Korean J Fam Pract. 2014;4:157-163 서울일개대학병원의입원노인환자에서 STOPP-START Criteria 에의한적절성평가 Original Article 이현우, 원장원 *, 안정연, 최현림, 김병성, 김선영 경희대학교의과대학교실 The Evaluation of Drug Appropriacy Using STOPP-START Criteria for Elderly Inpatients at a University Hospital in Seoul Hyun-Woo Lee, Chang-Won Won*, Jung-Yun Ahn, Hyun-Rim Choi, Byung-Sung Kim, Sun-Young Kim Department of Family Medicine, Kyung Hee University School of Medicine, Seoul, Korea Background: The Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP)-Screening Tool to Alert to Right Treatment (START) criteria have been formulated to complement the limitation of the Beer s criteria. This study aims to identify potentially inappropriate medicines (PIMs) and potential prescribing omissions (PPOs) according to the STOPP-START criteria at a university hospital in Seoul. Methods: The study included 240 inpatients older than 65 year-age who were admitted to a university hospital between January 2011 and December 2011. The medical records were reviewed. The STOPP-START criteria were applied to the medication information to find out whether medicine was properly prescribed. Results: The medical records showed that 161 (67.1%) out of 240 patients took more than 5 medications when they were hospitalized. Among the participants, 34 patients (14.2%, 34 PIMs) were using inappropriate drugs according to the STOPP criteria. The most frequently encountered PIM was a non-steroidal anti-inflammatory drug prescribed in patients with moderate-to-severe hypertension (23.5%, 8 PIMs), which was followed by calcium channel blockers prescribed in patients with chronic constipation (11.8%, 4 PIMs). The application of the START criteria showed 84 participants (35%, 145 PPOs) were not taking needed medications. The most frequent was lack of metformin in patients with diabetes (21.4%, 31 PPOs). The second most common PPO was hyperlipidemia treatment including statin therapy in diabetic patients with major cardiovascular risk factors (16.6%, 24 PPOs). Conclusion: The use of STOPP/START criteria in clinical practice is expected to help reduce the side effects that may come from inappropriately prescribed medications. It could also help medical professionals provide elderly patients with safer drug therapies. Keywords: Aged; Medication; Prescription; Mass Screening Received: August 29, 2013, Accepted: May 4, 2014 *Corresponding Author: Chang-Won Won Tel: 02-958-8696, Fax: 02-958-8699 E-mail: chunwon62@dreamwiz.com Korean Journal of Family Practice Copyright 2014 by The Korean Academy of Family Medicine 서론 우리나라는경제성장과의학기술발달로평균수명이늘어나면서노인인구도급격히증가하고있다. 1970년대에는전체인구중노인인구가 3.1% 를차지하였지만, 2001년 7.6%, 2011년 11.4% 로지속적증가추세를보이고있다. 향후 2017년에는 14.0% 고령사회진입, 2026년에는 20.8% 로초고령사회진입이예상되고있다. 1) 이처럼노인인구가급속도로증가하 Vol. 4, No. 2 Jun 2014 157
