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.
Before embarking on a clinical medication review it is helpful to establish the aims and objectives of drug therapy on the basis of the information available, i.e. patient demographics, medical and drug history, laboratory markers, social situation. Based on this information, likely treatment objectives can often be identified, but require agreement with the patient (see step 7).
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)
A rational first step of the medication review is to separate the list of drugs the patient is currently taking into those that are essential and should usually not be stopped from those that could potentially be stopped. Essential drugs in this respect are those that have a replacement function or may cause rapid symptomatic decline or loss of disease control.
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)
For the remaining drugs, it should be verified that each has a function in achieving the above defined therapeutic objectives and whether their use is supported by a sufficient evidence base. In addition to stopping drug therapy with expired indications, the continued need for prophylactic treatments in patients with a short life expectancy should be considered.
Step 4: Are therapeutic objectives being achieved?
Identify the need for adding/intensifying drug therapy in order to achieve therapeutic objectives
The next step is to check whether the remaining drugs are the most effective for the indication they are used for and whether they are actually achieving what they are intended to achieve. If this is not the case, the possibility of patient nonadherence should be investigated as a potential explanation. Otherwise, the need for intensifying doses or adding or replacing drugs may also be considered.
Step 5: Does the patient have ADR or is at risk of ADRs?
The presence of ADRs can sometimes be identified from laboratory data (e.g. hypokalaemia from diuretic use), or the patient reports such symptoms. However, ADR identification often requires a more pro-active approach of identifying ADR risks (including drug-drug and drug-disease interactions, but also the patient’s ability to selfmedicate) and asking the patient specific questions (e.g. about the presence of anticholinergic symptoms, dizziness or drowsiness).
Step 6: Is drug therapy cost effective?
Identify unnecessarily costly drug therapy by
Consider more cost-effective alternatives (but balance against effectiveness, safety, convenience)
Costly formulations ( dispersible)
Costly unlicensed ‘specials’
>1 strength of same drug
Unsynchronised dispensing intervals (28 or 56 day supplies)
Opportunities for cost minimisation should be explored, but changing drugs for cost reasons should only be considered if effectiveness, safety or adherence are not comprised.
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
Assessment of adherence has been mentioned in steps 4 and 5 as a way to explain drug therapy failure or identify drug therapy risks, but this steps aims at optimising the drug regimen so that adherence is as easy as possible. In order to maximise their involvement and cooperation, patients should be explicitly asked what they hope to achieve from drug therapy and be empowered to make decisions regarding effectiveness versus safety as well as symptom control versus longevity.