 OP | Diarrhoea without investigation: avoid antimotility agents Do not use antimotility agents* in case of mucohaemorrhagic diarrhoea, diarrhoea combined with high fever or postantibiotic diarrhoea without additional investigation |
| 60 Other | Testing for Clostridium difficile infection Systematically look for a C difficile infection in case of nosocomial diarrhoea (>72 hour), postantibiotic diarrhoea or diarrhoea with no other aetiology |
| 61 UP | Treatment of Clostridium difficile infection Prescribe as a first-line treatment for a first episode of Clostridium difficile infection:
|
| Constipation | |
| 62 OP | Drugs that may exacerbate constipation Avoid or use with caution drugs that may cause iatrogenic constipation* in patients suffering from constipation, or monitor and treat any aggravation |
| RHEUMATOLOGY | |
| Gout | |
| 63 UP | Acute gout: NSAID and/or colchicine or glucocorticoid as a first-line treatment Prescribe as a first-line treatment an NSAID and/or oral colchicine or even a glucocorticoid* to patients suffering from acute gout |
| 64 UP | Gout and long-term treatment: start allopurinol as a first-line treatment Prescribe allopurinol as a first-line treatment to patients for whom pharmacological treatment seeking to reduce uric acid levels is necessary* |
| 65 UP | Gout and long-term treatment initiation: add an NSAID or low-dose colchicine To avoid a gout attack, prescribe an NSAID or low-dose colchicine for the titration duration of a hypouricaemic background treatment or if the dose is changed |
| 66 OP | Drugs that may exacerbate gout When an alternative is available, avoid or use with caution drugs that may cause an increase in uric acid levels and gout attacks* in patients suffering from gout |
| Rheumatoid arthritis | |
| 67 Other | MTX and monitoring Monitor hepatic transaminases, complete blood count and renal function before starting treatment with MTX and then regularly during treatment (in particular if combined with other hepatotoxic, haematotoxic or nephrotoxic drugs*) |
| 68 UP | MTX: start folic acid Prescribe preventive treatment with daily or weekly folic acid in patients receiving long-term MTX |
| 69 OP | Avoid long-term CS Re-evaluate with a specialist and optionally stop long-term corticosteroid treatment in patients with RA with prolonged remission |
| Corticosteroids and osteoporosis | |
| 70 Other | Long-term CS: start patient education Provide patient education* to those receiving new long-term corticosteroid treatment (or caregivers) |
| 71 UP | Long-term CS and prevention of osteoporosis: start calcium/vitamin D Evaluate intake and prescribe calcium and vitamin D if needed to patients receiving corticosteroid treatment for an anticipated duration of≥3 months (irrespective of the dose) |
| 72 UP | Long-term CS and prevention of osteoporosis: start bisphosphonates Prescribe bisphosphonates to patients receiving CS with an increased risk of fracture* or to patients with a high risk of osteoporosis receiving long-term CS** |
| 73 UP | CS and bisphosphonates: prevent inappropriate administration Correct any hypercalcaemia or vitamin D deficiency* before beginning treatment with bisphosphonates. Prescribe bisphosphonates in the morning on an empty stomach** with a large glass of lowly mineralised water, separate from other medicines***, informing the patient to remain seated or standing for at least 30 min |
| NEUROLOGY | |
| Epilepsy and antiepileptics | |
| 74 OP | Drugs that may exacerbate epilepsy Avoid or use with caution treatments that may lower the seizure threshold* in an patient with epilepsy if an alternative is available |
| 75 DDI | Antiepileptic and DDIs Evaluate the risk of DDIs, and adjust the treatment if a new treatment is introduced in patients receiving antiepileptics (in particular with CYP and/or Pgp inducers/inhibitors*) |
| 76 UP | Antiepileptic and DDIs with contraception Use effective contraception means* if possible other than combined oral or intra-vaginal contraceptives, patches and pure progestogen pills in women of childbearing age who are treated with an enzyme-inducing anti-epileptic** and who have not planned to become pregnant |
| Parkinson's disease and Parkinson's medications | |
| 77 UP | Prevent the inappropriate administration of Parkinson's disease treatment Continue treatment for Parkinson's disease at the usual doses, times and dosing forms in case of hospitalisation. Adapt the dosing form and the dose in case of fasting or difficulty swallowing |