Hyun-Woo Lee, et al: Drug Appropriacy Using STOPP-START Criteria Foe Elderly Inpatients 면서노인의의료문제또한중요한사안이되고있는것이사실이다. 연령의증가에따라생리적기능저하및신체구성성분의변화로인해노인에서의약동학적과정이젊은성인과는차이를보이게된다. 또한대부분의노인환자들은다양한질환및만성질환을앓고있어많은종류의의약품을장기간사용하고있는것이특징이다. 이로인해복용약물개수가많아지게되고약물상호작용에의한약물이상반응의발생위험이높아지게된다. 2) 이러한문제점들을진단하기위해기존에는 Beers criteria 가널리이용되어왔으나현재우리나라에서사용하지않는약들이있으며, 몇몇연구에서약물부작용발생위험도와의연관성도떨어진다는보고도있어많은제한점이제기되었다. 3) 이런 Beers criteria의한계점을보완한 Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP)- Screening Tool to Alert to Right Treatment (START) criteria가 2008 년개발되었는데이에근거하여환자의병력을파악하면현재복용중이나잠재적으로해가될수있는약물, 또는환자에게꼭필요한약물이나아직복용하고있지않은약물을파악할수있다. 4) 외국의병원에입원한노인중부적절한약물복용이 1 개이상있는경우는 60% 란보고가있으며, 5) 국내의상급종합병원노인내과에입원한노인중 Beers 기준으로 50.4% 에서 STOPP 기준으로는 65.0% 에서부적절한약물복용이 1개이상있다고보고되었으나병원전체입원노인을대상으로한연구나 START 기준에따른미처방약물에대한연구는없었다. 6) 본논문에서는일개대학병원의일년동안의입원환자중 65세이상노인환자들이가지고있는질환과처방받은약물을파악하고이를바탕으로 STOPP-START criteria를적용하여, 노인환자에대한처방약물의적정성을분석하고자한다. 방법 1. 연구대상및기간 2011년 1월 1일부터 2011년 12월 31일까지일개대학병원 65세이상의환자에서매월 20명씩무작위로추출하여 240명을선정하여후향적으로의무기록을조사하였다. 환자선별시암병기 4기이상의말기암환자는대상에서제외되었다. 지입원하였고입원당시 65세이상노인환자를접수순서로나열한수각 40번째환자를무작위추출하여매월 20명씩총 240명을선정하여후향적으로의무기록과전산자료를조사함으로써환자연령과성별, 당시가지고있는질환과퇴원당시처방받은약의종류및총개수와용량을파악하였다. 본연구에서처방받은약물분석에서주사약과외용약은처방용량의적절성을평가하기용이하지않아서제외되었다. 2) 연구방법조사대상의연령을 65 69세, 70 74세, 75 79세, 80 84세, 85세이상으로구분하여분석하였다. 처방받은약물의개수를분석하기위하여처방약품의수를 1 4, 5 8, 9 12, 13개이상으로구분하여분석하였다. 이중 5개이상의약제를사용하는경우를다중약제사용으로정의하였다. 7) 약물사용의적합성을분석하기위하여 STOPP-START criteria 3) 에서제시한약물의처방종류와빈도를분석하였다. 이를바탕으로 STOPP-START 각각의 criteria에적용하여, 환자에게처방한약물중환자에게부적절한처방이어느정도이루어지고있는지, 환자의병력상필요한처방임에도불구하고처방하지않은약물은없는지확인하여처방약물의적정성을평가하였다. 이때부적절한약물이최소한 1개이상포함된처방을부적절처방으로정의하고, 환자병력상필요한처방임에도불구하고약물이 1개이상처방되지않은경우또한부적절한처방으로정의하였다. 4) 본연구는임상시험심사위원회의승인을받은후에진행되었다 (KMC IRB 1236-04). 3) 평가내용연구대상자의전반적인부적절한약물사용의경향을파악하기위해환자의과거질병력과현재의질병력, 현재복용중인약, 입원후처방받은약의종류및총개수와용량을파악하였다. 또한성별, 연령, 키, 몸무게, 혈압을통해대상환자의일반적특성을확인하였으며나트륨, 요소질소, 크레아티닌등의화학적검사수치, 소변검사결과를확인평가하였다. 이에추가적으로디곡신의사용평가를위해사구체여과율 (glomerular filtration rate) 을 (140-나이) ( 몸무게 kg) ( 여성에서 0.85)/(72 creatinine) 와같이계산하였으며변비, 낙상과거력, 소변줄사용여부를확인하였다. 대사증후군여부를확인하기위해주요심혈관위험인자를확인하였다. 2. 연구방법 1) 자료수집서울의일개대학병원에 2011년 1월 1일부터 12월 31일까 4) 통계분석본연구에서통계적분석은 Microsoft EXCEL 2007 프로그램 (Microsoft Inc., Redmond, WA, USA) 을사용하였으며, 조사 158 Vol. 4, No. 2 Jun 2014 Korean J Fam Pract
