Domain Steps Process
Aims
1. Step1: Identify aims and objectives of drug therapy

Review diagnoses and identify therapeutic objectives with respect to:

  • Management of existing health problems.
  • Prevention of future health problems.
Need
2. Step 2: Identify essential drug therapy

Identify essential drugs (not to be stopped without specialist advice)

  • Drugs that have essential replacement functions (e.g. thyroxine)
  • Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)
3. Step 3: Does the patient take unnecessary drug therapy?

Identify and review the (continued) need for drugs

  • with temporary indications
  • with higher than usual maintenance doses
  • with limited benefit in general or the indication they are used for

with limited benefit in the patient under review (see NNT section)

Effectiveness
4. Step 4: Are therapeutic objectives being achieved?

Identify the need for adding/intensifying drug therapy in order to achieve therapeutic objectives

  • to achieve symptom control
  • to achieve biochemical/clinical targets
  • to prevent disease progression/exacerbation
Safety
5. Step 5: Does the patient have ADR or is at risk of ADRs?

Identify patient safety risks by checking for

  • drug-disease interactions
  • drug-drug interactions (see ADR table)
  • robustness of monitoring mechanisms for high-risk drugs
  • drug-drug and drug-disease interactions
  • risk of accidental overdosing

Identify adverse drug effects by checking for

  • specific symptoms/laboratory markers (e.g. hypokalaemia)
  • cumulative adverse drug effects (see ADR table)
  • drugs that may be used to treat ADRs caused by other drug
Cost effectiveness
6. Step 6: Is drug therapy cost effective?

Identify unnecessarily costly drug therapy by

  • Consider more cost-effective alternatives (but balance against effectiveness, safety, convenience)
Adherence/Patient centeredness
7. Step 7: Is the patient willing and able to take drug therapy as intended?

Identify risks to patient non-adherence by considering:

  • Is the medicine in a form that the patient can take?
  • Is the dosing schedule convenient?
  • Is the patient able to take medicines as intended?
  • Might the patient benefit from the Chronic Medication Service (CMS)?
  • Is the patient’s pharmacist informed of changes to regimen?


Ensure drug therapy changes are tailored to patient preferences by:

  • Discuss with the patient/carer/welfare proxy  therapeutic objectives and treatment priorities
  • Decide with the patient/carer/welfare proxies what medicines have an effect of sufficient magnitude to consider continuation or discontinuation