Evaluating potentially inappropriate medications in elderly patients in a pharmacy setting in Bulgaria: A pilot study utilizing the EU (7)-PIM List
Authors: Milushewa Petya , Blagova Stilyana , Stefanova Presiyana , Tachkov Konstantin , Petrova Guenka 
Published: October 2023

Objective: The primary aim of this study was to evaluate, for the first time, the use of the EU-7 PIM List in identifying potentially inappropriate medications among older patients. Researchers have firmly established the connection between drug-related problems, which include increased morbidity and mortality rates and the heightened utilization of healthcare services. While previous studies have focused on methodologies for identifying potentially inappropriate medications in Bulgaria, further research is warranted to explore the applicability of the widely recognized EU(7)- PIM List.

Materials and methods: A prospective review was conducted on patient prescriptions aligned with the National Health and Insurance Fund, explicitly focusing on patients aged over 65 years from a single pharmacy in Veliko Turnovo City, Bulgaria. The review spanned from November 2022 to April 2023. The prescriptions analyzed in this study exclusively comprised medications covered by the insurance fund. The pharmacy manager provided patient prescription data in a coded form, which included information on the patients’ age, corresponding medications, and accompanying ICD codes.

Results: The study analyzed a sample of 255 patients. Healthcare providers prescribed 2,623 medications, and 61.96% of the patients had polypharmacy, taking more than five medications daily. Among the study population, 67% with polypharmacy had at least one PIM based on the EU (7)-PIM List criteria. In total, 173 potentially inappropriate medications (PIMs) were identified. The main PIMs were categorized into four groups: alimentary tract and metabolism, blood and blood-forming organs, cardiovascular system (CVS), and nervous system. Most PIMs (75.72%) were in the ATC cardiovascular system. Within the CVS category, 11 PIMs were associated with digoxin intake and 11 with antiarrhythmics such as propafenone, flecainide, and amiodarone. In addition, trimetazidine was linked to 9 PIMs, and centrally acting antiadrenergic agents had 22 PIMs, with moxonidine being the most prevalent (n=16). Peripherally acting agents were linked to 22 PIMs, primarily doxazosin. The study identified 24 PIMs related to diuretics, specifically spironolactone, and 18 PIMs related to selective calcium channel blockers such as verapamil. The antithrombotic agent category had the highest share, with 30 identified PIMs, including acenocoumarol, dabigatran, rivaroxaban, and apixaban. Furthermore, the examination of ICD codes confirmed that most PIMs occurred within CVS, with patients having ICD I11.0 and ICD I11.9 being associated with 40 and 47 PIMs, respectively.

Conclusion: This study highlights many PIMs among patients with cardiovascular diseases. Using the EU (7)-PIM List as a pilot study demonstrates its effectiveness in managing adult patients’ conditions. Given the significant role of PIMs in deprescribing strategies for older patients with polypharmacy, there is a need for prescribers, educators, and drug regulatory institutions to show increased interest in regulatory measures and specific aspects related to PIM use. This is important because the demographic trend of population ageing continues, and organizations increasingly focus on the elderly population.