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
- Pain control
- Bowel function
- Burden of medication
- Improvement in mobility where possible
- Shortness of breath
- Current smoker
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
- Levothyroxine: essential replacement therapy
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
- Edoxaban: Increased risk of gastrointestinal bleeding in combination with dexamethasone. Consider risks versus benefit of continued anticoagulation for atrial fibrillation in context of metastatic cancer and steroid use.
- Solifenacin and amitriptyline: two anticholinergic drugs prescribed with cumulative risk of adverse effects. Anticholinergics.
- Folic acid: Limited benefit in context of advanced malignancy
- Alogliptin and metformin: Reduced oral intake
- Diazepam: Indication unclear; falls risk due to concomitant sedatives
- Dexamethasone: significant impact on blood glucose control
- Atorvastatin: long-term survival benefit of statin therapy not relevant for patients with prognosis of less than 12 months
- Lidocaine: Limited comparative data and clinical effectiveness remains unclear. Ensure prescribing in line with palliative care guidelines.
- Trelegy Ellipta®: Difficulty administering dose; dry powder formulation
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
- Consider and discuss compliance in context of polypharmacy and mouth discomfort. Can all medicines be swallowed as prescribed?
- Analgesics: assess effectiveness and tolerability; check requirement of breakthrough doses of morphine
- Omeprazole: gastroprotection whilst taking dexamethasone
- Solifenacin/ amitriptyline: Stop if not beneficial, cumulative risk of anticholinergic effects
- Shortness of breath affecting mobility, may cause anxiety. Check inhaler compliance and assess technique. Alternative devices may be required.
- Consider ongoing therapeutic management of diabetes in context of reduced oral intake and steroid therapy
- Monitor bowel function. Adjust laxatives if required, rectal preparations may be necessary
- Assess oral pain and whether prescribed medications are contributing factors and/or oral thrush evident. Encourage to rinse mouth out with water and brush teeth after using inhaler
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
- Bleeding risk increased with edoxaban, dexamethasone and sertraline:
- Edoxaban: dose reduction required (if continued): 30mg once daily if creatinine clearance 15–50 mL/minute.
- Diabetes: review blood glucose targets, control potentially too tight, accounting for reduced oral intake
- Dexamethasone. Monitor for hyperglycaemia. Administer as a single dose in the morning
- If troublesome symptoms associated with high blood glucose, consider gliclazide or appropriate insulin. Administer once daily in the morning to reduce the risk of nocturnal hypoglycaemia
- Ramipril: No current hypertension. Long-term renal protective effect not relevant due to limited prognosis. Risk of hyperkalaemia in renal impairment and symptomatic hypotension as general condition declines
- Diazepam, opioids, amitriptyline and pregabalin: risk of falls, sedation and respiratory depression
- Morphine: opioid effects increased and prolonged in renal impairment: risk of opioid toxicity
- Pregabalin: dose reduction required: maximum 300mg daily in 2–3 divided doses if creatinine clearance 30–60mL/minute
- Solifenacin and amitriptyline: risk of anticholinergic side-effects, complaining of a dry mouth
Medication sick day guidance:
- Metformin: dehydration increases the risk of lactic acidosis
- Ramipril: dehydration can impair kidney function
Dexamethasone: ensure aware of steroid sick day guidance and ensure they have a steroid emergency card
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
- If other formulations are required, consult local guidance
- 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
- Stop:
- alogliptin
- atorvastatin
- folic acid
- metformin
- ramipril
- solifenacin (and assess symptoms)
- Reduce pregabalin dose
- Reduce edoxaban dose, if continuing
- Review amitriptyline and trial reducing dose or stopping
- Review diazepam: consider reducing dose with aim to stop
- Review lidocaine plasters; trial stoppage and stop if no benefit
- Dexamethasone: check dosing plan, ensure changes made by specialist team are implemented promptly. Review need for blood glucose monitoring
- Review laxatives; consider more palatable formulations
- Consider different inhaler device/ spacer
- Discuss possibility of changing opioids due to renal impairment and/or swallowing difficulties (e.g. oxycodone or transdermal fentanyl)
- Check if willing to stop smoking and start nicotine replacement therapy.
- Referral for management of nutritional needs, if appropriate
- Consider carer stress and support available. Provide details of local support services
Polypharmacy guidance: Appropriate prescribing making medicines safe, effective and sustainable 2026-2029
