Prescribing Appropriate Medicines to Older Adults: A Finnish Experience with the Web-Based Meds75+ Database

Abstract

The Finnish web-based Meds75+ database supports rational, safe and appropriate prescribing to older adults in primary care. This article describes the content and updating process of Meds75+ and demonstrates its applicability in everyday clinical practice. Meds75+ contains a classification (A–D) and recommendation texts for 450–500 drug substances when used in the treatment of older adults aged 75 years or older. The content of Meds75+ is continually updated. Each assessment of a drug substance begins with a structured collection of available information and research evidence. After that, an interdisciplinary expert panel discusses the classification and recommendation using a consensus method. A rolling 3-year updating cycle guarantees that all drug substances are reviewed regularly. Most drug substances are classified as class A (41%) (suitable, e.g. bisoprolol) or as class C (37%) (suitable with specific precautions, e.g. ibuprofen). One-fifth (20%) of the substances are in class D (avoid use, e.g. diazepam). Most commonly, older adults have purchased substances affecting the alimentary tract and metabolism (17%), the nervous system (16%) and the cardiovascular system (15%). In Finland, the proportion of older adults using class D substances (37%) has not changed between the years 2019 and 2022. Meds75+ has potential to support safer and more effective use of medications for older adults, since it offers up-to-date information on drug substances for healthcare professionals.

Full text

Vol.:(0123456789)
Drugs & Aging
https://doi.org/10.1007/s40266-024-01131-y
REVIEW ARTICLE
Prescribing Appropriate Medicines toOlder Adults: AFinnish
Experience withtheWeb‑Based Meds75+ Database
JohannaJyrkkä1 · JasminPaulamäki1 · SirpaHartikainen2 · JouniAhonen3· RiittaAntikainen4,5 ·
Hanna‑MariJauhonen6 · EsaJämsen7,8 · AnniinaKössi1 · JoukoLaurila4,5 · Hanna‑MariaRoitto9 ·
RiikkaSöderling10 · MiiaTiihonen2· RistoHuupponen11,12
Accepted: 23 June 2024
© The Author(s) 2024
Abstract
The Finnish web-based Meds75+ database supports rational, safe and appropriate prescribing to older adults in primary
care. This article describes the content and updating process of Meds75+ and demonstrates its applicability in everyday
clinical practice. Meds75+ contains a classification (A–D) and recommendation texts for 450–500 drug substances when
used in the treatment of older adults aged 75 years or older. The content of Meds75+ is continually updated. Each assess-
ment of a drug substance begins with a structured collection of available information and research evidence. After that, an
interdisciplinary expert panel discusses the classification and recommendation using a consensus method. A rolling 3-year
updating cycle guarantees that all drug substances are reviewed regularly. Most drug substances are classified as class A
(41%) (suitable, e.g. bisoprolol) or as class C (37%) (suitable with specific precautions, e.g. ibuprofen). One-fifth (20%) of
the substances are in class D (avoid use, e.g. diazepam). Most commonly, older adults have purchased substances affecting
the alimentary tract and metabolism (17%), the nervous system (16%) and the cardiovascular system (15%). In Finland, the
proportion of older adults using class D substances (37%) has not changed between the years 2019 and 2022. Meds75+ has
potential to support safer and more effective use of medications for older adults, since it offers up-to-date information on
drug substances for healthcare professionals.
Johanna Jyrkkä, Jasmin Paulamäki are equal contribution.
Risto Huupponen is deceased.
* Johanna Jyrkkä
johanna.jyrkka@fimea.fi
1 Development andInformation Services, Finnish Medicines
Agency, Kuopio/Tampere, P.O. Box55, FI-00034Fimea,
Finland
2 School ofPharmacy, University ofEastern Finland, Kuopio,
Finland
3 Hospital Pharmacy, Kuopio University Hospital, Kuopio,
Finland
4 Faculty ofMedicine, Center forLife Course Health Research,
University ofOulu, Oulu, Finland
5 Center forGeriatrics andGeneral Medicine, Oulu University
Hospital, Oulu, Finland
6 Ministry ofSocial Affairs andHealth, Council forChoices
inHealth Care inFinland (COHERE Finland), Helsinki,
Finland
7 Faculty ofMedicine (Clinicum), University ofHelsinki,
Helsinki, Finland
8 Department ofGeriatrics, Helsinki University Hospital,
Helsinki, Finland
9 Department ofSocial Services andHealth Care, Helsinki
Hospital, Helsinki, Finland
10 Division ofGeriatrics, Internal Medicine andRehabilitation,
Helsinki University Hospital, Helsinki, Finland
11 Institute ofBiomedicine, University ofTurku, Turku, Finland
12 Turku University Hospital, Turku, Finland

J.Jyrkkä et al.
