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 actions to address
- Feels tired and short of breath
- Carers wish to reduce sedation and improve his ability to interact socially
- Reduce ankle swelling, and falls risk
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
- Thiamine: may be redundant if no alcohol intake
- Bendroflumethiazide: no longer hypertensive. Potential for withdrawal
- Tramadol: indication unclear (may have been started after surgery)
- Trazodone or amisulpride: indication unclear. Consider withdrawal if not agitated
- Antihistamine and emollient: clarify cause of itch i.e. dermatological, CNS problem or ADR. If dermatological problem, consider non-pharmacological measures e.g. attention to washing powder, natural fabrics, etc. as well as regular use of simple emollients in sufficient quantity
- Antimicrobial cream: should only be used short-term - stop
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
- Thyroid function: check TFTs and correct hypothyroidism if present
- Ankle swelling and shortness of breath: consider presence of LVSD. Potentially highly effective treatment available (ACE/ARB, beta blocker) if present. Consider ECG, BNP, ECHO
- Reduce falls and fracture risk: mainly associated with sedative load; could consider fracture risk modification with osteoporosis prevention (e.g. bisphosphonates). Decision to treat needs to be balanced against expected efficacy (see NNT table) and ability to comply with treatment. Dental health needs to be considered. Unlikely to have time to benefit if life expectancy felt to be less than one year
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
- Actual ADR: over sedation
- Risk of CVD events: antipsychotics have increased risk of CVD events in dementia
- Risk of cognitive deterioration: antipsychotics, antihistamines, tramadol
- Risk of falls and fractures: antipsychotics, antidepressant, antihistamines
- Risk of serotonin syndrome: tramadol and trazodone
- Risk of steroid adverse effects: high dose topical steroid
- ACB burden score 4 increases risk of falls, confusion
- Medication Sick Day Guidance: ensure staff have clear information on medicines to withhold if dehydrated (in this case bendroflumethiazide)
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
- Care home advised to dispose of medicines through community pharmacy and advised to only order what is needed
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
- Stop:
- bendroflumethiazide
- thiamine
- Fucibet® cream
- Reduce trazodone and amisulpride to decrease sedation and falls/fracture risk
- Reduce and review:
- Review the need to start bisphosphonate and calcium/vitamin D, taking a person-centred approach
Polypharmacy guidance: Appropriate prescribing making medicines safe, effective and sustainable 2026-2029