이현우외 : 입원노인환자에서약물적정성평가 된각각의항목을성별, 연령별로분석하여백분율 (%) 로비교하였다. 또한필요한경우각각의평균을이용하였다. 결과 1. 대상환자의일반적특성대상환자는전체 240명이었고남자가 107명으로 44.6% 를차지하였다. 연령별로는 65 69세가 87명 (36.3%), 70 74세가 72명 (30.0%), 75 79세가 46명 (19.2%), 80 84세가 23명 (9.6%), 85세이상은 12명 (5.0%) 으로 65 69세가가장높은비율을나타났다. 평균나이는 72.8세였으며남자평균나이는 71.5세이었고여자평균나이는 73.9세로여자평균나이가더많았다 (Table 1). 대상자중흡연하고있는자는 18명 (7.5%), 음주를하는자는 35명 (14.6%) 이었다. Table 1. Age and gender distribution of the subjects Gender Age groups (y) Total Male Female 65 69 87 (36.3) 47 (43.9) 40 (30.1) 70 74 72 (30.0) 25 (23.4) 47 (35.3) 75 79 46 (19.2) 19 (17.8) 27 (20.3) 80 84 23 (9.6) 10 (9.3) 13 (9.8) 85 12 (5.0) 6 (5.6) 6 (4.5) 240 (100.0) 107 (44.6) 133 (55.4) Values are presented as number (%). 진단받은상병명으로는고혈압이전체 240명중 167명 (69.6%) 으로가장많았고, 그뒤로당뇨 87명 (36.3%), 뇌졸중 59명 (24.6%), 협심증 24명 (10.0%), 전립선비대증 20명 (8.3%), 신부전 19명 (7.9%) 순이었다 (Table 2). 입원당시처방받은약물개수는 1개부터 17개사이로평균개수는 1인당 5.81개였다. 1 4개가 79명, 5 8개가 126명, 9 12개가 31명, 13개이상이 4명으로 5 8개사이의약물을처방받은환자비율이가장높게관찰되었다. 2. Screening Tool of Older Persons Potentially Inappropriate Prescriptions Criteria를이용한노인부적절약물분석 STOPP에서제시한노인부적절약물항목이남자 18명 (7.5%), 여자 16명 (6.7%) 으로전체 34명 (14.2%) 에서확인되었고건수로는 34건이었다. STOPP criteria에서제시된전체 65개의노인부적절항목중 12개의항목 (18.4%) 에서노인부적절약물이처방되고있었다. 부적절한약물을처방받은환자의평균연령은 72.0세였다. 작용계통별로확인한결과근골격계열약물 10건 (29.4%) 으로가장많았고, 심혈관계열약물 8건 (23.5%), 비뇨기계열약물 6건 (17.6%), 중추신경계열약물 6건 (17.6%), 진통계열 2 건 (5.9%) 순이었다. 각항목중중등도이상고혈압에서비스테로이드성소염제계열약물처방이 8건 (23.5%), 만성변비환자에서칼슘채널길항제를사용하는건이 4건 (11.8%), 빈번한요실금증상이있는환자에서알파길항제를사용하는건이 4 건 (11.8%), 만성변비환자에서 2주이상완화제없이마약성 Table 2. Presenting diseases Disease Total Male (n=107) Gender Female (n=133) Hypertension 167 (69.6) 70 (29.2) 97 (40.4) Diabetes mellitus 87 (36.3) 41 (17.1) 46 (19.2) Cerebrovascular accident 59 (24.6) 26 (10.8) 33 (13.8) Angina 24 (10.0) 10 (4.2) 14 (5.8) Benign prostatic hypertrophy 20 (8.3) 20 (8.3) 0 Glomerular filtration rate<50 19 (7.9) 4 (1.7) 15 (6.3) Dyslipidemia* 14 (5.8) 4 (1.7) 10 (4.2) Coronary artery occlusive disease 12 (5.0) 5 (2.1) 7 (2.9) Values are presented as number (%). Each patient was allowed to choose multiple diagnosis. *Dyslipidemia: total cholesterol>200 mg/dl, low density lipoprotein cholesterol>130 mg/dl, high density lipoprotein cholesterol<60 mg/ dl, triglyceride>150 mg/dl. Vol. 4, No. 2 Jun 2014 159
