Polypharmacy icon of two pills

1. What matters to the patient

Review diagnoses and identify therapeutic objectives

  • Manage the breathlessness
  • Manage heart failure
  • Manage the use of preventative treatments
  • Minimise medication related harm
  • Help patient quit smoking

2. Need

Review need for essential drugs (stop only on expert advice)

  • None
  • The drugs for symptomatic deterioration of moderate heart failure need to be titrated for optimal benefit

3. (Continued) Need For Drugs

Identify non-essential drugs and review continued need – consider stopping or reducing dose (deprescribe)

  • Proton pump inhibitor: review need and identify indication for use if possible. If symptomatic then use lowest dose to manage symptoms (maintenance dose is 15 mg/day)
  • Heart failure: examination indicates that shortness of breath is more likely to be due to heart failure than airways disease. Consider stopping salbutamol inhaler
  • Trazodone: Good candidate for dose reduction (desprescribing) as is drowsy in the mornings (See 3.3)

4. Effectiveness

Identify if therapeutic objectives are being met and whether therapy should be added or intensified

  • Heart failure: In order to manage symptoms consider titrating all relevant medicines whilst balancing benefit with increased risk of ADRs. Monitor pulse and U+Es

5. Safety

Identify patient safety risks

Identify adverse drug effects

  • Actual ADR: over sedation
  • Actual ADR: amlodipine contribution to ankle swelling
  • Actual ADR: anticholinergic effect of tolterodine may contribute to confusion. Are there other anticholinergic symptoms? Review whether tolterodine is providing benefit and consider stopping (deprescribe)
  • Drug-drug interaction: simvastatin and amlodipine. Reduce dose of amlodipine as ACEI is added and dose titrated
  • Drug-drug interaction: clopidogrel and omeprazole. Review need for clopidogrel. Consider switching to lansoprazole 15mg or H2 receptor antagonist
  • Risk of fallsand fractures: over sedation
  • Sick Day Rules guidance: Ensure staff have clear information on drugs to withhold if dehydrated, especially if ACEI added

6. Cost-effectiveness

Opportunities for cost minimisation (e.g. generic substitution) should be explored

Ensure prescribing in keeping with current formulary recommendations

7. Patient centeredness

Are the outcomes of the review understood?

Are changes tailored to patient preferences

Agree and communicate plan

  • Preferences and understanding:
    • May need support with inhaler and inhaler technique if continuing treatment
    • Ensure patient understands breathlessness is due to heart failure rather than asthma
    • Ensure patient and care home staff understand the reason for medication changes, i.e. increase in bisoprolol and addition of ACE Inhibitor
    • Consider options for smoking cessation