The Norwegian General Practice (NORGEP) criteria for assessing potentially inappropriate prescriptions to elderly patients

Figures & data

Table I.  Norwegian General Practice (NORGEP) explicit criteria (EC) for single drugs and drug dosages considered potentially pharmacological inappropriate for patients ≥70 years in general practice.

EC no.	NORGEP criteria	Comments*
1.	Amitriptyline	Tricyclic antidepressants: Anticholinergic effects, risk of impaired cognitive function^13,34 (EC 1–4)
2.	Doxepine	Tricyclic antidepressants are cardiotoxic (EC 1–4)
3.	Clomipramine
4.	Trimipramine
5.	Chlorpromazine	First-generation low potency antipsychotics: Anticholinergic effects, extrapyramidal effects (EC 5–8)
6.	Chlorprothixene
7.	Levomepromazine
8.	Prochlorperazine	Often prescribed for dizziness despite lack of documentation (EC 8)
9.	Diazepam	Long-acting benzodiazepines: Prolonged elimination half-life, risk of accumulation, muscular weakness, falls and fractures^21,23,24,30 (EC 9–11)
10.	Nitrazepam
11.	Flunitrazepam
12.	Oxazepam >30 mg/24 h	High doses of benzodiazepines and benzodiazepine-like agents: Risk of muscular weakness, falls and fractures^21,23,24,30 (EC 12–13)
13.	Zopiclone >7.5 mg/24 h
14.	Carisoprodol	Centrally acting muscle relaxants: Anticholinergic effects, risk of addiction (EC 14)
15.	Dextropropoxyphene	Analgesics: More toxic than its comparators (EC 15)
16.	Theophylline	Pulmonary drugs: Risk of arrhythmias, No documented effect in COPD (EC 16)
17.	Sotalol	Cardiovascular drugs: Risk of arrhythmias, poor safety record (EC 17)
18.	Dexchlorfeniramine	First-generation antihistamines: Anticholinergic effects, prolonged sedation (EC 18–21)
19.	Promethazine
20.	Hydroxyzine
21.	Alimemazine (trimeprazine)

Notes: *Numbers in superscript refer to the reference list while numbers in parentheses refer to EC numbers for which the statement is valid.

Abbreviations: NSAID = non-steroid anti-inflammatory drug; ACE = angiotensin converting enzyme; SSRI = selective serotonin reuptake inhibitor; TCA = tricyclic antidepressant; COPD = chronic obstructive pulmonary disease; ARB = angiotensin receptor blocker.

Table II.  Norwegian General Practice (NORGEP) explicit criteria (EC) for drug combinations considered potentially pharmacologically inappropriate for patients >70 years in general practice.

EC no.	NORGEP criteria	Comments*
22.	Warfarin+NSAID	Warfarin combinations: Increased risk of intestinal bleeding^19 (EC 22)
23.	Warfarin+ofloxacin or ciprofloxacin	Increased risk of bleeding due to inhibition of warfarin metabolism^16,^19 (EC 23–24)
24.	Warfarin+erythromycin or clarithromycin
25.	Warfarin+SSRI	Increased risk of bleeding due to a direct platelet-inhibiting effect^16 (EC 25)
26.	NSAID (or coxib)+ACE inhibitor (or ARB)	NSAIDs combinations: Increased risk of renal failure^32,33 (EC 26)
27.	NSAID+diuretic	Reduced effect of diuretics^18 (EC 27)
28.	NSAID+glucocorticoid	Increased risk of intestinal bleeding. Risk of fluid retention^27(EC 28)
29.	NSAID+SSRI	Increased risk of gastrointestinal bleeding^15,^25 (EC 29)
30.	Erythromycin or clarithromycin+statin	Other combinations: Increased risk of adverse effects of statins, including rhabdomyolysis, due to inhibition of statin metabolism^17,26,29. Highest risk for simvastatin and lovastatin (EC 30)
31.	ACE inhibitor+potassium or potassium-sparing diuretic	Increased risk of hyperkalemia^22,31 (EC 31)
32.	Fluoxetine or fluvoxamine+ TCA	Increased risk of adverse effects of TCAs due to inhibition of TCA metabolism^20 (EC 32)
33.	Beta blocker+cardioselective calcium antagonist	Increased risk of atrioventricular block and myocardial depression^14 (EC 33)
34	Diltiazem+lovastatin or simvastatin	Increased risk of adverse effects of statins, including rhabdomyolysis, due to inhibition of statin metabolism^26 (EC 34)
35	Erythromycin or clarithromycin+carbamazepine	Increased risk of adverse effects of carbamazepine due to inhibition of its metabolism^20 (EC 35)
36.	Concomitant prescription of three or more drugs within the groups centrally acting analgesics, antipsychotics, antidepressants and/or benzodiazepines	Increased risk of muscular weakness, falls, fractures and cognitive impairment^24 (EC 36)

