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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.

 

 

Table 2a: An overview of the ‘7-steps’ with Links to section of greater detail

Domain

Steps

Process

  

Aims

1.

What matters to the patient

Review diagnoses and identify therapeutic objectives with respect to:

  • What matter to me (the patient)?
  • Understanding of objectives of drug therapy
  • Management of existing health problems
  • Prevention of future health problems
  
 

Need

2.

Identify essential drug therapy

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

  • Drugs that have essential replacement functions (e.g. levothyroxine)
  • Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)
  

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 for the indication they are used for  
  • With limited benefit in the patient under review (see Drug efficacy & applicability (NNT) table)
  

Effectiveness

4.

 

Are therapeutic objectives being achieved?

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

  • To achieve symptom control 
  • To achieve biochemical/clinical targets
  • To prevent disease progression/exacerbation
  

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

  • Drug-disease interactions
  • Drug-drug interactions (see ADR table)
  • Robustness of monitoring mechanisms for high-risk drugs
  • Drug-drug and drug-disease interactions 
  • Risk of accidental overdosing (see Yellow Card Scheme)

 Identify adverse drug effects by checking for

  • Specific symptoms/laboratory markers (e.g. hypokalaemia)
  • Cumulative adverse drug effects (see ADR table)
  • Drugs that may be used to treat ADRs caused by other drugs

Sick Day Rules Guidance

  
 

Cost-effectiveness

6.

Is drug therapy cost-effective?

Identify unnecessarily costly drug therapy by:

  • Consider more cost-effective alternatives (but balance against effectiveness, safety, convenience)
  

Patient centeredness

7.

Is the patient willing and able to take drug therapy as intended?

 

Does the patient understand the outcomes of the review?

  • Does the patient understand why they need to take their medication?
  • Consider Teach back

Ensure drug therapy changes are tailored to patient preferences

  • Is the medication in a form the patient can take?
  • Is the dosing schedule convenient?
  • Consider what assistance the patient might have and when this is available
  • Is the patient able to take medicines as intended?

Agree and Communicate Plan

  • 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
  • Inform relevant healthcare and social care carers change in treatments across the care interfaces
  

The 7-Steps to appropriate polypharmacy

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.

Table 2b: Drug groups for the ‘7-steps’ with Links to greater detail by Therapeutic Area

Essential drug therapy – Only consider stopping following specialist advice

Discuss with expert before stopping

Discuss with expert before altering
  • Diuretics - in LVSD (7)
  • ACE inhibitors - in LVSD (17)
  • Steroids
  • Heart rate controlling drugs
  • Anti-epileptics
  • Antipsychotics
  • Mood stabilisers
  • Antidepressants
  • DMARDs
  • Thyroid hormones
  • Amiodarone
  • Antidiabetics (34)
  • Insulin

 

Potentially unnecessary drug therapy

Check for expired indication

Check for valid indication

Benefit versus Risk
  • PPI(1) /H2 blocker  (2)
  • Laxatives (3)
  • Antispasmodics (4)
  • Oral steroid (22)
  • Hypnotics/anxiolytics (24)
  • H1 blockers (29)
  • Metoclopramide (28)
  • Antibacterials (oral/topical) (32)
  • Antifungals (oral/topical) (33)
  • Sodium/potassium suppl. (44, 45)
  • Iron supplements (44)
  • Vitamin suppl.(44)
  • Calcium/Vitamin D (44)
  • Sip feeds (44)
  • NSAIDs (46)
  • Drops, ointments, sprays etc. (49)
  • Anticoagulant (5)
  • Anticoagulant + antiplatelet (6)
  • Aspirin (6)
  • Dipyridamole (6)
  • Diuretics (7)
  • Digoxin (9)
  • Peripheral vasodilators (10)
  • Quinine (11)
  • Antiarrhythmics (13)
  • Theophylline (21)
  • Antipsychotics (25)
  • Tricyclic antidepressants (27)
  • Opioids (30)
  • Levodopa
  • Nitrofurantoin (32)
  • Alpha-blockers  (39)
  • Finasteride (40)
  • Antimuscarinics (urological) (41)
  • Cytotoxics/immunosuppressants (43)
  • Muscle relaxants (47)