Hyun-Woo Lee, et al: Drug Appropriacy Using STOPP-START Criteria Foe Elderly Inpatients 진통제를사용하는건이 4건 (11.8%), 중복계열약물을사용하는경우가 2건 (5.9%) 순이었다 (Table 3). 3. Screening Tool to Alert to Right Treatment Criteria를이용한노인에서추가해야할약물분석 START 에서제시한노인에서추가해야할약물항목은전체 84명 (35.0%) 에서 145건이확인되었다. 작용계통별로확인해본결과내분비계열약물 75건 (51.7%), 심혈관계열약물 이 64건 (44.1%), 근골격계열약물 6건 (4.1%) 순이었다. 각항목중제2형당뇨병에서 metformin을처방해야하는경우 31건 (21.4%) 으로가장많았으며주요심혈관위험인자가있는당뇨환자에서 statin 약을사용해야하는경우 24건 (16.6%), 여명이 5년이상되고일상생활에서자립이가능한심혈관, 뇌혈관, 말초혈관질환을가진환자에 statin 약이필요한경우가 24 건 (16.6%) 순이었다 (Table 4). Table 3. Potentially inappropriate medications identified by STOPP criteria STOPP Value Musculoskeletal system NSAID with moderate-to-severe hypertension (risk of exacerbation of hypertension) 8 (23.5) Long-term use of NSAID (>3 mo) for symptom relief of mild osteoarthritis (simple analgesics preferable and usually as effective for pain relief) Cardio-vascular system Calcium channel blockers with chronic constipation (may exacerbate constipation) 4 (11.8) Loop diuretic as first-line monotherapy for hypertension (safer, more effective alternatives available) Aspirin with a past history of peptic ulcer disease without histamine H2-receptor antagonist or proton pump inhibitor (risk of bleeding) Urogenital system α-blockers in males with frequent incontinence, i.e., one or more episodes of incontinence daily (risk of urinary frequency and worsening of incontinence) 4 (11.8) Antimuscarinic drugs with chronic constipation (risk of exacerbation of constipation) 1 (2.9) α-blockers with long-term urinary catheter in situ, i.e., more than 2 months (drug not indicated) 1 (2.9) Neuro-psychiatric system TCAs with an opiate or calcium channel blocker (risk of severe constipation) SSRIs with a history of clinically significant hyponatremia (non-iatrogenic hyponatremia<130 mmol/l within the previous 2 months) TCAs with constipation (likely to worsen constipation) Analgesic drugs Regular opiates for more than 2 weeks in those with chronic constipation without concurrent use of laxatives (risk of severe constipation) Duplicate drug classes Any duplicate drug class prescription, e.g. two concurrent opiates, NSAIDs, SSRIs, loop diuretics, angiotensin converting enzyme inhibitors (optimization of monotherapy within a single drug class should be observed prior to considering a new class of drug). Total 34 (100.0) Values are presented as case (%). STOPP: Screening Tool of Older People s potentially inappropriate Prescriptions, NSAID: non-steroidal anti-inflammatory drug, TCAs: tricyclic antidepressants, SSRIs: selective serotonin re-uptake inhibitors. 160 Vol. 4, No. 2 Jun 2014 Korean J Fam Pract
