1. Aims: What matters to the individual about their condition(s)?
Review diagnoses and consider:
- Therapeutic objectives of drug therapy
- Management of existing health problems
- Prevention of future health issues, including lifestyle advice
Ask person to complete PROMs (Questions to answer before medicines review) before their review
Person specific issues to address
- Wants to reduce side effects of sedation and ensure able to swallow necessary medication
2. Need: Identify essential drug therapy
Identify essential drugs (not to be stopped without specialist advice)
- Drugs that have essential replacement functions (e.g. levothyroxine)
- Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)
Person specific issues to address
3. Does the individual take unnecessary drug therapy?
Identify and review the continued need for drugs
- what is medication for?
- with temporary indications
- with higher than usual maintenance doses
- with limited benefit/evidence for use
- with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)
Person specific issues to address
- Pregabalin: review as may aggravate motor symptoms of PD
- Co-codamol: review as may aggravate non-motor symptoms of PD (constipation) – consider paracetamol alone if needed for pain
- Sertraline: review mood and continued need. Reduce dose to 50mg if ongoing indication (see Quality Prescribing for Antidepressants guidance)
- Consider non-pharmacological management of depression
4. Effectiveness: Are therapeutic objectives being achieved?
Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives
- to achieve symptom control
- to achieve biochemical/clinical targets
- to prevent disease progression/exacerbation
- is there a more appropriate medication to achieve goals?
Person specific issues to address
- Suggestions to discuss with PD team include:
- Review formulation and timings as dispersible tablet may be easier in the morning, as that is when swallowing is most difficult
- First dose should ideally be on waking, which is before the carers visit at breakfast time
- Ensure speech and language therapy (SALT) referral for swallowing assessment and advice
5. Safety: Does the individual have or is at risk of ADR/ side effects? Does the patient know what to do if they’re ill?
Identify individual safety risks by checking for
Identify adverse drug effects by checking for
- specific symptoms/laboratory markers (e.g. hypokalaemia)
- cumulative adverse drug effects (see ADR table)
- drugs used to treat side effects caused by other drugs
Medication Sick Day guidance
- Ensure discussion and clear information on which medicines to withhold at times of dehydrating illness
Person specific issues to address
- Potential for interaction between pregabalin, sertraline, codeine (in co-codamol) and co-beneldopa, increasing sedation. Review ongoing need for the non-PD medication
- Due to importance of timing of medication, if the person is acutely ill, e.g. vomiting which may affect absorption of medication, seek specialist advice on antiparkinsonian medication dose replacement/alternatives (e.g. transdermal)
6. Sustainability: Is drug therapy cost-effective and environmentally sustainable?
Identify unnecessarily costly drug therapy by
- considering more cost-effective alternatives, formulary choices, safety, convenience
Consider the environmental impact of
- Inhaler use
- Single use plastics
- Medicines waste
- Water pollution
Person specific issues to address
- All medicines are formulary choices
- Advised to dispose of medicines through the community pharmacy
- Advised to only order what is needed, do not stockpile medicines
7. Person-centredness: Is the person willing and able to take drug therapy as intended?
Does the person understand the outcomes of the review?
Ensure drug therapy changes are tailored to individual’s preferences. Consider
- is the medication in a form they can take?
- is the dosing schedule convenient?
- what assistance is needed?
- are they able to take medicines as intended?
Agree and communicate plan
- discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
- include lifestyle and holistic management goals
- inform relevant health and social care providers of changes in treatments across the transitions of care
Ask person to complete PROMs (Questions to answer after medicines review) after their review
Agreed plan
- If agreed with PD team, change co-beneldopa dispersible to early morning, to be taken on waking. Remaining co-beneldopa to be given at breakfast, lunchtime, teatime and bedtime
- Ensure timing of medication is specified in dose instructions (for transfer to ECS/KIS)
- Trial reduction of pregabalin, by 25mg every two weeks and monitor pain and sedation
- Trial paracetamol alone, in place of co-codamol for chronic pain. Monitor pain and constipation side effects
- Reduce sertraline to 50mg, and review mood and continued need at next appointment
- There is an Anticipatory Care Plan in place, the individual wishes to remain at home for as long as possible. Welfare POA arrangements are in place and relevant clinical systems (e.g. KIS) are updated with individual’s wishes
- Referral to SALT is made to highlight the increased swallowing difficulties
Polypharmacy guidance: Appropriate prescribing making medicines safe, effective and sustainable 2026-2029
