Loop diuretic for dependent ankle oedema only i.e. no clinical signs of heart failure (no evidence of efficacy, compression hosiery more appropriate).
Thiazide diuretic with a history of gout (may exacerbate gout).
Beta-blocker in combination with verapamil (risk of symptomatic heart block).
TCAs (Tricyclic Antidepressants) with dementia, narrow angle glaucoma, cardiac conduction abnormalities, prostatism, or prior history of urinary retention (risk of worsening these conditions).
Benzodiazepines for ≥ 4 weeks (risk of prolonged sedation, confusion, impaired balance, falls).
Antipsychotics in patients with behavioural and psychological symptoms of dementia (BPSD) unless symptoms are severe and other non-pharmacological treatments have failed.
PPIs for uncomplicated peptic ulcer disease or erosive peptic oesophagitis at full therapeutic dosage for > 8 weeks (dose reduction or earlier discontinuation indicated).
Theophylline as monotherapy for COPD (safer, more effective alternative inhaled bronchodilators available).
NSAIDs with a history of peptic ulcer disease or gastrointestinal bleeding, unless with concurrent PPI or H2 antagonist.
Long-term NSAIDs (>3 months) for relief of mild osteoarthritis pain (paracetamol preferred).
Benzodiazepines, neuroleptics, vasodilator drugs (e.g. alpha-1 blockers, calcium channel blockers, long-acting nitrates, ACEI, ARBs) in patients with a history of recurrent falls.
Clinical Details
When to Use
When to Use
Dual Action
Formula & Logic
Structure
Common STOPP Examples
| Cardiovascular | Loop diuretics as first-line for hypertension (stop). |
| CNS / Psych | Tricyclic antidepressants in patients with dementia or glaucoma (stop). |
| Gastrointestinal | PPIs at full dose for > 8 weeks without clear indication (stop or taper). |
| Falls | Benzodiazepines in patients with a history of recurrent falls (stop). |
Common START Examples
| Cardiovascular | ACE inhibitors following an acute myocardial infarction (start). |
| Respiratory | Inhaled LABA/LAMA in mild-to-moderate asthma/COPD (start). |
| Musculoskeletal | Vitamin D and Calcium in patients with known osteoporosis or prior fragility fracture (start). |
Pearls/Pitfalls
Physiological Approach
Next Steps
Management
Evidence Appraisal
Primary Reference
STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation.
Gallagher P et al. • Int J Clin Pharmacol Ther.. 2008;46(2):72-83. The original validation. Note: Updated versions (e.g., Version 3 in 2023) continue to expand the rules.
Origins
European Standard
Last Comprehensive Review: 2026