7 Steps process in idiopathic pulmonary fibrosis

Respiratory : Quality prescribing strategy - a guide for improvement
Scottish Government Effective Prescribing & Therapeutics Division
Polypharmacy icon of two pills

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. 
  • Ask patient to complete Patient Reported Outcomes Measures (PROMs) (questions to prepare for my review) before the review
  • How does the condition affect patient’s day to day life / activities
    • cough interfering with ability to work
  • Patient awareness of the reason for taking medications- to preserve lung function with anti-fibrotic treatment
  • Patient awareness of side effect profiles of medicines versus benefit
  • Pulmonary Rehabilitation (PR)
  • Discuss monitoring oxygenation when mobilising

 

Step 2 - Identify essential drug therapy

  • Assess adherence
  • Confirm ongoing need for and effectiveness of medication and screen for side effects
  • Ensure therapy is optimised with no drug interaction

 

Step 3 - Does the patient take unnecessary drug therapy?

  • Is there evidence of benefit from taking the treatment, e.g. reassuring physiology, maintaining exercise tolerance?

 

Step 4 - Are therapeutic objectives being achieved?

  • Halted rate of decline of lung function
  • Ensure regular monitoring of physiology
  • Review oxygenation at rest and on mobilizing
  • Medication should be titrated to a dose which balances maximum clinical efficacy with minimal risk and stopped if found to be ineffective or if adverse effects outweigh benefits
  • Once the dose is stable and effectiveness has been established, ongoing recorded review should occur as clinically appropriate for the individual patient, bearing in mind that side effects can develop after established on therapy
  • Vaccinations should be offered if not up to date (influenza, pneumococcal, DTaP (if not vaccinated in adolescence) and Covid-19)
  • Can the patient use their inhaler properly?
  • Patients should be encouraged to engage in appropriate physical activity. Social prescribing such as exercise dependent on ability, singing classes  
  • 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 - Does the patient have ADRx/side effect or is at risk of side effects

  • Discuss side effect profile with perceived benefit of treatment - often patients may not be aware that side effects are related to the drug treatment
  • Ensure regular drug monitoring as per local protocol
  • Consider additional therapy to control side effects e.g. loperamide for GI upset, morphine for cough
  • Review potential drug interactions which can potentiate side effects
  • Yellow card reporting of ADRs 

 

Step 6 - Sustainability

  • Discuss dispensing options with patient e.g., potential home delivery schemes
  • Ensure that drug is either within current guidelines or has been discussed at a regional IPF multidisciplinary team

 

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

  • A personalised action plan is key to this approach, with focus on maintain lung function, preserving quality of life
  • Agree with the patient arrangements for repeat prescribing. Signpost to Home care delivery arrangements / Medicines Care and Review (MCR) service in community pharmacy
  • 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
  • Ask patient to complete the post-review PROMs questions after their review