| 78 OP | Parkinson's disease and antinausea neuroleptics: prefer domperidone Avoid using dopamine antagonist antinausea medications crossing the haematoencephalic barrier to treat nausea and vomiting in patients with Parkinson's disease. Prefer domperidone |
| PSYCHIATRY | |
| Psychotropic illness and drugs | |
| 79 OP | Avoid prescribing two psychoactive drugs from the same therapeutic class Avoid prescribing two psychoactive drugs from the same therapeutic class without seeking a specialised opinion |
| Depression and antidepressants | |
| 80 UP | Optimise the dose of an antidepressant medication if a suboptimal response is observed Do not stop an insufficiently effective antidepressant treatment before optimising the dose up to the effective dose and verifying patient observance, except in the case of side effects |
| 81 UP | Severe depression: start SSRI as a first-line treatment Prescribe an antidepressant* with or without combining psychotherapy in patients suffering from severe depression |
| Insomnia, sedatives and hypnotics | |
| 82 OP | Hypnotics: Treatment duration and re-evaluation Re-evaluate hypnotic treatment every 2 weeks and on hospital discharge. Do not stop hypnotic treatment abruptly |
| 83 OP | Hypnotics: drugs to avoid as a first-line treatment Do not prescribe sedative neuroleptics or antihistamines as a first-line treatment for insomnia (except with specific indications) |
| Schizophrenia and neuroleptics | |
| 84 DDI | Neuroleptics: Drugs that prolong the QT interval Avoid prescribing drugs that may prolong the QT interval* in patients receiving a neuroleptic, in particular if their pre-treatment QT interval is long or when there is a risk of torsade de pointes |
| PAIN and ANALGESIA | |
| Neuropathic pain | |
| 85 UP | Neuropathic pain: start an anticonvulsant* or an antidepressant** as a first-line treatment Prescribe as a first-line treatment an anticonvulsant* or an antidepressant** to treat chronic neuropathic pain requiring pharmacological treatment |
| 86 UP | Neuropathic pain: combine analgesics as a second-line treatment Potentially combine an opiate antalgic with a first-line drug* in case of chronic neuropathic pain after the failure of two monotherapies or a bi-therapy of first-line drugs |
| Acute pain and opiates | |
| 87 UP | Start opioids in the case of acute moderate to severe pain Prescribe an opiate antalgic in the case of moderate (level 2) to severe (level 3) acute pain, preferably orally, when allowed by the patient's clinical situation (VAS>4 according to the WHO scale) |
| 88 Other | Analgesia and opioids: switching and equianalgesic dose ratios Switch opioids* and apply the rules of equianalgesic dose ratios to determine the initial dose to be administered in patients with side effects, in case of inefficacy despite correct titration, in case of harmful drug interactions or if a change in the administration route is necessary |
| 89 DDI | Combine opioids of different release rates Avoid combining two opioids with the same release kinetics or combining pure agonists–partial agonists |
| 90 UP | Opioids: start prophylactic measures* to prevent constipation Take prophylactic measures* to prevent constipation from the start of an opioid treatment |
| Migraines | |
| 91 UP | Start a triptan for patients not responding to NSAIDs +/– in combination Prescribe a triptan in the case of a migraine attack not responding to NSAIDs +/– in combination* or in case of severe migraine |
| 92 UP | Start migraine prophylaxis Prescribe a background treatment for migraines in patients with more than two incapacitating migraines/week or very frequently using migraine medication* |
| INFECTIOLOGY | |
| Urinary infections | |
| 93 Other | Urinary tract infection: replace the urinary catheter before starting antibiotic treatment* Remove the urinary catheter or change it before starting suitable antibiotic treatment* in patients with urinary infection with a catheter in place for more than 2 weeks |
| Pulmonary-related and tuberculosis-related infections | |
| 94 UP | Pneumonia: use beta-lactam, macrolide and/or fluoroquinolone as empirical therapy Prescribed an antibiotic from the family of beta-lactam, macrolide and/or fluoroquinolone, depending on the gravity factors and local recommendations, in empirical therapy for community-acquired pneumonia in hospitalised patients |