Key Points
1. Meds75+ supports clinical decision-making by pro-
viding recommendations regarding suitability for older
adults based on drug substances, independent of the
indication.
2. Meds75+ contains approximately 190 medicines suit-
able for older persons, 170 medicines that should be used
with caution and more than 90 medicines to be avoided.
3. Meds75+ is introduced as part of the healthcare
professionals’ basic education and post-graduate train-
ing, and it can be implemented free of charge into
both national and international healthcare systems and
softwares.
1 Introduction
One of the biggest challenges for physicians is to select
safe and effective treatments for each patient as the basis of
high-quality care. Appropriate pharmacotherapy for older
adults can be challenging because of the multi-morbidity and
age-related changes in pharmacokinetics and pharmacody-
namics [1]. To ensure safe pharmacotherapy in older adults,
knowledge on appropriate and potentially inappropriate
medications (PIMs) and adjusting the dose individually are
necessary. Appropriate prescribing is based on comprehen-
sive assessment of patients and care planning together with
the patient, including the setting of individual therapeutic
goals and a careful risk–benefit assessment of prescribed
medicines [2]. There is a need for better medication man-
agement practices in healthcare, as up to one in four (23%)
hospital admissions among persons aged 65 years or older
have potential to be related to medication [3].
The consequences of prescribing PIMs to older adults
include the risk for adverse drug events, functional decline,
emergency department visits, hospitalisations and poorer
health-related quality of life [4–6]. The use of PIMs is com-
mon in older adults, as nearly a quarter (23%) of community-
dwelling older adults [7] and half (50%) of nursing home
residents are using PIMs [8]. Moreover, 60% of older adults
with a cognitive disorder use at least one PIM, and 27% use
at least two PIMs [9].
Several sets of criteria and tools have been published to
help physicians prescribe appropriately to older adults [10,
11]. The most commonly cited criteria are Beers criteria
[12], Screening Tool of Older Persons’ Potentially Inappro-
priate Prescriptions and Screening Tool to Alert to Right
Treatment (STOPP/START) [13, 14], a French consensus
panel list (Laroche) [15], Fit fOR The Aged (FORTA) [16]
and a list of PIMs consented by experts from seven Euro-
pean countries (EU(7)-PIM) [17]. The existence of several
published criteria highlights the importance of adapting the
criteria nationally, as treatment guidelines and prescrib-
ing practices as well as the availability of medicines dif-
fer between countries [10, 18, 19]. Furthermore, a uniform
classification could promote communication, comparison
and medication safety across different countries. In addi-
tion, a clear drawback of the existing criteria is that they
are used mostly as printed lists, and they are not integrated
in electronic medical record systems to be used as clinical
decision support.
The Finnish web-based Meds75+ was developed to
support rational, safe and appropriate prescribing to older
adults in primary care. The development of the Meds75+
database is in line with the European Medicines Agency’s
(EMA) strategy to improve the availability of information
for safer use of medicines in older adults [20] and with the
World Health Organization’s (WHO) global patient safety
issues [21]. The aim of Meds75+ is to offer information on
suitability for older adults on the basis of drug substances
to healthcare professionals to support clinical decision-
making in pharmacotherapy of persons aged 75 years or
older. Meds75+ and its content about concerns and possible
adverse effects is valid regardless of the indication, including
off-label use. The purpose of this article is to describe the
content and updating process of Meds75+ and to demon-
strate its applicability in everyday clinical practice.
2 Description ofMeds75+
Meds75+ includes drug substances that are used commonly
among older adults in primary healthcare. It is primarily
intended for physicians and other healthcare professionals,
and the content of the Meds75+ is available as an open data
and free of charge on Finnish Medicines Agency (Fimea)
website [22]. The Meds75+ is published and maintained in
two national languages, Finnish and Swedish, and in Eng-
lish. In Finland, it is included, for example, in some elec-
tronic patient record systems used in primary healthcare and
hospitals and other medicine-related databases and web-
based health portals widely used by pharmacists. Patients,
as well as their family members and caregivers, can also
use the database as a reliable source of medicine informa-
tion. However, Meds75+ includes a notification saying that
changes to a person’s pharmacotherapy should only be made
under a physician’s supervision.
