Applying 7 Steps

Review diagnoses and identify therapeutic objectives

• Patient reports: In pain constantly, but especially when getting up from chair. Feel like I cannot catch my breath and needing to use salbutamol inhaler frequently. Manage the pain
• Therapeutic objectives: Pain and asthma management. Smoking cessation

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

• Inhalers to manage asthma. Patient complains of breathlessness and examination confirms that asthma treatment is suboptimal. Inhaler technique and suitability should be checked

Review need for unnecessary drugs  – consider stopping or reducing dose (deprescribe)

• Treatment dose PPI: check indication and aim for lowest dose to manage symptoms (deprescribe)
• Pain management: Pain is constant and in the low back with no referred pain or neurological effects. Gabapentin is not indicated so consider alternatives and dose reduction and withdrawal (deprescribe)
• Insomnia management: has taken long term zopiclone, which will no longer be effective and is causing symptoms. Dose reduction and withdrawal should be considered (Section 3.4)
• Depression management: discuss depression and review current treatment. Explore other support that may be available locally

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

• Pain control: Review expectations and current regimen in order to manage pain more appropriately. Existing treatments should be reduced and withdrawn before considering additional analgesia. Lack of success may be due to unrealistic expectations and lack of physical activity
• Insomnia control: review expectations and need for ongoing hypnotic
• Smoking cessation: Consider options for smoking cessation and referral for support
• Asthma control: ensure adequate treatment plan for asthma. There is over use of salbutamol suggesting under treatment. Review inhaler technique and use of preventative treatment. If these are appropriate then consider stepping up treatment

Identify patient safety risks

Identify adverse drug effects

• Actual ADR: drowsiness with zopiclone and drug to drug interaction with tramadol and gabapentin. Resulting cognitive impairment may effect activities such as driving
• Risk of dependence: zopiclone, gabapentin and tramadol
• Risk of overdose: high doses of analgesics and adjuvants increase potential for accidental overdose

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

Ensure prescribing in keeping with current formulary recommendations

Does the patient understand the outcomes of the review?

Ensure drug therapy changes are tailored to patient preferences

Agree and communicate plan

• Preferences and understanding:
  • Asthma management: struggles to remember to use preventer inhaler and relies of frequent use of reliever when feels short of breath. Management plan, education and support may help
  • Smoking cessation: patient doesn’t feel ready to stop and so ‘park’ this for now and review at some stage
  • Non-medication pain management: Signpost to other strategies patients can engage with for pain management. She is not yet convinced of the benefits so will require further encouragement
  • Medication reduction: patient agrees to a go slow approach to medication reduction and thinks that she will benefit from regular support and review