| 95 UP | Tuberculosis: treatment for at least 6–18 months Continue antituberculosis treatment for at least 6–18 months (depending on the location and the germ) in patients who are treated for active tuberculosis |
| 96 OP | Anti-tuberculosis drugs: be careful with potentially hepatotoxic drugs* Avoid or use with caution potentially hepatotoxic drugs* in patients who are treated with antituberculosis drugs, and monitor the hepatic function closely |
| 97 DDI | Rifampicin and DDIs Evaluate the risk of DDIs and favour the use of drugs not interacting* with rifampicin or adapt treatment in patients treated with rifampicin |
| Abdominal infections | |
| 98 UP | Intra-abdominal infection: antibiotics covering anaerobic germs* Prescribe an antibiotic covering, in particular, anaerobic germs* as an empirical treatment of a serious acute intra-abdominal infection |
| Endocarditis | |
| 99 OP | Endocarditis prophylaxis: only in patients at very high risk* and undergoing a very high-risk procedure** Prescribe preventive endocarditis treatment only in patients at very high risk* and undergoing a very high-risk procedure** for bacterial endocarditis |
| Osteoarticular infections | |
| 100 UP | Osteoarticular infection: antibiotics with correct bone penetration* Prescribe a highly bioavailable antibiotic with correct bone penetration* that is suitable for the germ and its sensitivity when it is identified during an osteoarticular infection |
| HIV infection | |
| 101 DDI | HIV infection: HAART and DDIs Evaluate the risk of DDIs and favour the use of drugs with no interaction with HAART, or adjust the doses if a new treatment is started in patients infected with HIV who are treated with HAART |
| 102 UP | HIV infection and cardiovascular risk: start statins Prescribe statins to patients infected with HIV, considering the DDIs. The therapeutic objective in those patients is determined based on their cardiovascular risk level* |
| Hepatitis C virus infection | |
| 103 DDI | HCV infection: direct-acting antivirals against HCV and DDIs Evaluate the risk of DDIs*, and adapt the treatment if a new treatment is introduced in patients infected with HCV receiving direct-acting antiviral therapy |
| Hepatitis B virus infection | |
| 104 UP | HBV infection: do not suspend long-term antiviral therapy Do not suspend long-term antiviral therapy with nucleosidic analogues in patients who are infected with HBV without an evaluation by a specialist |
| Prevention/prophylaxis | |
| 105 UP | Prophylaxis for Pneumocystis jiroveci pneumonia and bone marrow transplant Prescribe or continue prophylactic treatment against Pneumocystis pneumonia in patients having received a bone marrow transplant |
| 106 UP | Prophylaxis for P jiroveci pneumonia and solid organ transplant Prescribe or continue prophylactic treatment against Pneumocystis pneumonia in patients having received a solid organ transplant and receiving immunosuppressants |
| 107 UP | Prophylaxis for P jiroveci pneumonia and HIV infection Prescribe or continue prophylactic treatment against Pneumocystis pneumonia in patients who are HIV-infected with a CD4 count of<200 cells/mm3 |
| 108 UP | Prophylaxis for P jiroveci pneumonia and highly immunosuppressive drugs Consider prophylactic treatment against Pneumocystis pneumonia in patients receiving highly immunosuppressive treatments* |
| 109 UP | Isoniazid and the prevention of peripheral neuropathy: start vitamin B6 Prescribe a vitamin B6 supplement in patients who are treated with isoniazid and with a risk of deficiency* or showing signs of peripheral neuropathy |
| Proper use of antibiotics | |
| 110 Other | Re-evaluate empiric antibiotic treatment within 24–72 hours Re-evaluate empiric antibiotic treatment within 24–72 hours after it is started and adapt it based on the patient's clinical condition and the results of bacteriological samples |
| 111 Other | Antibiotics through parenteral route: re-evaluate the route of administration Favour the OR* as soon as the patient's clinical condition allows it, considering the bacteriological documentation and choosing an antibiotic with good oral bioavailability* |