Effectiveness                       

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
  • Laxative - Constipation (3)
  • Antihypertensives - BP control (15)
  • Antidiabetics - HbA1c control (34)
  • Warfarin - INR control
  • Rate limiting drugs - Heart rate?
  • Respiratory drugs – Symptoms?
  • Pain control
  • see Drug efficacy & applicability (NNT) table
  • CHD - Antithrombotic, statins, ACEI/ARB, beta blocker
  • Previous stroke/TIA - Antithrombotic, statin, ACEI/ARB
  • LVSD - Diuretic, ACEI/ARB, beta blocker
  • AF - Antithrombotic, rate control
  • DMT2 - Metformin
  • High fracture risk – Bone protection

Safety

Drugs poorly tolerated in frail adults

High –risk clinical scenarios

 

See Gold National Framework on frailty

  • Antipsychotics (incl. phenothiazines)
  • NSAIDs (46)
  • Digoxin (doses ≥ 250 micrograms) (9)
  • Benzodiazepines (24)
  • Anticholinergics (incl. TCAs) (27)
  • Combination analgesics

See ADR table

See “Sick day rules” cards

  • Metformin + dehydration
  • ACEI/ARBs + dehydration
  • Diuretics + dehydration  
  • NSAIDs + dehydration
  • NSAID + ACEI/ARB + diuretic
  • NSAID + CKD
  • NSAID + age >75 (without PPI)
  • NSAID + history of peptic ulcer
  • NSAID + antithrombotic
  • NSAID + CHF
  • Glitazone + CHF
  • TCA + CHF
  • Warfarin + macrolide/quinolone
  • ≥2 anticholinergics (see Anticholinergics)

Cost-effectiveness

Check for

 

 
  • Costly formulations (e.g. dispersible)
  • Costly unlicensed ‘specials’
  • Branded products
  • >1 strength or formulation of same drug
  • Unsynchronised dispensing intervals (28 or 56 day supplies)

Adherence/patient centredness

Check Self-Administration (Cognitive)

Check Self-Administration (Technical)
  • Warfarin/DOACs
  • Anticipatory care meds e.g. COPD
  • Analgesics
  • Methotrexate
  • Tablet Burden
  • Inhalers
  • Eye Drops
  • Any other devices
  • Bisphosphonates/Calcium

Table 2c: Information on targeted drugs (by BNF) with Links to section of greater detail

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

1

PPIs

 
  • If long term treatment is necessary, ensure dose does not exceed usual maintenance doses

 
  • CAUTION: Clostridium difficile, osteoporosis, hypomagnesaemia

2

H2 blockers

 

3

Laxatives

 
  • CAUTION: Vicious cycle of fluid loss > hypokalaemia > constipation
  • If >1 laxative, Do not stop abruptly. Reduce stimulant first and monitor effect
  • See advice here on non-pharmacological options

4

Antispasmodics

 
  • Rarely effective, rarely indicated long term

 
  • CAUTION: Anticholinergic side effects

Cardiovascular System

5

Anticoagulants

 
  • Check for expired indications (e.g. temporary loss of mobility  that has now resolved)

 
  • Much more effective for stroke prevention in AF than anti-platelets

 
  • CAUTION: Bleeding events. Avoid combinations of anticoagulants, anti-platelets and NSAIDs

 
  • Ensure patient adherence to dosing / monitoring regimen
  • If patient is unfit for warfarin for cognitive reasons (DOACs may not be indicated either)

6

Antiplatelets

 
  • NOTE: Anti-Platelets are no longer indicated for primary prevention of CHD

 
  • Aspirin plus clopidogrel indicated for maximum 12 months after ACS only

 
  • CAUTION: Bleeding events. Avoid combinations of anticoagulants, antiplatelets and NSAIDs
  • Consider PPI in those with additional GI risk factors (consider lansoprazole or pantoprazole in preference to (es)omeprazole in patients taking clopidogrel)

 
  • Consider anti-platelets as part of secondary prevention strategy after CVD events
  • First line anti-platelet for secondary stroke prevention is clopidogrel (rather than dipyridamole)

7

Diuretics

 
  • Usually essential for symptom control in heart failure
  • Note: Not indicated for dependent ankle oedema (consider medication causes, e.g. CCBs)

 
  • CAUTION: AKI and electrolyte disturbances

 
  • Advise patient to stop during intercurrent illness (See Sick Day Rule Cards); is U&E monitoring robust?

