7 Steps process in bronchiectasis

A polypharmacy review (following the 7 Steps approach) should ensure optimal management of respiratory conditions, and include addressing aggravating lifestyle factors, consideration of the most appropriate medication at the right dose with regular review.

The 7 Steps to appropriate polypharmacy demonstrate that the review process is not a linear single event, but cyclical, requiring regular repeat and review as shown in the image below.

The circle is centred on what matters to the individual, ensuring they are provided with the right information, tools and resources to make informed decisions about their medicines and treatment options.

Step 1 - What matters to the patient?

Ask the patient what matters to them?
- chronic sputum production
- frequency of exacerbations
- breathlessness
- cough
Ask patient to complete PROMs (questions to prepare for my review) before their review
How does the condition affect patients' day to day life/activities
Side effects of medicines versus benefit
Patient’s awareness of the reason for taking medications
- antibiotics for exacerbations
- preventative treatments
- inhaled therapies
- mucolytics
A holistic Polypharmacy 7-Steps approach is recommended to ensure treatment is optimised giving consideration to co-morbidity

Step 2 - Identify essential drug therapy

Confirm ongoing need for and effectiveness of medication and screen for side effects
- all patients on long term macrolide should have assessment of hearing/tinnitus

Step 3 - Does the patient take unnecessary drug therapy?

Assess adherence and ensure patient understands treatment regime
Is there evidence of benefit from taking the treatment, e.g. reassuring physiology, maintaining exercise tolerance
Assess the benefit of mucolytic therapy – is it warranted?

Step 4 - Are therapeutic objectives being achieved?

Frequency of infective exacerbations
- is there a role for long term antibiotic therapy?
Ensure regular monitoring of physiology
Ensure sputum cultures are up to date. Discuss sputum cultures, including annual nontuberculous mycobacterial (NTM) cultures
Check antibiotic course duration is appropriate
Vaccinations should be offered if not up to date (influenza, pneumococcal, DTaP (if not vaccinated in adolescence) and Covid-19)
Patients should be encouraged to engage in appropriate physical activity. Social prescribing such as exercise dependant on ability, singing classes
Discuss Pulmonary Rehabilitation (PR)
Smoking cessation should be advised and the adverse effects of smoking on children highlighted. Offer appropriate support. Signpost patients to the NHS inform Quit Your Way Scotland website (which includes community pharmacy services)
Weight reduction is recommended in obese patients (BMI >30)
Nutritional advice and support will be necessary in those with a BMI less than 20

Step 5 - 5.Does the patient have ADRs/side effect or is at risk of side effects

Ensure regular drug monitoring as per local protocol
Review potential drug interactions which can potentiate side effects
Discuss side effect profile with perceived benefit of treatment
Confirm antibiotic allergy/side effect profile
- Consider referral for penicillin allergy de-labelling⁵² if available locally
Yellow card reporting of ADRs

Step 6 - Sustainability

Ensure drugs are either within current guidelines or have been discussed at a specialist multidisciplinary team meeting.
Course length of antibiotics?

Step 7 - Is the patient willing and able to take drug therapy as intended?

Are at-home antibiotics appropriate for the patient to enable self-management?
Make patient aware of support information
Non-attenders should be followed up – alternative strategies to encourage engagement may be required, (e.g. through community pharmacy/Near Me/telehealth, acknowledging limitations)
Agree with the patient arrangements for repeat prescribing. Signpost to Medicines Care and Review (MCR) service in community pharmacy.
Ask patient to complete the post-review PROMs questions after their review