The foundation of Meds75+ was created by the Finnish
Center for Pharmacotherapy Development (ROHTO) dur-
ing the years 2008–2010. Since 2010, the ownership and

Finnish Meds75+ Database Helps to Prescribe Appropriate Medicines for Older Adults
responsibility for maintenance and development was handed
over to Fimea, which published the first version of the data-
base in August 2010.
Conventionally, the chronological calendar age of 65
years and older is used when referring to older adults. How-
ever, chronological age seldom correlates with biological
age, as many recently retired people are healthy and in
good condition. From a clinical point of view, biological
changes affect the medicine treatment mainly after the age
of 75 years, which justifies the use of this age threshold in
Meds75+.
2.1 Expert Panel
Meds75+ is continually updated by a multidisciplinary
expert panel. The panel consists of healthcare profession-
als with expertise in geriatric pharmacotherapy, including
geriatricians, clinical pharmacologists, general practitioners
and pharmacists. Among these representatives is at least one
member from all Finnish universities teaching medicine and/
or pharmacy (title of professor, clinical lecturer or senior
researcher). In addition, the expert panel includes research
and development specialists and researchers representing
Fimea. Later, other pharmacology and healthcare profession-
als have been included to ensure a wide variety of expertise
in the expert panel. The size of the panel has been quite
stable, with 12 members. The expert panel meets ten times
a year to assess substances already in Meds75+ and to con-
sider whether there are new substances worth including. The
continual process updates the information on medicines in a
3-year cycle (i.e. each medicine is reviewed regularly at least
once per cycle) (Fig.1).
2.2 Assessment ofDrug Substances
The assessment of a drug substance begins with a structured
data collection that focusses especially on the substance’s
efficacy, effectiveness, interactions and adverse effects in
older adults. The data are collected through a literature
search conducted by Fimea’s representatives. The structured
Figure1 Inclusion criteria of
drug substances and updating
process of the Meds75+ data-
base in Finnish subjects aged
75 years or older (n = 588,453
in 2022)
EPM: Consensus on changes to
classification and recommendation
text or omitting the substance
Annual data on drug substance
purchases among Finnish persons
aged 75 years or older from the
Prescription Centre
(n = 588,453 in 2022)
Collection of substances with
500 or more users yearly
Structured data collection
Other PIM criteria
Medicine databases
PRAC recommendations
Scientific articles
EPM: consensus on classification
and recommendation text
Updating the Meds75+ database
Monitoring the use of drug
substance through register-based
prescription data (new substances,
omitted substances)
Updating structured
data collection form
UPDATING PROCESS
PRAC Pharmacovigilance Risk Assessment Committee of the European Medicines Agency; EPM Expert
Panel Meeting; PIM Potentially inappropriate medication

J.Jyrkkä et al.
data collections of each drug substance, utilised by the
expert panel, are not disclosed to third parties, since they
are intended to support the panel’s work only. After data
collection, the expert panel discusses the findings. Before
each meeting, one or two experts familiarise themselves
with 20–40 medicines, evaluate the available evidence and
relevant clinical evidence of each medicine and present their
notes on recommendation and possible concerns related to
use in older adults to the other panel members. In a situation
where specific expertise is required, the panel can request an
external expert to participate in the meeting.
The consensus decision regarding each active substance
is not reached adhering strictly to the Delphi method’s prin-
ciples, which is the most commonly used consensus-based
method. However, the decision-making process used in the
production requires that disagreements are discussed until
the expert panel reaches consensus. Compared with the Del-
phi method, this more flexible processing of drug substances
allows for changes in classifications to be made faster when
required. In consequence, individual members of the expert
panel cannot process the classification of the substances
from a completely independent perspective. In other words,
the experts’ views regarding the classification of substances
are unavoidably influenced by the other panel members.
3 Content ofMeds75+
3.1 Selection ofDrug Substances tobe Included
To be included into Meds75+, the medicine has principally
at least 500 users in the Finnish population aged 75 years
or older (n = 588,453 in 2022) [23]. Since 2019, data are
collected from the national Prescription Centre (i.e. a nation-
wide comprehensive and obligatory register of prescrip-
tions) that contains electronic information on all purchased
prescription medicines. The decision to include new sub-
stances and remove existing substances from the database
(e.g. due to expired marketing authorisation) is made by the
expert panel. When the number of users drops below 500
annual users, the expert panel can preserve these medicines
in Meds75+ for a valid reason to include critical drug sub-
stances. Over-the-counter medicines are included when they
are considered relevant for older adults. Meds75+ does not
include substances used only in hospitals, highly specialised
care or vaccines.