8

Spironolactone

 
  • CAUTION: Hyperkalaemia. Risk factors include CKD (CI if eGFR<30ml/min), dose >25 mg daily, co-treatment with ACEI/ARBs, amiloride, triamterene, potassium supplements

9

Digoxin

 
  • CAUTION: Toxicity. Risk factors are: CKD, dose>125 micrograms daily, poor adherence, hypokalaemia, drug-drug interactions

10

Peripheral vasodilators

 
  • Rarely effective; rarely indicated long term

11

Quinine

 
  • Use short term only when nocturnal leg cramps cause regular disruption of sleep

 
  • Review effectiveness regularly

 
  • CAUTION: Thrombocytopenia, blindness, deafness

 

12

Antianginals

 
  • Consider reducing antianginal treatment if mobility has decreased
  • CAUTION: Hypotension (consider use of other BP lowering drugs; avoid the combination of nitrates with PDE-5 inhibitors) 

13

Antiarrhythmic

Amiodarone

 
  • In AF: Rate control usually has better benefit/risk balance than rhythm control

 
  • CAUTION: Overdosing. Maintenance should be max 200mg/day
  • CAUTION: Thyroid complications. Ensure monitoring tests are being done
  • Monitor LFTs 

14

Statins

 
  • Recommended for primary and secondary prevention in patients at high risk of CVD

 
  • CAUTION: Rhabomyolysis: Check interactions (e.g. fibrates, dihydropyridines, antiinfectives)

 
  • Consider need for and intensity of treatment in light of life expectancy and ADR risk

15

BP Lowering Drugs

 
  • Limited evidence supporting tight BP control in older frail group

 
  • Individualise BP targets for primary and secondary prevention of CVD guidelines

 
  • Consider need for and intensity of treatment in light of CVD risk life expectancy and ADR risk

16

Beta-blockers

 
  • Usually essential for rate and angina control in CHD and CHF (and often in AF)

 
  • BNF recommends up-titration of beta-blockers dose in CHF to evidence based target doses

 
  • CAUTION: Bradycardia in combination with diltiazem/verapamil, digoxin and amiodarone

17

ACEI/ARBs

 
  • Usually essential for symptom control in CHF. For other potential benefits: see NNT table

 
  • BNF recommends up-titration of ACEI/ARB doses in CHF to evidence based target doses

 
  • CAUTION: Acute Kidney Injury. Avoid combination with NSAIDs and advise patient to stop when at risk of dehydration (See Sick Day Rule Cards)

18

CCBs

 
  • CAUTION: Constipation, ankle oedema
  • Dihydropyridines – CAUTION: Reflex tachycardia/cardiodepression: Avoid nifedipine in CHD/CHF
  • oDiltiazem/verapamil – CAUTION: Bradycardia in comb. with beta-blockers or digoxin (digoxin levels increased)

19

Spironolactone

 
  • Recommended in moderate to severe CHF: See NNT table

 
  • CAUTION: Hyperkalaemia. Risk factors CKD, combination with ACEI/ARB, triamterene, amiloride

 
  • CAUTION: AKI. Avoid combination with NSAIDs and advise patient to stop when at risk of dehydration

Respiratory System

20

Inhalers

 
  • Assess symptom control (SIGN 153 recommends : ask about frequency of inhaler use/adherence)

 
  • Assess inhaler technique and adherence to dosing schedule
  • Also see NHS Scotland Respiratory Prescribing Strategy

21

Theophylline

 
  • Monotherapy in COPD is not appropriate – safer, more effective alternatives are available

 
  • CAUTION: Toxicity (tachycardia, CNS excitation)
  • Avoid combination with macrolides and quinolones

22

Steroids

 
  • Long term oral use for respiratory disease is rarely indicated
  • Withdraw gradually if: use >3 weeks, >40 mg prednisolone/d
  • When stepping down use of steroid inhalers: Reduce dose slowly (by 50% every 3 months)