이현우외 : 입원노인환자에서약물적정성평가 Table 4. Potentially requirable medications identified by START criteria START Value Endocrine system Metformin with type 2 diabetes±metabolic syndrome (in the absence of renal impairment*) 31 (21.4) Statin therapy in diabetes mellitus if coexisting major cardiovascular risk factors present 24 (16.6) Antiplatelet therapy in diabetes mellitus with coexisting major cardiovascular risk factors 18 (12.4) ACE inhibitor or angiotensin receptor blocker in diabetes with nephropathy, i.e., overt urinalysis proteinuria or microalbuminuria (>30 mg/24 h)±serum biochemical renal impairment* (serum creatinine>150 μmol/l or estimated GFR<50 ml/min) 2 (1.4) Cardio-vascular system Statin therapy with a documented history of coronary, cerebral or peripheral vascular disease, where the patient s functional status remains independent for activities of daily living and life expectancy is greater than 5 years Aspirin or clopidogrel with a documented history of atherosclerotic coronary, cerebral or peripheral vascular disease in patients with sinus rhythm 24 (16.6) 10 (6.9) B-blocker with chronic stable angina 10 (6.9) Warfarin in the presence of chronic atrial fibrillation 6 (4.1) ACE inhibitor with chronic heart failure 6 (4.1) Aspirin in the presence of chronic atrial fibrillation, where warfarin is contraindicated, but not aspirin 4 (2.8) Antihypertensive therapy where systolic blood pressure consistently>160 mm Hg 2 (1.4) ACE inhibitor following acute myocardial infarction 2 (1.4) Musculoskeletal system Calcium and vitamin D supplement in patients with known osteoporosis (previous fragility fracture, acquired dorsal kyphosis) 6 (4.1) Total 145 (100.0) Values are presented as number (%). START: Screening Tool to Alert to Right Treatment, ACE: angiotensin converting enzyme, GFR: glomerular filtration rate. *Serum creatinine>150 μmol/l or estimated GFR<50 ml/min. 고찰 노인환자는약물의대사과정및약리학적반응이저하되어있으며만성질환을복합적으로가지고있어동시에여러약물을복용하는것이일반적이어서약물상호작용에의한약물이상반응의발생위험이높아진다. 2) 외국의경우노인입원환자의 20% 는약물사용에따른부작용과관련된입원으로노인입원의 5번째흔한원인으로알려져있다. 8) 또한 5가지이상의약물을복용하고있는 다약제복용 (polypharmacy) 도노인에서는흔히관찰되어노인환자의 20 40% 가 5가지이상의약물을복용하는것으로알려져있다. 8) 그리고노인에서자주관찰되는비전형적증상에대해올바른평가가이루어지지못한채로증상완화를위해투여된약물이또다른약물과이상반응을유발하여새로운증상이초래되고이를해결하기 위해약물이추가되는악순환에빠질위험에노출되어있다. 따라서노인의료를담당하는전문가들은노인이라는특수대상집단의특성을이해하고이들의약물요법에필요한많은지식과노인환자에게적절하고간편하게사용할수있고, 일반화가가능하여유용성이높은부적절약물을규정하는도구를만드는것이필요하다. 이전의 Beer s criteria의제한점을보완한 STOPP/START criteria는 65개의부적절한약물사용에대한내용을 START 는 22개의사용해야하는데생략된약이나필요에의해추가해야할약물에대한내용을포함하고있는최초의인체생리적인면을고려한기준으로노인에서약물처방부적절성을평가한간이평가도구이다. 65세이상노인환자에서임상에서보기흔한질병과이에관련하여많이사용되는약제를대상으로하여만들어진간이평가도구이기때문에입원환자뿐만 Vol. 4, No. 2 Jun 2014 161