3.2 Structure
The content of Meds75+ is organised according to WHO’s
Anatomical Therapeutic Chemical (ATC) classification
system. Each medicine is classified in one of the four
Meds75+ classes – A, B, C or D (Table1) – on the basis
of the consensus of the expert panel regarding the balance
between benefits and risks associated with the use. A short
recommendation text and a colour code (e.g. green for class
A and red for class D) are labelled to each substance to ori-
ent healthcare professionals. In class A, the drug substance
is suitable for older adults and does not require significant
modifications compared with practice in younger adults.
Substances in class C can be used for older adults but require
changes, for example, in dosing, due to age-related changes
such as renal impairment. Moreover, substances in class C
may predispose the user to adverse drug events (ADEs) or
drug–drug interactions considered harmful for older indi-
viduals. In class D, the risks usually outweigh the benefits,
and these medicines are referred to as PIMs. Furthermore,
the Meds75+ database includes a category for drug sub-
stances that are used among older adults but for which the
supporting information is still scarce, thus making a recom-
mendation not possible (class B).
3.3 Proportion ofDrug Substances inClasses
Currently, Meds75+ contains classifications and recommen-
dations for 458 drug substances or their combinations (31
December 2023) (Table2). Most of the substances belong
to class A (41%) or class C (37%). In 2022, the seven most
frequently purchased substances among older adults aged
75 or older in Finland were classified as class A (Table3).
Most commonly, older adults purchased substances affecting
the alimentary tract and metabolism (17%), the nervous sys-
tem (16%) and the cardiovascular system (15%). One-fifth
(20%) of substances are classified in class D, that is, they
should be avoided in the treatment of older adults. In 2022,
paracetamol–codeine combination was the most commonly
(7%) used class D substance among the Finnish population
aged 75 years or older (Table4). Six out of ten of the most
used class D substances are medicines affecting the nervous
system.
3.4 Changes inClasses overTime
The expert panel reclassified 85 substances during the years
2013–2023. Most substances were moved from class C to
class A (n = 26, e.g. valsartan and atorvastatin) and from
class A to class C (n = 22, e.g. metronidazole and hydro-
chlorothiazide). In addition, 20 substances (e.g. tramadol
and paracetamol-codeine combination) were moved from
class C to class D, and 5 substances from class D to class C
(e.g. propranolol and pregabalin).
Both changes in prescribing habits and marketing
authorisations (including entry of new combinations ther-
apies) have modified the content of Meds75+ during the
10-year period. Due to the continual updating process, new

Finnish Meds75+ Database Helps to Prescribe Appropriate Medicines for Older Adults
Table 1 Classification
(A–D) used in the Meds75+
database and examples of drug
substances included
Class
Description
A (green)
Suitable for older adults. Drug substance can be used as in younger patients.
Changes due to aging do not affect the dose or dosing frequency. Adverse effects are
not different from those in younger patients.
Example (Class A)
Pantoprazole
Suitable for older adults. For short-term use (less than 2 months). Consider the
numerous potential interactions. Avoid long-term use. Long-term use carries an
increased risk of adverse effects. (updated 18.3.2024)
Example (Class A)
Bisoprolol
Suitable for older adults. Reduce the dose in severe renal impairment. Significant
adverse effects include bradycardia and orthostatic hypotension. Consider
interactions, especially with drugs affecting the conduction system of the heart.
(updated 13.3.2023)
B (grey)
Current evidence on or experience with use in older adults is inconclusive, or
the medicine is insufficiently effective in older adults.
Example (Class B)
Sumatriptan
Current evidence on or experience with use in older adults is inconclusive, or the
medicine is insufficiently effective in older adults. Consider adverse effects on the
heart and the cardiovascular system. It is not known if renal impairment affects the
dosage. (updated 2.5.2022)
C (yellow
) Suitable for older adults with specific precautions. Drug substance can be used
with consideration. Dose or dosing frequency must be adjusted due to age-related
changes and/or decreased renal function. A significant risk of interactions or adverse
effects may be associated with the use of substance.