 
  • CAUTION: Osteoporotic fractures: Consider bone protection if long term treatment necessary
  • Ensure use of steroids aligned with COPD GOLD guideline

23

Antihistamines (1st Generation)

 
  • Rarely indicated long term

 

CAUTION: Anticholinergic ADRs. See Anticholinergics

Central Nervous System

24

Hypnotics and anxiolytics

 
  • CAUTION: Risk of falls/fractures, confusion, memory impairment
  • See Section 3.4 for specific information on benzodiazepines and Z drugs withdrawal,  and see insomnia guidelines here
  • CAUTION: Risk of dependency

25

Antipsychotics

 
  • CAUTION: Risk of stroke and death in elderly patients with dementia See Antipsychotics
  • CAUTION: Anticholinergic ADRs for phenothiazines (e.g. chlorpromazine). See Anticholinergics
  • CAUTION: Worsening of Parkinson’s disease (specialist advice is recommended)

 

26

Antidementia Drugs

 
  • Formally assess benefit: Continue if drug benefits global, functional or behavioural symptoms
  • Cognitive scores e.g. MMSE can help as a guide but should not rely only on cognition scores if these are inappropriate in the individual patient e.g. communication, language difficulty. See NICE Guidance.   

27

Antidepressant Tricyclics

 
  • Confirm need (First episode: Treat for 6-9 months; Second + episode: Treat for ≥2 years)

 
  • CAUTION: Anticholinergic ADRs. See Anticholinergics. SSRIs are better tolerated in the elderly
  • CAUTION: Risk of GI bleeding may be increased
  • Avoid combination with MAOIs because of the risk of serotonin syndrome

28

Metoclopramide

 
  • Now only licensed for a maximum of 5 days (does not apply to off label use in palliative care)

 
  • CAUTION: Worsening of Parkinson’s disease (domperidone is more suitable but note contra-indications in cardiac disease and severe liver disease)

29

Antihistamines

 
  • Rarely indicated for long term treatment of vertigo

 

30

Opioids

 
  • Assess effectiveness/choice (is pain neuropathic or otherwise not responsive to opiates? e.g. chronic back pain, widespread pain, fibromyalgia, medically unexplained symptoms)

 
  • CAUTION: Constipation. Use laxatives
  • CAUTION: Cognitive impairment and respiratory depression, dependency, immunosuppression and suppression of sex hormones

31

Paracetamol

 
  • CAUTION: Overdosing
  • Ensure patient is aware of minimum interval between doses and maximum daily dose
  • Avoid more than 1 paracetamol containing product
  • Dose reduction where low body weight [<50kg]or renal or hepatic impairment

32

Antiepileptics

 
  • Assess effectiveness/dose if used for pain management: Is pain neuropathic, use DN4 or LANSS to aid diagnosis. Titrate dose up to assess effectiveness. Limited evidence for musculoskeletal pain/fibromyalgia) See SIGN 136

 
  • CAUTION: Dizziness, blurred vision and sedation. Check renal function. Reduce dose in CKD.

Infections

32

Antibacterials (Oral)

 

 

 

Nitrofurantoin

 
  • Evidence of no benefit for treating asymptomatic bacteriuria (ASB) in diabetes or older adults
  • Review use of long term antibiotics for recurrent UTI (every 6 months)
  • Lack of evidence for antibiotic use in preventing catheter-associated ASB

 
  • CAUTION: Pulmonary/renal ADRs; avoid in renal impairment; contraindicated if eGFR<30ml/min

33

Antifungals

 
  • CAUTION: Risk of exacerbation of heart failure with azole antifungals.
  • CAUTION:  Many serious drug interactions with azole antifungals.

