Polypharmacy icon of two pills

Background details  - age, sex, occupation, baseline function

  • Male
  • Age 78
  • MRC Grade 4 shortness of breath

History of presentation/reason for review

  • Presented to clinic with persistent cough which impacted on his ability to work
  • Slow progression of condition

Current medical history and relevant co-morbidities

  • No previous medical history, previously fit and well

Current medication and drug allergies (include OTC preparation and herbal remedies)

  • Struggled to tolerate therapy, with multiple side effects but treatment eventually established - had to switch from pirfenidone to nintedanib
  • Opiates (morphine sulfate 10mg/5ml oral solution, 2.5ml) to control cough/breathlessness due to progression
  • Oxygen (maintain saturation/promote mobility)

Lifestyle and current function (incl. frailty score for >65yrs) alcohol/smoking/diet/exercise

  • Condition slowly progressed – required opiates to control breathlessness

Results e.g. biochemistry, other relevant investigations or monitoring

  • Investigations confirmed IPF
  • Monitored at clinic - when lung function showed evidence of progression antifibrotic treatment started

Most recent consultations

  • Despite progressive condition and high symptom burden he was able to maintain a reasonable quality of life, socialising, spending time with family, travelling and painting.

 

7 Steps: Person specific issues to address for asthma case study 

1.  Aims: What matters to the individual about their condition(s)?

Review diagnoses and consider:

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

Ask patient to complete PROMs questions to prepare for my review before their review

Person specific actions

  • Persistent cough, impacting ability to work
  • Slow progression of condition

 

2.  Need: 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)

Person specific actions

  • Nintedanib, started by specialist respiratory consultant to reduce loss of lung function

 

3.  Need: Does the individual take unnecessary drug therapy?

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 actions

  • None

 

4.  Effectiveness: Are therapeutic objectives being achieved?

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 actions

  • Cough and breathlessness symptoms due to progression of IPF controlled by addition of opiates (morphine sulfate 10mg/5ml solution, 2.5ml dose)
  • Oxygen therapy to maintain saturation and promote mobility

 

5.  Safety: Does the individual have or is at risk of ADR/ side effects? Does the person know what to do if they’re ill?

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 actions

  • Side effect profiles for the anti-fibrotic drugs differ and previous therapy not tolerated due to side effects. Now established on nintedanib. Side effects associated with nintedanib are liver injury, blood monitoring required
  • Common side effects of nintedanib are diarrhoea, nausea, abdominal pain, weight loss and decreased appetite

 

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

Identify unnecessarily costly drug therapy by

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

Consider the environmental impact of

  • Inhaler use
  • Single use plastics
  • Medicines waste
  • Water pollution 

Person specific actions

  • Anti-fibrotic therapy is monitored and reviewed by specialist IPF teams

 

7.  Patient centeredness: Is the patient willing and able to take drug therapy as intended?

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
  • agree with them what medicines have an effect of sufficient magnitude to consider continuation or discontinuation
  • inform relevant health and social care providers of changes in treatments across the transitions of care

Ask patient to complete the post-review PROMs questions after their review

Agreed plan

  • Continued treatment with nintedanib
  • Opiate use for control of cough and breathlessness symptoms
  • Oxygen for mobility