Example (Class C)
Pregabalin
Suitable for older adults, with specific precautions. Sedative. Consider especially
central nervous system adverse effects. Reduce the dose already in mild renal
impairment. Addiction may develop. (updated 19.9.2022)
Example (Class C)
Citalopram
Suitable for older adults, with specific precautions. Serotonergic. Risk of QT
p
rolongation. A significant adverse effect is low serum sodium level. Increases risk
of falls. Consider potential interactions, especially with preparations that increase
risk of bleeding. (updated 12.2.2024)
D (red
) Avoid use in older adults. Risks of adverse effects typically exceeds the benefits.
Use only in exceptional cases.
Example (Class D)
Diazepam
Avoid use in older adults. Sedative. Long-acting. Increases the risk of drug
addiction, cognitive disorder and traffic accidents. Increases risk of falls.
Paradoxically, may increase anxiety, restlessness and aggression. Avoid grapefruit.
(updated 15.1.2024)
Example (Class D)
Repaglinide
Avoid use in older adults. Risk of hypoglycaemia. Consider the numerous potential
interactions. (updated 13.12.2021)
Example (Class D,
combination
)
Codeine + Paracetamol
Codeine: Avoid use in older adults. Sedative. Prodrug. Genotype affects the
response. Increases the risk of confusion and falling. Start a laxative to prevent
constipation. Consider potential interactions. (updated 2.5.2022)
Paracetamol: Suitable for older adults. Maximum dose in regular use 2–3 grams per
day. Consider paracetamol in OTC drugs and combination products. Overdose is
hepatotoxic. Over 2 grams can be used concurrently with warfarin if INR values are
monitored. (updated 2.5.2022)

J.Jyrkkä et al.
pharmacotherapies (e.g. gliflozins) have been evaluated as
soon as the growing number of users has been reflected in
the data.
4 Meds75+ andOther Criteria orIndicators
In preparation of the review and evaluation by the expert
panel, the drug substance’s inclusion in the following crite-
ria is checked: Beers [12], STOPP/START [13, 14], EU(7)-
PIM [17], Sweden’s indicators for the pharmacotherapy of
older people [24], STOPPFall [25], FORTA classification
[16], PRISCUS list [26] and the Norwegian General Practice
(NORGEP) [27, 28] criteria. Principally, the classification
by the expert panel follows the recommendation stated in
Table 2 Distribution of
drug substances or their
combinations included in
the Meds75+ database by
ATC group and classification
(A/B/C/D) (date 31 December
2023)
ATC grou
p
Class A
n = 187
n (%)
Class B
n = 7
n (%)
Class C
n = 171
n (%)
Class D
n = 93
n (%)
Total
n = 458
n (%)
A
Alimentary tract and metabolism 37 (20) 0 (0) 24 (14) 17 (18) 78 (17)
B
Blood and blood forming organs 6 (3) 0 (0) 12 (7) 2 (2) 20 (4)
C
Cardiovascular system 26 (14) 1 (14) 35 (20) 8 (9) 70 (15)
D
Dermatologicals 25 (13) 2 (29) 8 (5) 0 (0) 35 (8)
G
Genitourinary system and sex hormones 6 (3) 0 (0) 8 (5) 13 (14) 27 (6)
H
Systemic hormonal preparations, excl. sex
hormones and insulins
2 (1) 0 (0) 6 (4) 1 (1) 9 (2)
J
Anti-infectives for systemic use 7 (4) 0 (0) 14 (8) 5 (5) 26 (6)
L
Antineoplastic and immunomodulating agents 0 (0) 0 (0) 1 (1) 0 (0) 1 (0)
M
Musculo-skeletal system 5 (3) 3 (43) 18 (11) 5 (5) 31 (7)
N
Nervous system 8 (4) 1 (14) 31 (18) 34 (37) 74 (16)
P
Antiparasitic products, insecticides and
repellents
0 (0) 0 (0) 3 (2) 0 (0) 3 (1)
R
Respiratory system 34 (18) 0 (0) 7 (4) 8 (9) 49 (11)
S
Sensory organs 32 (17) 0 (0) 3 (2) 0 (0) 35 (8)
Table 3 Proportion (%) and number of Finnish subjects aged 75 years
or older (n = 588,453) who were prescribed ten of the most pre-
scribed class D (avoid use) drug substances or their combinations in
the year 2022
Drug substance Proportion
of users, %
(n)
Codeine + paracetamol 7.0 (41,124)
Quetiapine 4.5 (26,684)
Risperidone 4.1 (23,944)
Ciprofloxacin 2.5 (14,655)
Tramadol 2.3 (13,544)
Nitrofurantoin 2.3 (13,457)
Zolpidem 2.1 (12,289)
Amitriptyline 2.0 (11,685)
Metoclopramide 1.8 (10,686)
Tizanidine 1.7 (9735)
Table 4 The 15 most frequently prescribed orally taken drug sub-
stances as the number and proportion of users (%) in the Finnish pop-
ulation aged 75 years or older (n = 588,453) in the year 2022
a Does not include combinations that include the substance in different
ATC codes.