| 112 OP | Proper use of antibiotics: re-evaluate the duration of therapy Re-evaluate the continuation of effective antibiotic treatment after 5–7 days. Continuation of the treatment past 10 days should be reserved for certain serious infections or situations* |
| 113 Other | Aminoglycoside and vancomycin: therapeutic drug monitoring Monitor plasma concentrations for antibiotics with a dose-dependent toxicity* in the case of suspicion of toxicity or risk situation for toxicity** and/or in the case of risk of underdosing**. Then, adjust the dosing regimens |
| 114 DDI | Macrolides and long QT syndrome or drugs that prolong the QT interval Exercise caution when using macrolides, in particular azithromycin, in patients with a high cardiovascular risk*, especially if combined with drugs with the potential to cause QT prolongation |
| 115 Other | Aminoglycosides and once-daily dosing Preferably use an aminoglycoside with a once-daily dosing regimen by intravenous route (30 min perfusion) combined with another antibiotic and for a duration of≤5 days (unless there is a particular situation*) |
| ENDOCRINOLOGY | |
| Diabetes mellitus | |
| 116 UP | DM: adjust therapy according to HbA1c targets Adjust the antidiabetic treatment in a customised manner, optionally combining several molecules, to obtain a HBA1c target that is adapted to the patient* |
| 117 OP | DM: avoid drugs that may alter the blood glucose level* Exercise caution in using drugs that may alter the blood glucose level** in patients with diabetes and perform a close monitoring of blood glucose* in case of use |
| 118 Other | DM: CS and blood glucose monitoring Monitor blood glucose closely if CS are introduced to patients with diabetes or patients with glucose intolerance, and optionally adjust the antidiabetic treatment |
| 119 Other | DM or microalbuminuria*/proteinuria and HTN: start ACEI or ARB (nephroprotective effects) Favour an ACEI or ARB combined or not with another first-line antihypertensive drug to treat HTN in patients with diabetes or patients with microalbuminuria*/proteinuria |
| 120 UP | DM: start statins in patients with a high or very high cardiovascular risk Prescribe or continue statins in patients with diabetes with a high or very high cardiovascular risk* |
| 121 UP | DM: start low-dose aspirin in patients with a high cardiovascular risk or as secondary prevention Consider a low-dose aspirin treatment* in patients with diabetes with a high cardiovascular risk**. Prescribe it as secondary prevention of cardiovascular events |
| 122 UP | T2DM: start metformin as a first-line treatment Prescribe metformin as a first-line treatment for pharmacological treatment for T2DM |
| 123 OP | T2DM and metformin: withhold metformin in unstable conditions If necessary, withhold metformin in hospitalised patients with diabetes in unstable conditions, in case of surgery or in case of the injection of an iodine contrast product, particularly with polymorbidity or renal failure |
| 124 Other | T2DM and sulfonylurea: monitor blood glucose in unstable conditions Monitor blood glucose closely in the case of treatment using sulfonylurea* in hospitalised patients with diabetes with unstable conditions (particularly in the case of renal failure, frequent hypoglycaemia or difficulties perceiving the signs of hypoglycaemia) |
| 125 Other | DM and renal failure: adjust the doses of antidiabetics Monitor blood glucose and adjust the doses of antidiabetics* in the case of impaired renal function |
| Thyroid disorders | |
| 126 Other | Hypothyroidism: measure the serum TSH 6 weeks after changing the levothyroxine dose Measure the serum TSH 6 weeks after changing the levothyroxine dose or after any change in a levothyroxine-based agent and assess whether a new titration of the dose is necessary |
| 127 Other | Hypothyroidism: levothyroxine and usual mode of administration Continue treatment with levothyroxine under the usual mode of administration. In the case of initiation, favour the administration on an empty stomach in the morning* in the absence of substances that may decrease its absorption** |
| 128 OP | Hypothyroidism: levothyroxine and OR unavailable It is not necessary to administer levothyroxine parenterally to dysthyroidal patients with stable euthyroidism who are unable to receive oral treatment for an anticipated duration of<7 days |
| 129 OP | Thyroid disorders: be careful with drugs that may induce hypothyroidism or hyperthyroidism* Monitor the TSH before and 6 weeks after the introduction of a treatment that may induce thyroid disorders* |
