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
- Assess pain control and function as states struggling with pain during the day and at work
- Biopsychosocial assessment to determine if other factors worsening pain
- Diabetes well controlled
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
- Duloxetine and amitriptyline: review effectiveness of these, determining which has been the most beneficial. Optimise the dose and gradually reduce the other
- Tramadol not recommended as treatment for neuropathic pain, consider stopping
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
- Diabetes well controlled, continue with treatment and lifestyle measures
- Pain poorly controlled, optimise medicines and encourage use of self-management strategies
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
- Duloxetine, tramadol and amitriptyline: all serotonergic, review for signs and symptoms of serotonin syndrome and rationalise therapy
- On several psychoactive substances including cannabis. Educate on cannabis use in pain, and use health behaviour change techniques to encourage stopping
- Assess for other ADR
- Counsel on potential long-term issues with regular opioids. Advise gradual dose reduction of tramadol with aim to stop
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
- He is happy to take less medication and does not want to take medicines that are “doing more harm than good”
- Stop: agreed to reduce amitriptyline and then stop
- Increase: duloxetine could be increased up to a maximum of 120mg daily
- Review: tramadol could be reduced and stopped once other pain management strategies are in place
- Signposted to NHS Inform and pain management websites for information on self-management
Polypharmacy guidance: Appropriate prescribing making medicines safe, effective and sustainable 2026-2029
