Polypharmacy - 7 Steps process

The 7-Steps person-centred medication review process can be used at both initiation of new medications and when reviewing existing treatments, including non-pharmacological approaches. This process ensures a shared decision-making approach to prescribing, with discussion of risks and benefits of treatments and enable safe, sustainable and effective person-centred care.

The following 7-Steps are intended as a guide to structure the review process.

Step 1: Aim: What matters to the person?

Step 2: Need: Identify essential drug therapy.

Step 3: Need: Does the person take unnecessary drug therapy

Step 4: Effectiveness: Are therapeutic objectives being achieved?

Step 5: Safety: Is the person at risk of ADRs or suffers actual ADRs?

Step 6: Sustainability: Is therapy cost-effective and environmentally sustainable?

Step 7: Patient-centred: Is the person willing and able to take therapy as intended?

The 7-Steps to appropriate polypharmacy demonstrate that the review process is not in fact a linear single event, but cyclical, requiring regular repeat and review (see figure below). The circle is centred on what matters to the individual, ensuring they are provided with the right information, tools and resources to make informed decisions about their medicines and treatment options. It should be used at both initiation and review of medicines.

Image showing 7 steps cycle

See case studies for examples of applying the 7-step medication review process.

The following 7-Steps are intended as a guide to structure the review process. They are also available as a pdf by clicking on the image below.

Step 1 - Aims - What matters to the individual about their condition(s)?

Process

Review diagnoses and consider:

Therapeutic objectives of drug therapy
Management of existing health problems
Prevention of future health issues, including lifestyle advice

Ask individual to complete PROMs (questions to prepare for my review) before their review

Person specific issues to address

Ensure person-centred approach
Consider non-pharmacological options where appropriate
Before initiation of treatment discuss the risk of dependency / withdrawal reaction with use

Step 2 - Need - Identify essential drug therapy

Process

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

Drugs that have essential replacement functions
Drugs to prevent rapid symptomatic decline

* with advice from healthcare professional with specialist interest

Person specific issues to address

Although not classed as an essential medicine, prescribers should be aware of the potential for dependence and withdrawal reaction with these medicines

Step 3 - Does the patient take unnecessary drug therapy?

Process

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

consider non-pharmacological approaches where appropriate, either alone or as an adjunct to medicines (e.g. CBT)
if first episode of depression treated for six months and course complete, consider managed reduction and stop
Ensure optimum dose of therapy e.g. 20’s plenty (fluoxetine, citalopram) or 50’s enough (sertraline) for depression

Step 4 - Effectiveness - Are therapeutic objectives being achieved?

Process

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

With SSRIs there is limited additional benefit and increased risk of adverse effects with increasing doses (see dose response curve). Review and decrease dose where appropriate
If no response to optimal dose within two to four weeks consider change to alternative medication, rather than increase dose further
Consider non-pharmacological approaches

Step 5 - Safety - Does the patient have or is at risk of ADRs/side effects? Does the person know what to do if they are ill??

Process

Identify individual safety risks by checking for

appropriate individual targets
drug-disease interactions
drug-drug interactions (see ADR table)
monitoring mechanisms for high-risk drugs
risk of accidental overdosing

Identify adverse drug effects by checking for

specific symptoms/laboratory markers
cumulative adverse drug effects (see ADR table)
drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Person specific issues to address

Consider combinations of high-risk medications e.g. NSAIDs and SSRIs
Some antidepressants can have a high anticholinergic burden that can be additive
Consider the increased potential for harm in combination with other CNS depressants
Co-prescribing of benzodiazepine or z-drugs for antidepressant induced insomnia is no longer recommended
Co-prescribing of two antidepressant agents for depression should be for specialist initiation only

Step 6 - Sustainability - Is drug therapy cost-effective and environmentally sustainable??

Process

Identify unnecessarily costly drug therapy by

considering more cost-effective alternatives, safety, convenience

Consider the environmental impact of

Inhaler use
Single use plastics
Medicines waste
Water pollution

Person specific issues to address

Are all medicines formulary choices?
Advise to dispose of medicines through community pharmacy to ensure safe disposal
Medicines should not be disposed of in household waste, pouring down sink or flushing down toilet
Advise to only order what is needed, do not stockpile medicines

Step 7 - Person-centeredness - Is the patient willing and able to take drug therapy as intended?

Process

Does the person understand the outcomes of the review?

Consider teach-back

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 individual to complete the post-review PROMs questions after their review

Agreed plan

Consider review period for management of depression
If there is dosage reduction, agree a reduction plan and agree with individual to prevent withdrawal
Signpost appropriate non-pharmacological support and resources (e.g. NHS Inform)

Key concepts in this case

Take a holistic person-centred approach with regular reviews of treatment
Consider the use of non-pharmacological options where appropriate
For a polypharmacy review, if reviewing existing treatment prior to initiation of antidepressant medicines, use read code 8B31B Polypharmacy medication review.