Notes: *Numbers in superscript refer to the reference list while numbers in parentheses refer to EC numbers for which the statement is valid.

Abbreviations: NSAID =non-steroid anti-inflammatory drug; ACE = angiotensin converting enzyme; SSRI = selective serotonin reuptake inhibitor; TCA = tricyclic antidepressant; COPD = chronic obstructive pulmonary disease; ARB = angiotensin receptor blocker.

Table III.  Norwegian General Practice (NORGEP) explicit criteria (EC) for single drugs and drug dosages considered potentially pharmacologically inappropriate for patients >70 years in general practice. Validating the clinical relevance of the criteria by a specialist panel during a three-round postal Delphi process: mean scores¹ during third round with inter-quartile range (IQR)² and standard deviation (SD), and mean change in score from first to third round.

ECno.	NORGEP criteria	Rating score in Round 3 Mean (Median)	IQR, Round 3	SD, Round 3	Change in opinion from Round 1 to 3 Mean (95 % CI)
1.	Amitriptyline	85.3 (85,0)	12.0	11.9	2.7 (−1.6 to 6.9)
2.	Doxepine	84.7 (85,0)	11.0	12.6	3.0 (−0.8 to 6.9)
3.	Chlomipramine	85.4 (85,0)	12.0	11.5	0.1 (−3.8 to 2.1)
4.	Trimipramine	84.1 (80,0)	11.0	11.5	0.2 (−3.9 to 4.3)
5.	Chlorpromazine	83.9 (85,0)	10.0	13.0	2.7 (−2.3 to 7.6)
6.	Chlorprothixene	82.5 (80,0)	10.0	14.1	1.4 (−2.8 to 5.6)
7.	Levomepromazine	87.3 (90,0)	20.0	13.4	0.1 (−3.6 to 3.4)
8.	Prochlorperazine	81.3 (80,0)	15.0	12.0	1.7 (−2.9 to 6.4)
9.	Diazepam	83.7 (80,0)	10.0	11.5	4.4 (−0.7 to 9.6)
10.	Nitrazepam	84.8 (85,0)	10.0	11.3	4.3 (−0.3 to 8.9)
11.	Flunitrazepam	92.3 (92,0)	10.0	8.4	1.1 (−2.2 to 4.5)
12.	Oxazepam >30 mg/24 h	87.2 (90,0)	20.0	10.8	3.8 (0.6 to 10.6)
13.	Zopiclone >7.5 mg/24 h	88.4 (90,0)	15.0	11.8	0.5 (−2.1 to 3.1)
14.	Carisoprodol	94.0 (95,0)	10.0	7.2	2.9 (−0.7 to 6.5)
15.	Dextropropoxyphene	88.5 (90,0)	15.0	12.6	3.4 (−1.7 to 8.5)
16.	Theophylline	72.4 (74,0)	21.0	17.8	5.1 (−0.8 to 11.1)
17.	Sotalol	72.2 (70,0)	10.0	17.4	6.1 (−0.9 to 13.2)
18.	Dexchlorpheniramine	88.0 (80,0)	15.0	13.1	0.8 (−2.3 to 4.1)
19.	Promethazine	81.4 (80,0)	17.0	13.2	1.5 (−2.1 to 5.3)
20.	Hydroxyzine	80.9 (80,0)	15.0	13.2	2.3 (−3.5 to 8.2)
21.	Alimemazine (trimeprazine)	76.9 (75,0)	20.0	16.6	3.0 (−2.6 to 8.8)

Notes: ¹Rating scores are given on visual analogue scales (VAS) from 0 to 100 (0 = complete disagreement, 100 = complete agreement). ²Consensus is by definition achieved if the inter-quartile range (IQR) falls within any one-third of the rating scale.