b Does not include oestradiol because it is not possible to separate
local use (class A) and systemic use (class D), as the ATC code is the
same for both administration routes
Drug substancea,b Proportion of users % (n) Meds75+
classifica-
tion
Paracetamol 46 (268,913) A
Bisoprolol 36 (214,702) A
Amlodipine 24 (139,129) A
Atorvastatin 23 (133,956) A
Pantoprazole 22 (130,703) A
Furosemide 21 (122,243) A
Calcium + vitamin D 20 (115,382) A
Simvastatin 17 (98,623) C
Levothyroxine 17 (98,571) A
Metformin 15 (89,728) C
Rosuvastatin 15 (88,112) C
Losartan 15 (87,537) A
Artificial tears 13 (77,592) A
Apixaban 13 (76,459) C
Ramipril 12 (70,869) C

Finnish Meds75+ Database Helps to Prescribe Appropriate Medicines for Older Adults
other criteria, but the consensus is based on independent
review and evaluation. A recent study demonstrated that the
overlap between Meds75+ and other PIM criteria in identi-
fying the proportion of persons aged 75 years or older using
PIMs varied from 57% (Danish Red-Yellow-Green list) to
99% (Swedish indicators) in 2017–2019 [29]. In addition,
the content of Meds75+ has some similarities with FORTA,
as it gives positive and negative labels for medicines when
used in older adults. However, contrary to the indication-
based FORTA, Meds75+ provides substance-based informa-
tion independent of the indication [16].
For a justified reason, the recommendation may devi-
ate from the other criteria and sources of information. For
example, Meds75+ considers the duration of treatment
only in exceptional cases, such as when advising short-term
use of medium-acting benzodiazepines. The advantage of
Meds75+ is that it is also one of the few tools that assess the
suitability of drug substances that are used only temporar-
ily, such as antibiotics. Another advantage of Meds75+ is
the continual updating process and substance-based infor-
mation on concerns and possible ADEs. Consequently, the
substance-based information is valid also when substances
are used in off-label indications, such as the use of mirtazap-
ine as a hypnotic.
5 Implementation andApplication
Meds75+ is a criterion to support prescribing and the choice
of appropriate medicines as well as the assessment of correct
dosing, especially in the case of renal impairment. Two-
fifths of all substances included in Meds75+ are classified
as suitable for older adults (class A), meaning a wide vari-
ety (approximately 200) of safe pharmacotherapy options
(Table2). The substance-based approach is also suitable for
medication reviews when considering the appropriateness
of a whole medication regimen [30]. Consequently, the sub-
stance-based criteria support deprescribing when the need
and efficacy of medicines in their indication are the primary
focus [31].
5.1 National indicator reporting class D medicine
use
The proportion of Finnish adults aged 75 years or older
using class D medicines is being followed as a national indi-
cator to direct and guide social and healthcare services. On
the basis of the indicator data, the proportion of older adults
using class D substances (at least one purchase per year) has
remained at approximately 37% between the years 2019 and
2022. These medicines contain all prescription purchases,
including both regularly and as-needed medicines. Nev-
ertheless, since the number of older adults in society has
increased over time, the number of older adults using class
D medicines increased by 13.5% during the 4-year follow-
up. In addition, a recent study has shown that the prevalence
of class D medicine use is not uniformly distributed across
the Finnish regions, and the differences are associated with
factors such as personnel shortages in social and healthcare
and a higher share of older adults with polypharmacy [32].
Finnish indicator data are published annually in the
Sotekuva service (indicator number 5036) maintained by
the Finnish Institute for Health and Welfare (THL) [33]. The
data can be reviewed both nationally and between regions,
which allows for the comparison across the wellbeing ser-
vices counties responsible for providing social and health-
care services. Since PIMs are associated with an increased
use of health services without health benefits [34], the
indicator addresses the need for support and guidance of
healthcare professionals for safe implementation of phar-
macotherapy in older adults.