| 130 UP | Hyperthyroidism: start a beta-blocker Consider prescribing a beta-blocker in patients with hyperthyroidism, particularly at the beginning of pharmacological management |
| Contraception | |
| 131 DDI | Contraception and DDIs Verify contraceptive use in all hospitalised women of childbearing age, and if necessary monitor the lack of DDI with the treatments* that are received or started during hospitalisation |
| OPHTHALMOLOGY | |
| Glaucoma | |
| 132 UP | Glaucoma and medication history at admission: continue ophthalmic drop treatment Verify ophthalmic drop intake during drug medication history at admission and continue glaucoma treatment in patients who are treated for that indication |
| 133 OP | Acute angle-closure glaucoma: drugs that may exacerbate acute glaucoma Avoid the use of drugs that may induce acute closed-angle glaucoma* in at-risk individuals who have not had an iridotomy |
| DEPENDENCIES | |
| Addictions and hospitalisation | |
| 134 Other | Addiction: rapid interview and brief intervention Perform a rapid interview to detect addiction if an addiction problem is suspected, and if needed, perform a brief intervention to address the addiction problem |
| Alcohol dependence | |
| 135 Other | Alcohol dependence: rapid identification test for alcohol dependence and brief intervention In case of suspicion, perform a rapid identification test for alcohol dependence in hospitalised patients |
| 136 UP | Alcohol withdrawal: start close monitoring and optional prophylaxis with a BZD* Provide close monitoring using a predictive evolution scale and optionally prescribe an appropriate oral BZD* in hospitalised patients with a risk of alcohol withdrawal. If close monitoring is not feasible, prescribe an appropriate oral BZD* |
| 137 UP | Alcohol dependence: start vitamin B1 and multivitamins Prescribe treatment with vitamin B1 in alcohol-dependent patients and multivitamins in case of malnutrition |
| Tobacco use and tobacco withdrawal | |
| 138 UP | Tobacco dependence: start nicotine replacement therapy if needed If needed, prescribe treatment with a nicotine replacement therapy for hospitalised smokers |
| 139 UP | Tobacco dependence and chronic ischaemic heart disease/respiratory diseases: start smoking cessation intervention Offer assistance for tobacco cessation to any patient suffering from ischaemic heart disease or chronic respiratory disease |
| Benzodiazepine dependence | |
| 140 UP | BZD dependence: continue BZD treatment at the usual dose during the acute phase of hospitalisation Continue BZD treatment at the usual dose for hospitalised patients with BZD dependency. Suggest a progressive tapering out of the acute phase of hospitalisation |
| Opioid dependence | |
| 141 UP | Opioid dependence: continue maintenance opioid substitution Continue opioid substitution treatment at the usual doses or an equivalent treatment, while respecting the rules of dose equivalence, in hospitalised patients with an opioid dependency and receiving a substitution treatment |
| 142 DDI | Opioid dependence and buprenorphine: be careful when prescribing opioid analgesics Avoid or be careful when prescribing methadone or a step 2 or 3 opioid analgesic in patients receiving buprenorphine substitution |
| OBESITY | |
| Proper use of drugs in the case of obesity | |
| 143 Other | Obese patients: increase doses of injectable antithrombotic agents (LMWH/heparin/fondaparinux) Increase the doses of heparin or fondaparinux in obese patients requiring antithrombotic treatment |
| 144 Other | Obese patients: prefer oral and intravenous routes Favour the oral and intravenous routes in obese patients when they are appropriate for the patient and the drug |
| 145 Other | Obese patients: Adjust initial doses of aminoglycosides according to the adjusted body weight* Adjust the initial dose of aminoglycosides in obese patients according to the adjusted body weight* and then re-evaluate the dose based on the plasma concentrations |
| 146 Other | Obese patients: Adjust the initial doses of vancomycin according to the total body weight Adjust the initial dose of vancomycin in obese patients according to the total body weight and then re-evaluate the dose based on the plasma concentrations |
| PHARMACOLOGY and TOXICOLOGY | |
| Clinical pharmacology | |