Abbreviations: NSAID = non-steroid anti-inflammatory drug. ACE = angiotensin converting enzyme. SSRI = selective serotonin reuptake inhibitor. TCA = tricyclic antidepressant. ARB = angiotensin receptor blocker. 95% CI = 95% confidence interval.

Table IV.  Norwegian General Practice (NORGEP) explicit criteria (EC) for drug combinations considered potentially pharmacologically inappropriate for patients >70 years in general practice. Validating the clinical relevance of the criteria by a specialist panel during a three-round postal Delphi process: mean scores¹ during third round with inter-quartile range (IQR)² and standard deviation (SD), and mean change in score from first to third round.

ECno.	NORGEP criteria	Rating score, Round 3 Mean (Median)	IQR, Round 3	SD, Round 3	Change in opinion from Round 1 to 3 Mean (95 % CI)
22.	Warfarin+NSAID	88.0 (90,0)	15.0	16.0	5.3 (−2.2 to 12.8)
23.	Warfarin+ofloxacin or ciprofloxacin	71.3 (70,0)	16.0	16.4	4.1 (−2.9 to 11.2)
24	Warfarin+erythromycin or clarithromycin	74.3 (75,0)	10.0	17.9	3.1 (−4.0 to 10.4)
25	Warfarin+SSRI	69.8 (70,0)	27.0	17.3	1.0 (−7.6 to 5.6)
26.	NSAID (or coxib)+ACE inhibitor (or ARB)	80.1 (80,0)	15.0	16.8	2.6 (−2.2 to 7.5)
27.	NSAID+diuretic	81.0 (80,0)	15.0	16.3	3.0 (−1.3 to 7.5)
28.	NSAID+glucocorticoid	78.3 (80,0)	10.0	19.0	4.9 (−0.5 to 10.3)
29.	NSAID+SSRI	68.0 (65,0)	20.0	19.6	6.2 (−1.8 to 14.3)
30.	Erythromycin or clarithromycin+statin	74.4 (75,0)	10.0	13.7	1.5 (−3.7 to 6.8)
31.	ACE inhibitor+potassium or potassium-sparing diuretic	86.1 (85,0)	12.0	15.4	4.7 (0.4 to 9.0)
32.	Fluoxetine or fluvoxamine+TCA	87.4 (90,0)	18.0	11.2	10.7 (2.7 to 18.7)
33.	Beta blocker+cardioselective calcium antagonist	88.3 (90,0)	10.0	11.0	0.7 (−4.7 to 6.1)
34.	Diltiazem+lovastatin or simvastatin	77.8 (75,0)	15.0	10.5	0.8 (−5.9 to 4.4)
35.	Erythromycin or clarithromycin+carbamazepine	78.2 (80,0)	5.0	11.1	1.9 (−1.7 to 5.5)
36.	Concomitant use of three or more psychotropic drugs^3	95.0 (95,0)	10.0	5.1	4.4 (−0.8 to 11.1)

Notes: ¹Rating scores are given on visual analogue scales (VAS) from 0 to 100 (0 = complete disagreement, 100 = complete agreement). ²Consensus is by definition achieved if the inter-quartile range (IQR) falls within any one-third of the rating scale. ³Centrally acting analgesics, antipsychotics, antidepressants, and/or benzodiazepines.

Abbreviations: NSAID = non-steroid anti-inflammatory drug. ACE = angiotensin converting enzyme. SSRI = selective serotonin reuptake inhibitor. TCA = tricyclic antidepressant. ARB = angiotensin receptor blocker. 95% CI = 95% confidence interval.