Domain |
Steps |
Process |
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Aims |
1. |
What matters to the patient |
Review diagnoses and identify therapeutic objectives with respect to:
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Need |
2. |
Identify essential drug therapy |
Identify essential drugs (not to be stopped without specialist advice)
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3. |
Does the patient take unnecessary drug therapy? |
Identify and review the (continued) need for drugs:
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Effectiveness |
4. |
Are therapeutic objectives being achieved? |
Identify the need for adding/intensifying drug therapy in order to achieve therapeutic objectives:
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Safety |
5. |
Does the patient have ADR/Side Effects or is at risk of ADRs/Side Effects?
Does the patient know what to do if they’re ill? |
Identify patient safety risks by checking for
Identify adverse drug effects by checking for
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Cost-effectiveness |
6. |
Is drug therapy cost-effective? |
Identify unnecessarily costly drug therapy by:
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Patient centeredness |
7. |
Is the patient willing and able to take drug therapy as intended?
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Does the patient understand the outcomes of the review?
Ensure drug therapy changes are tailored to patient preferences
Agree and Communicate Plan
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The 7-Steps medication review
![Polypharmacy icon of two pills](/media/1264/polypharmacy-icon.png)
The following 7-Steps are intended as a guide to structure the review process and are presented as:
- table 2a an overview of key considerations at each step
- table 2b an overview of therapeutic groups by each step
- table 2c provides greater detail on table 2b by therapeutic area and is an amalgamation of existing collections of medication assessment tools (START/STOP, DQIP and others)
N.B. No list can be comprehensive and the reviewers clinical judgement and experience continues to be essential in tailoring the advice given to the needs of an individual patient and to identify other additional medication related problems.
Step 1: (Aim) What matters to the patient.
- Identify aims and objectives of drug therapy by asking the patient what matters to you.
- Explain any key information such as laboratory markers
- Establish treatment objectives with patient through shared decision making
Step 2: (Need) Identify essential drug therapy.
- Separate the list of medicines which the patient is taking
- Ensure patient understand the importance of essential drug therapy
- All medication whether herbal, prescribed or traditional remedies should be included
Step 3: (Need) Does the patient take unnecessary drug therapy?
- For the remaining drugs, it should be verified that each has a function in achieving the therapeutic goals or outcomes that matter most to the patient
- Review preventative treatment to ensure the patient is able to continue taking medicine for required time to gain benefit (Drug Efficacy (NNT) table).
- Can lifestyle changes replace any unnecessary drug therapy?
Step 4: (Effectiveness) Are therapeutic objectives being achieved?
- Check treatment choice is the most effective to achieve intended outcomes
- If this is not the case, the possibility of patient non-adherence should be investigated as a potential explanation. Otherwise, the need for dose titration may also be considered. 50% of patients taking four or more medicines don’t take them as prescribed. (Medication Adherence: WHO Cares?).
Step 5: (Safety) Is the patient at risk of ADRs or suffers actual ADRs?
- The presence of ADRs can sometimes be identified from laboratory data (e.g. hypokalaemia from diuretic use)
- The patient may report such symptoms (including drug-drug and drug-disease interactions, but also the patient’s ability to self-medicate)
- Ask the patient specific questions (e.g. about the presence of anticholinergic symptoms, dizziness or drowsiness). If patient is experiencing ADRs, use Yellow Card Reporting.
Step 6: (Efficiency) Is drug therapy cost-effective?
- Opportunities for cost minimisation should be explored, but changing drugs for cost reasons should only be considered if effectiveness, safety or adherence would not be comprised.
- Ensure prescribing is in line with current formulary recommendations
Step 7: (Patient-Centred) Is the patient willing and able to take drug therapy as intended?
- Does the patient understand the outcome of the review?
- Ensure drug therapy is tailored to patient preferences
- Agree and communicate plan with patient and/or welfare proxy
- Even if adult lacks capacity, adults with Incapacity Act still requires that the adult's views are sought. "Adults with Incapacity Documentation" in place.
The 7-Steps to appropriate polypharmacy demonstrates that the patient review process is not in fact a linear one off event, but cyclical, requiring regular repeat and review. The circle is centred around what matters to the patient, as they play a vital part in making informed decisions about their medicines, as long as they provided with the right information, tools and resources.
Essential drug therapy – Only consider stopping following specialist advice |
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Discuss with expert before stopping |
Discuss with expert before altering |
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Potentially unnecessary drug therapy |
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Check for expired indication |
Check for valid indication |
Benefit versus Risk |
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Effectiveness |
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If therapeutic objectives are not achieved: Consider intensifying existing drug therapy |
For patients with the following indications: Consider if patient would benefit from specified drug therapy |
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Safety |
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Drugs poorly tolerated in frail adults |
High –risk clinical scenarios |
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See ADR table See “Sick day rules” cards
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Cost-effectiveness |
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Check for |
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Adherence/patient centredness |
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Check Self-Administration (Cognitive) |
Check Self-Administration (Technical) |
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The table below briefly provides the rationale behind targeting each drug or drug group as well as some practical guidance. It may be used as a reference while preparing for a face to face medication review. The list is an amalgamation of existing collections of explicit medication assessment tools (including START/STOPP, DQIP and others), but it is important to note that no list can be comprehensive and the reviewer’s clinical judgement and experience continue to be essential in tailoring the advice given to the needs of an individual patient and to identify any additional medication related problems.
Gastrointestinal system |
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1 |
PPIs |
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2 |
H2 blockers |
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3 |
Laxatives |
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4 |
Antispasmodics |
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Cardiovascular System |
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5 |
Anticoagulants |
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6 |
Antiplatelets |
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7 |
Diuretics |
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8 |
Spironolactone |
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9 |
Digoxin |
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10 |
Peripheral vasodilators |
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11 |
Quinine |
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12 |
Antianginals |
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13 |
Antiarrhythmic Amiodarone |
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14 |
Statins |
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15 |
BP Lowering Drugs |
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16 |
Beta-blockers |
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17 |
ACEI/ARBs |
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18 |
CCBs |
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19 |
Spironolactone |
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Respiratory System |
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20 |
Inhalers |
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21 |
Theophylline |
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22 |
Steroids |
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23 |
Antihistamines (1st Generation) |
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CAUTION: Anticholinergic ADRs. See Anticholinergics |
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Central Nervous System |
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24 |
Hypnotics and anxiolytics |
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25 |
Antipsychotics |
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26 |
Antidementia Drugs |
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27 |
Antidepressant Tricyclics |
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28 |
Metoclopramide |
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29 |
Antihistamines |
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30 |
Opioids |
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31 |
Paracetamol |
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32 |
Antiepileptics |
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Infections |
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32 |
Antibacterials (Oral)
Nitrofurantoin |
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33 |
Antifungals |
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Endocrine System |
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34 |
Antidiabetics |
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35 |
Metformin |
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Sulfonylureas |
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Glitazones |
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36 |
Steroids |
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37 |
Bisphosphonates |
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Genito-urinary system |
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39 |
Alpha-blockers |
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40 |
Finasteride |
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41 |
Antimuscarinics |
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42 |
Female Hormones |
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BNF Chapter 8: Malignant Disease and Immunosuppression |
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43 |
Cytotoxics etc. |
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BNF Chapter 9: Nutrition & Blood |
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44 |
Supplements |
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45 |
Potassium |
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Musculoskeletal System |
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46 |
NSAIDs |
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47 |
Skeletal Muscle Relaxants |
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48 |
DMARDs
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Eye, skin, nose & oropharynx |
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49 |
Drops, sprays, ointments |
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