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FORTA, "Fit fOR The Aged", is a drug classification system designed as a clinical tool to help in monitoring and optimizing the drug therapy and care management of older patients.
273 items consisting of the most frequently used substances/substance classes for the long-term drug therapy of older patients (with exceptions to this rule) aligned to 29 diagnoses/indication areas have been assigned positive and negative labels ranging from A-B-C-D according to the state of evidence as to risk/benefits and age-appropriateness.
This drug has proved indispensable; there are clear-cut benefits in terms of efficacy/safety ratio in elderly patients for a given indication
This drug has proven or obvious efficacy in the elderly, but does also have limitations in the extent of effect or additional safety concerns
This drug has questionable efficacy/safety profiles in the elderly, should be avoided or omitted in the presence of too many drugs; lack of benefits or emerging side effects; review/find alternatives
This drug should be avoided in the elderly; omit first and review/find alternatives
This innovative approach aimed at improving and facilitating the screening, prescribing and monitoring of drug therapy for older patients, is currently being developed in the area of Clinical Pharmacology in cooperation with the Division of Geriatric Medicine, Medical Division IV (Geriatric Center) together comprising the Center for Geriatric Pharmacology, at the University of Heidelberg in Mannheim. The FORTA Project is a two-part development program funded by the German Research Foundation, Grant Nr. WE 1184/15-1. This approach represents another advance in worldwide research efforts aimed at adding a new dimension to already-existing classification systems and negative listings of potentially inappropriate medications for the elderly
Delphi Expert Consensus Validation 2012
The Delphi Consensus Procedure for the FORTA List: this project, conducted from March-October 2012, involved the expert validation of the labels for 190 substances/substance groups aligned to 20 indication groups. The FORTA concept is outlined in a previously published article and the results of this procedure are compiled in the Expert Consensus Validation 2012 of the FORTA List.
The project involved the implementation of the validated FORTA List in a controlled clinical setting. The impact of the FORTA classification system on the quality of drug prescribing/screening, and ultimately on patient outcome, was tested on a total of 409 patients in geriatric wards in two German hospitals. Nearly half of the patients received standard care and the other half received standard care plus the FORTA method.
The primary end point (FORTA score: a composite measure of over-, under- and mistreatment) was significantly more reduced in the intervention vesus control group. Moreover, both over- and under-treatment were significantly improved in the intervention group as compared to the control group. In addition, the total number of adverse drug reactions (ADRs) was significantly reduced by FORTA and activities of daily living and renal failure improved significantly. The results of the VALFORTA study are shown in a recently published article
- Pazan F, Weiss C, Wehling M. The EURO-FORTA (Fit fOR The Aged) list: international consensus validation of a clinical tool for improved drug treatment in older people. Drugs Aging 35, 61-71, 2018
- Pazan F, Burkhardt H, Frohnhofen H, Weiss C, Throm C, Kuhn-Thiel A, Wehling M. Changes in prescription patterns in older hospitalized patients: the impact of FORTA on disease-related over- and under-treatments. Eur J Clin Pharmacol 2 Dec 2017, doi: 10.1007/s00228-017-2383-3 [Epub ahead of print]
- Wehling M, Collins R, Gil VM, Hanon O, Hardt R, Hoffmeister M, Monteiro P, Quinn TJ, Ropers D, Sergi G, Verheugt FWA. Appropriateness of oral anticoagulants for the long-term treatment of atrial fibrillation in older people: results of an evidence-based review and international consensus validation process (OAC-FORTA 2016). Drugs Aging 34, 499-507, 2017
Original sources outlining the FORTA Concept
- Wehling M. Drug therapy in the elderly: too much or too little, what to do? A new assessment system: fit for the aged FORTA. Dtsch Med Wochenschr 2008;133(44):2289-91.
- Wehling M. Multimorbidity and polypharmacy: how to reduce the harmful drug load and yet add needed drugs in the elderly? Proposal of a new drug classification: fit for the aged. J Am Geriatr Soc 2009;57(3):560-561.
Original author-based FORTA List
- Wehling M, Burkhardt H. Arzneitherapie für Ältere. Springer-Verlag, Heidelberg, 3. Auflage 2013.
- Wehling M, Ed., Drug Therapy for the Elderly. Springer, Wien 2013. Co-Authors Heinrich Burkhardt, MD; University Hospital Mannheim, Heidelberg University, Germany Lutz Frölich, MD; Central Institute of Mental Health, Mannheim, Germany Stefan Schwarz, MD; Central Institute of Mental Health, Mannheim, Germany Ulrich Wedding, MD; University Hospital, Jena, German
Clinical validation of the FORTA List
- Wehling et al., VALFORTA: a randomised trial to validate the FORTA (Fit fOR The Aged) classification. Age Ageing. 2016;45(2):262-267.
The LUTS-FORTA project
As the first detailed comparative assessment of individual drugs by the FORTA system (FORTA-PLUS), 16 urological drugs frequently used to treat lower urinary tract symptoms (LUTS) were chosen and rated by 5 international experts. A two-stage Delphi process was implemented after a systematic review of literature on clinical trials in older patients treated by those drugs.
In total, only 25 papers with such data could be identified, underpinning the lack of evidence in the field which is typical for this age group. As result, no drug was rated at the FORTA-A-level (indispensable). Only three were assigned to FORTA B (beneficial): dutasteride, fesoterodine and finasteride. The majority was rated FORTA C (questionable): darifenacin, mirabegron, extended release oxybutynin, silodosin, solifenacin, tadalafil, tamsulosin, tolterodine and trospium. FORTA D (avoid) was assigned to alfuzosin, doxazosin, immediate release oxybutynin, propiverine and terazosin. The results demonstrate that ratings for drugs from the same group, e.g. antimuscarinergics, may differ considerably: for this group ratings span from B (Beneficial) through C (Careful) to D (Don't) underlining the need for careful choice and patient monitoring to avoid harmful side effects.
Further details in: Oelke et al. Appropriateness of oral drugs for long-term treatment of lower urinary tract symptoms in older persons: results of a systematic literature review and international consensus validation process (LUTS-FORTA 2014). Age Ageing. 2015;44(5):745–755.
Delphi Expert Consensus Validation 2015
An update of the FORTA List which followed the same two step-Delphi procedure as stated for its first version was performed in 2015.
Further details in Pazan et al. The FORTA (Fit fOR The Aged) List 2015: Update of a Validated Clinical Tool for Improved Pharmacotherapy in the Elderly. Drugs Aging. 2016;33(6):447–449.
Martin Wehling, MD
Professor of Clinical Pharmacology and creator of the FORTA Concept
Coordinator of the FORTA Project and English language consultant
Christel Weiß, PhD
Professor of Statistics, Biomathematics and Information Processing, Consultant for statistical analysis