Hyun-Woo Lee, et al: Drug Appropriacy Using STOPP-START Criteria Foe Elderly Inpatients 아니라 65세이상외래노인환자에서도일상적으로폭넓게적용할수있는기준이될수있겠다. 본연구는입원중인노인환자를대상으로약물사용의적합성을분석하기위하여대상을성별과연령대별로세분화하여 2008년발표된 STOPP-START criteria를사용하여약물의처방종류와빈도를분석하였다. 평가결과 STOPP criteria 에따라부적절한약물을처방받고있는환자는전체 240명의환자중 14.1% (34건), START criteria에따라추가해야할약물이있는환자는 35% (84명[145 unit]) 로확인되었다. 세부항목을살펴보면제2형당뇨병에서 metformin을처방해야하는경우가 START criteria에서 31건 (21.4%) 으로가장높게확인되었다. 보통노인의당뇨병은유병기간이길고저혈당의위험성에빠질위험이많아 metformin 처방이많지않지만신장기능이정상적이며특히비만같은대사증후군을가진환자에서는 metformin의처방이고려되어야하겠다. 9) 두번째로주요심혈관위험인자가있는당뇨환자에서 statin을사용해야하는경우 24건 (16.6%) 으로높게확인되었다. 당뇨에서고지혈증을동반하는경우동맥경화에동반하는합병증발생률이높아지기때문에고지혈약제를추가하여야한다. 10) 2010년재정된 National Cholesterol Education Program (NCEP) IV 진료지침에따르면관상동맥질환 ( 심근경색, 불안정성협심증, 안정형협심증, 관상동맥성형술또는우회술을한경우, 심혀혈증거가확인된경우 ) 을가지고있거나관상동맥질환에준하는질환 ( 당뇨, 증상이있는경동맥질환, 말초동맥폐쇄질환, 복부대동맥류, 위험인자가 2개이상이고계산한 10년심장질환위험도가 20% 를초과하는환자 ) 을가진경우고위험군으로분류되어저밀도지단백콜레스테롤농도를 70 mg/dl 미만으로수치가유지하도록명시하고있다. 10) STOPP criteria에서는중등도이상고혈압에서비스테로이드성소염제계열약물을처방하는건이 8건 (23.5%) 으로가장높게확인되었다. 노인환자에서비스테로이드성소염제계열의약물을처방하는것은여러가지만성통증질환의증상완화를위해서는선택할수밖에없다. 하지만이는상당한부작용이발생할수있는가능성이있으며특히심장과신장에영향을미쳐체액구성및전해질이상, 고혈압, 심부전, 급성신부전, 신증후군등을일으킬수있다. 11) 그래서노인고혈압환자에서는비스테로이드성소염제처방을신중히해야하며심장, 신장기능을유심히관찰하면서되도록통증발생초기에는다른기전을가지고있는 acetaminophen을우선처방해야하는것을고려해야하겠다. 두번째로는만성변비환자에서칼슘채널길항제를사용하는건이 4건 (11.8%) 으로확인되었다. 칼슘채널길항제는칼 슘이혈관평활근에유입되는것을막아심혈관이완작용을통해고혈압과허혈성심질환을치료하는데사용되는데이기전이위장혈관에도작용하여위장관운동이저하되어변비를일으키는부작용이생기게된다. 12) 특히나노인환자에서는성인들보다활동량이적고소화능력또한저하되어있기때문에칼슘채널길항제를처방할시에는자세한병력청취를통해소화능력을평가하여처방을해야하겠다. 본연구의제한점으로는첫째, 본연구의대상자가일개대학병원 1년동안입원한적이있는환자를대상으로진행하여본연구결과를한국의전체노인입원환자로일반화할수없다는것이다. 둘째, 약물유해반응인과성평가가공인된약물유해반응분석도구를사용하지않아명확한인과관계평가가어려웠다는점이다. 또한셋째로연구가시행된 2011년에는 Beers criteria 개정전이므로개정된 Beers criteria에비해 STOPP-START criteria가노인부적절약물을선별하고약물유해반응의발생을예측하는데우수한가를비교해보는것이불가능하였다는점이다. 이러한제한점에도불구하고일개대학병원입원한 65세이상의노인환자를대상으로국내에서 STOPP뿐만아니라 START 에대한평가가이루어진것이국내최초라는것에충분한의의가있다. 결론적으로 2008년개정된새로운약물적정성기준인 STOPP-START criteria를노인환자의약물중재도구로사용하면중복처방의위험성을줄여주고필요한약제를추가함으로써약제와관련한부작용의위험을줄이고보다효율적으로안전하고효과적인고령환자약물요법을수행할수있을것으로기대된다. 향후새로개정된 Beers criteria 와 STOPP-START 를이용한비교한연구가필요하리라생각된다. 요약 연구배경 : 노인부적절약물을규정하는기준으로 Beers criteria를많이사용해왔으나, 많은한계점을가지고있다. 본연구자는서울의일개대학병원외래에내원한 65세이상입원환자를대상으로새로발표된 Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP)-Screening Tool to Alert to Right Treatment (START) criteria를적용하여이에대해평가한내용및결과를소개하고자한다. 방법 : 2011년 1월부터 2011년 12월까지서울의일개대학병원퇴원환자중당시 65세이상노인환자중 240명을선정하였다. 후향적으로의무기록지를분석하여내원당시복용약물과개수, 용량을파악한후 STOPP-START criteria 기준을적용 162 Vol. 4, No. 2 Jun 2014 Korean J Fam Pract