5.2 Integration intoFinnish Health Portals
andElectronic Social andHealthcare Record
Systems
The most important factor driving the increasing use of
Meds75+ has been its integration into Finnish web-based
health portals, such as the scientific database of the Finnish
Medical Society Duodecim, commonly used by healthcare
professionals. Among other information aiding daily clinical
practice, these health portals include summaries of prod-
uct characteristics, prescribing and clinical practice guide-
lines (e.g. older adults, drug–drug interactions, kidney and
liver function) and patient information leaflets. Meds75+
is also implemented into some electronic social and health-
care record systems used in primary care and hospitals. For
example, the electronic social and healthcare record system
Apotti© [35], which is used in the Helsinki metropolitan
area (1.7 million inhabitants), notifies the physician when
they are prescribing a class D medicine to older adults.
In addition to primary healthcare, Meds75+ has also
been introduced in pharmacies. The content has been imple-
mented in pharmaceutical assistant applications utilised by
pharmacists, especially when dispensing prescription medi-
cines. In addition, the recommendations in Meds75+ are
also available via the database of the Association of Finnish
Pharmacies, which is an overall evaluation tool for medica-
tion reviews and supporting patients to follow the instruc-
tions on how to use their medicines.
5.3 Implementation ofMeds75+ Outside Finland
The English version of Meds75+ enables the integration
of the content with other electronic medicine databases in
collaboration with other countries. Meds75+ is applicable

J.Jyrkkä et al.
especially in the Nordic and other European countries with
a similar medicine regimen in the treatment of older adults.
Thus far, the State Agency of Medicines in the Republic
of Latvia has included Meds75+ in their medicine register
[36]. In addition, the county of Central Norway has included
Meds75+ in their medicine register, which contains basic
information about medicines on the market in Norway [37].
5.4 Meds75+ inEveryday Practice
User experience interviews concerning the applicability of
Meds75+ were conducted among healthcare representatives
from pharmacies, hospitals and software developers in the
fall 2023. In the interviews, the healthcare professionals
emphasised the need for easy-to-use information in busy
everyday work. Meds75+ also meets the needs of profes-
sionals by providing concise recommendations on how to
conduct safe pharmacotherapy in older adults. In addition,
the content is available in three languages, enabling health-
care personnel speaking Swedish or English to utilise the
content. The recommendation text of each drug substance
clearly and briefly explains why the medicine is considered
suitable or inappropriate, and the arguments are easy to con-
vey to the attending physician. The content is considered
reliable and independent, since an objective authority has
the responsibility for its maintenance.
Promoting the use of Meds75+ and enhancing its adop-
tion as part of healthcare practices is progressing, as the
database is introduced and its use is being taught as part of
the basic education in both academic universities and univer-
sities of applied sciences. In addition to undergraduate edu-
cation, Meds75+ is included in further training of healthcare
professionals, such as nursing staff with a medication license
and medication reviews carried out by pharmacies (e.g. in
automated multi-dose systems for dispensing medicines for
long-term treatments). To further promote the utilisation of
Meds75+, the expert panel intends to publish summarised
guidelines on the basis of the content of Meds75+.
6 Discussion
The Meds75+ contains medicines suitable for older adults as
well as medicines that should be avoided. Substance-based
classification and short expert comments provide important
information on the drug substance to the healthcare profes-
sional. As the information is independent of diagnosis, put-
ting information into practice requires professional skills.
Most of the commonly used criteria, for example Beers,
introduce only PIMs and do not consider medicines suit-
able for older adults. Meds75+ is available free of charge to
everyone via Fimea’s Medicines Database [22], allowing all
participants in the medication process to obtain reliable and
up-to-date information on medicines used for older adults.
This supports the collaborative, shared decision-making
process between patients and physicians in prescribing and
deprescribing [38]. The English version of the Meds75+
database also enables its integration with other electronic
medicines databases and software in collaboration with other
countries.
The medicine regimen in Meds75+ is quite similar with
the Nordic and other European countries, which makes
Meds75+ widely applicable. Although the prescribing prac-
tices across countries vary, the drug-substance-based infor-
mation in the database is valid regardless of the indication
in the treatment of older adults. Incorporating prescribing
tools directly into a computerised prescribing system has
the potential to positively impact the quality of care and
patient outcomes.