| 147 OP | Allergies and new medication: rule out allergies Verify the absence of allergies when a new medication is introduced in patients |
| 148 OP | QT prolongation: drugs that prolong the QT interval Avoid the use of drugs* that may prolong the QT interval in patients suffering from congenital long QT syndrome or at risk of torsade de pointes** |
| 149 DDI | Serotonin syndrome: drugs that are associated with serotonin syndrome Avoid prescribing two drugs that may induce serotonin syndrome* when an alternative is available or monitor patients closely |
| 150 OP | Drug-induced Parkinsonism: drugs that may induce extrapyramidal symptoms Avoid prescribing drugs that may induce extrapyramidal symptoms in patients with that syndrome |
| 151 OP | G6PD deficiency: drugs that may cause haemolytic anaemia* Avoid or use with caution drugs that may cause haemolytic anaemia* in patients with G6PD deficiency |
| 152 UP | Antifolates* and haematotoxicity: start folinic acid Prescribe folinic acid to patients with haematotoxicity related to taking antifolates* |
| Drug–drug interactions | |
| 153 DDI | DDI: strong enzyme inducers and inhibitors* Adapt the doses of substrate drugs as needed if a strong enzyme inducer or inhibitor* is introduced, and monitor the clinical response |
| 154 DDI | DDI: re-evaluate drug doses within 15 days following the discontinuation of a strong enzyme inducer Re-evaluate doses of substrate drugs within 15 days following the cessation of a strong enzyme inducer |
| TRANSPLANTS | |
| 155 UP | Immunosuppressive drugs*: therapeutic drug monitoring Continue immunosuppressive treatment* in transplanted patients; do not modify that treatment without consulting the referring physician but monitor the plasma or blood concentrations** in case of altered renal function or in the presence of a health condition that may influence the plasma or blood concentrations |
| 156 DDI | Immunosuppressive drugs and DDIs Evaluate the risk of DDIs, and optionally monitor plasma or blood concentrations* if a new treatment is introduced or if a drug is removed from a transplanted patient receiving immunosuppressants (in particular with CYP and/or Pgp inducers/inhibitors**) |
| VACCINATIONS | |
| 157 UP | Annual influenza vaccination Offer an annual influenza vaccination to patients with a high risk of complications* |
| 158 UP | Pneumococcal vaccination: high-risk patients* Offer pneumococcal vaccination to patients at high risk of invasive pneumococcal infection* |
| 159 OP | Vaccination and immunocompromised patients*: avoid live attenuated vaccines Avoid the use of live attenuated vaccines in immunocompromised patients* |
| 160 UP | Vaccines: check vaccination status Verify the vaccination status of hospitalised patients, and suggest catch-up for mandatory and recommended vaccines, if necessary* |
Colour code of PIM: green stands for UPs, red for OPs, amber for DDIs and grey for other kind of PIM.
*, **, *** Stars refers to information that is available in online supplementary table 2.
ACEI, angiotensin conversion enzyme inhibitors; AF, atrial fibrillation; ARB, angiotensin II receptor antagonists; BP, blood pressure; BPH, benign prostatic hyperplasia; BZD, benzodiazepine; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disorder; CrCl, creatinine clearance; CS, corticosteroids; CYP, cytochrome P450; DDI, drug–drug interaction; DOAC, direct-acting oral anticoagulant; DM, diabetes mellitus; DVT, deep vein thrombosis; ESA, erythropoiesis-stimulating agent; G6PD: glucose-6-phosphate dehydrogenase; GDU, gastroduodenal ulcer; HAART, highly active antiretroviral therapy; Hb, haemoglobin; HBA1c, glycated haemoglobin; HBV, hepatitis B virus; HCV: hepatitis C virus; HF, heart failure; HTN, hypertension; ICS, inhaled corticosteroids; INR:,international normalised ratio; LVEF, left ventricular ejection fraction; MTX, methotrexate; NSAIDs, non-steroidal anti-inflammatory drug; OP, overprescription; OR, oral route; PE, pulmonary embolism; Pgp, P-glycoprotein, PPIs, proton pump inhibitors; RA, rheumatoid arthritis; STEMI, ST-segment elevation myocardial infarction; TIA, transient ischaemic attack; TSH, thyroid-stimulating hormone; T2DM, type 2 diabetes mellitus; UP, underprescription; VAS, visual analogue scale; Vitamin B1, thiamine; Vitamin B6, pyridoxine; VKA, vitamin K antagonist; VTE, venous thromboembolism.