Endocrine System

34

Antidiabetics

 
  • Indicated to control symptoms of hyperglycaemia (metformin is first line in DMT2)

 
  • NOTE: It takes years for the benefit (mostly microvascular risk) of tight HbA1C control to accrue. Establish individual HbA1C targets balancing any benefits vs hypoglycaemia risk. See NNT Table

35

Metformin

 
  • CAUTION: Risk of lactic acidosis. Avoid if eGFR < 30 ml/min. Stop when at risk of dehydration

Sulfonylureas

 
  • CAUTION: Hypoglycaemia: Active metabolites can accumulate when renal function is impaired

Glitazones

 
  • Avoid in patients with heart failure

36

Steroids

 
  • Rarely indicated for long term use. Consider dose reduction/withdrawal where possible

37

Bisphosphonates

 
  • Consider need for treatment in light of risk factors for osteoporotic fractures: previous osteoporotic fragility fracture, parental history of hip fracture, alcohol intake ≥ 4 units/d, rheumatoid arthritis, oral steroids, BMI<22kg/m2), ankylosing spondylitis, Crohn’s disease, prolonged immobility, untreated menopause. See NNT table

 
  • Check patient’s ability and willingness to take bisphosphonates (and calcium) as instructed
  • If the patient has been taking a bisphosphonate for osteoporosis for at least 3 years, discuss the option of discontinuing. There is no consistent evidence of benefit or harm of continued use after at least 3 years therapy. See NICE guidance. Continue calcium and vitamin D supplements.
  • There are no current guidelines for bisphosphonate holidays/discontinuation in the UK. See NICE Multimorbidity guidance
  • There is no evidence to guide monitoring after discontinuation of bisphosphonate therapy
  • Women who stop alendronate after 5 years rather than continuing for 10 years show moderate decline in bone mineral density and a gradual rise in biochemical markers but no high fracture risk except clinically asymptomatic fractures.
  • Women at high fracture risk may benefit from continuing alendronate beyond 5 years but this should be a considered decision rather than automatic continuation

Genito-urinary system

39

Alpha-blockers

 
  • Generally not indicated if patient has a long term catheter

40

Finasteride

 
  • Generally not indicated if a patient has a long term catheter – discuss with Urology re: stopping

41

Antimuscarinics

 
  • Review continued need/effectiveness after 3 to 6 months

 
  • CAUTION: Anticholinergic ADRs (oxybutynin may decrease MMSE score in people with dementia)

42

Female Hormones

 
  • NOTE: There is no cardio-protective effect or cognitive protection in older women

 
  • CAUTION: Carcinogenic potential in breast and endometrium

 
  • Discuss with patient individual balance of benefits and risk

BNF Chapter 8: Malignant Disease and Immunosuppression

43

Cytotoxics etc.

 
  • Is treatment still consistent with treatment objectives? Refer to prescriber who initiated treatment

BNF Chapter 9: Nutrition & Blood

44

Supplements

 
  • Confirm continued need/effectiveness after 3 to 6 months
  • Monitor weight

45

Potassium

 
  • CAUTION: Hyperkalaemia. Risk factors: Use without stop/review date, CKD, co-treatment with ACEI/ARBs, spironolactone, amiloride, triamterene, trimethoprim)

Musculoskeletal System

46

NSAIDs

 
  • CAUTION: Gastro-intestinal ADRs (Risk factors: age>75, GI ulcer, antithrombotics, steroids, SSRIs, high alcohol use)
  • If NSAIDs are essential: Consider gastro-protection with a PPI in those with GI risk factors
  • CAUTION: Cardiovascular ADRs (Risk factors: CVD risk>20%, previous CVD events, heart failure)
  • CAUTION: Renal ADRs (Risk factors: age>65, on ACEI, ARBs and/or diuretics, CKD or heart failure
  • If NSAIDs are essential: Monitor eGFR; advise patient to stop during intercurrent illness

47

Skeletal Muscle Relaxants

 
  • Rarely indicated long term (except for spasticity)

 
  • CAUTION: Anticholinergic ADRs

48

DMARDs

 

 
  • Assess effectiveness and discuss any need for changes with secondary care specialist

 
  • Ensure patient adherence to dosing/monitoring regimen

 
  • CAUTION: Methotrexate overdosing. Avoid preparations with different strengths

Eye, skin, nose & oropharynx

49

Drops, sprays, ointments

 
  • Set a review/stop date for topical antibacterial/antifungal and sympathomimetic preparations

 
  • Review need for preservative free eye drops (e.g. previous preservative toxicity)