A clear benefit of the database is that professionals in
geriatric medicine and geriatric pharmacotherapy update the
information on the basis of the latest research evidence. The
updating cycle is 3 years, but medicines are also assessed
earlier if there is need for it. This kind of synthesised and
reliable information is valuable in clinical care, as research
evidence on the effectiveness and efficacy of medicines in
older adults accumulates slowly. This is because this popu-
lation subgroup is often excluded from randomised clinical
trials. The expert panel responsible for Meds75+ is actively
engaged in discussions with representatives of the pharma-
ceutical industry regarding the classifications of substances
and the associated recommendations, which emphasises the
importance ascribed to Meds75+ in healthcare.
7 Conclusions
Meds75+ supports rational, safe and appropriate prescrib-
ing to older adults in primary care. It is continually updated
and provides recommendations on how to use medicines
among older adults on the basis of the latest research evi-
dence to support clinical decision-making. Compared with
other published criteria intended to guide appropriate pre-
scribing, the content of Meds75+ is valid regardless of indi-
cation. Moreover, the web-based content can be integrated
free of charge with healthcare and patient record systems.
Meds75+ is widely adopted in clinical practice and educa-
tion of healthcare professionals nationally. In society, the
Meds75+ indicator is utilised in the development and ser-
vice planning of Finnish healthcare. The implementation
of Meds75+ promotes communication, comparison and
medication safety across different countries. As the popula-
tion is aging globally, healthcare professionals increasingly
encounter older adults in everyday clinical practice, which
addresses the essential need for easy-to-use information.

Finnish Meds75+ Database Helps to Prescribe Appropriate Medicines for Older Adults
Acknowledgements Meds75+ expert panel wants to thank all former
members for their valuable contributions to the content. In addition,
we warmly thank medicine and pharmacy students who have offered
their help to the working of the expert panel.
Declarations
Funding Open Access funding provided by Finnish Medicines Agency.
Conflict of Interests Johanna Jyrkkä, Jasmin Paulamäki, Sirpa Harti-
kainen, Jouni Ahonen, Riitta Antikainen, Hanna-Mari Jauhonen, Esa
Jämsen, Anniina Kössi, Jouko Laurila, Hanna-Maria Roitto, Riikka
Söderling,Miia Tiihonen and Risto Huupponen have no conflicts of
interest that are directly relevant to the content of this article.All au-
thors are or have been the members of the Meds75+ expert panel.
Ethics Approval Not applicable.
Consent to Participate Not applicable.
Consent to Publication Not applicable.
Availability of Data and Material The content of Meds75+ is avail-
able as open data via Fimea’s website (https:// fimea. fi/ en/ datab ases_
and_ regis teries/ medic ines_ infor mation/ datab ase_ of_ medic ation_ for_
older_ perso ns). Content is integrated into FimeaWeb (https:// fimea. fi/
en/ datab ases_ and_ regis ters/ fimea web). The National indicator report-
ing Class D medicine use is available via THL’s website, indicator 5036
(https:// sotek uva. fi/ en/#/ guides).
Code Availability Not applicable.
Author Contributions Concept and design: all authors. Conception and
design: all authors. Acquisition, analysis or interpretation of data: all
authors. Data analysis: J.J. and J.P. Drafting of the manuscript: J.J.,
J.P., S.H., H.J., A.K. and R.H. Critical revision of the manuscript for
important intellectual content: all authors. All authors approved the
final version of the manuscript.
Duplicate Publication Abstract concerning this review article was pub-
lished (Eur Geriatr Med 2023;14(Suppl 1):348)as part of the academic
meeting of Eu-GMS congress on 20–22 September 2023 (word count
258).
Open Access This article is licensed under a Creative Commons Attri-
bution-NonCommercial 4.0 International License, which permits any
non-commercial use, sharing, adaptation, distribution and reproduction
in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Com-
mons licence, and indicate if changes were made. The images or other
third party material in this article are included in the article's Creative
Commons licence, unless indicated otherwise in a credit line to the
material. If material is not included in the article's Creative Commons
licence and your intended use is not permitted by statutory regula-
tion or exceeds the permitted use, you will need to obtain permission
directly from the copyright holder. To view a copy of this licence, visit
http:// creat iveco mmons. org/ licen ses/ by- nc/4. 0/.
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