이현우외 : 입원노인환자에서약물적정성평가 하여약물적절성평가에대한조사를시행하였다. 결과 : 5개이상다중약물요법을사용하는환자는 161명 (67.1%) 이었다. 240명의환자군에서시행한약물적절성평가에서 STOPP은전체 34건 (14.2%) 으로중등도이상고혈압에서비스테로이드성소염제계열약물을처방하는경우 8건 (23.5%) 으로가장많았으며만성변비환자에서칼슘채널길항제를사용하는건이 4건 (11.8%) 으로확인되었다. 또한 START 는전체 84명 (35% [145건]) 으로제2형당뇨병에서 metformin을처방해야하는경우 31건 (21.4%) 으로가장많았으며주요심혈관위험인자가있는당뇨환자에서고지혈증약을사용해야하는경우 24건 (16.6%) 으로확인되었다. 결론 : 노인환자에서새롭게도입된기준인 STOPP/START criteria를이용한약물적절성평가를통해약제와관련한부작용과합병증의위험을줄이고보다효율적으로안전하고효과적인고령환자약물요법을수행할수있을것으로기대된다. 중심단어 : STOPP-START 기준 ; 노인약물 ; 처방 ; 선별검사 REFERENCES 1. Ministry of Health and Welfare. Health and welfare white paper. Seoul: Ministry of Health and Welfare; 2010. 2. McLean AJ, Le Couteur DG. Aging biology and geriatric clinical pharmacology. Pharmacol Rev 2004;56:163-84. 3. Levy HB, Marcus EL, Christen C. Beyond the beers criteria: a comparative overview of explicit criteria. Ann Pharmacother 2010;44:1968-75. 4. Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment): consensus validation. Int J Clin Pharmacol Ther 2008;46:72-83. 5. Wahab MS, Nyfort-Hansen K, Kowalski SR. Inappropriate prescribing in hospitalised Australian elderly as determined by the STOPP criteria. Int J Clin Pharm 2012;34:855-62. 6. Lee JH, Roh JH, Suh YW, Lee JH, Lee ES, Lee BK, et al. Comparison between Beers criteria and Screening Tool of Older Person s Prescriptions as a Screening Tool for the Detection of potentially inappropriate Medicines and adverse drug events in the elderly patients. J Korean Geriatr Soc 2013;17:28-36. 7. Denham MJ. Adverse drug reactions. Br Med Bull 1990;46:53-62. 8. Turnheim K. Drug therapy in the elderly. Exp Gerontol 2004;39: 1731-8. 9. Mooradian AD. Drug therapy of non-insulin-dependent diabetes mellitus in the elderly. Drugs 1996;51:931-41. 10. Martin SS, Metkus TS, Horne A, Blaha MJ, Hasan R, Campbell CY, et al. Waiting for the National Cholesterol Education Program Adult Treatment Panel IV Guidelines, and in the meantime, some challenges and recommendations. Am J Cardiol 2012;110:307-13. 11. Whelton A. Clinical implications of nonopioid analgesia for relief of mild-to-moderate pain in patients with or at risk for cardiovascular disease. Am J Cardiol 2006;97(9A):3-9. 12. Dougall HT, McLay J. A comparative review of the adverse effects of calcium antagonists. Drug Saf 1996;15:91-106. Vol. 4, No. 2 Jun 2014 163