Polypharmacy prescribing guidance - draft: consultation

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

• Feels tired and short of breath
• Carers wish to reduce sedation and improve his ability to interact socially
• Reduce ankle swelling, and falls risk

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)

• None

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 and applicability (NNT) table)

• Thiamine: may be redundant if no alcohol intake
• Bendroflumethiazide: no longer hypertensive. Potential for withdrawal
• Tramadol: indication unclear (may have been started after surgery)
• Trazodone or amisulpride: indication unclear. Consider withdrawal if not agitated
• Antihistamine and emollient: clarify cause of itch i.e. dermatological, CNS problem or ADR. If dermatological problem, consider non-pharmacological measures e.g. attention to washing powder, natural fabrics, etc. as well as regular use of simple emollients in sufficient quantity
• Antimicrobial cream: should only be used short-term - stop

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?

• Thyroid function: check TFTs and correct hypothyroidism if present
• Ankle swelling and shortness of breath: consider presence of LVSD. Potentially highly effective treatment available (ACE/ARB, beta blocker) if present. Consider ECG, BNP, ECHO
• Reduce falls and fracture risk: mainly associated with sedative load; could consider fracture risk modification with osteoporosis prevention (e.g. bisphosphonates). Decision to treat needs to be balanced against expected efficacy (see NNT table) and ability to comply with treatment. Dental health needs to be considered. Unlikely to have time to benefit if life expectancy felt to be less than one year

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• Ensure discussion and clear information on which medicines to withhold at times of dehydrating illness

• Actual ADR: over sedation

• Risk of CVD events: antipsychotics have increased risk of CVD events in dementia
• Risk of cognitive deterioration: antipsychotics, antihistamines, tramadol
• Risk of falls and fractures: antipsychotics, antidepressant, antihistamines
• Risk of serotonin syndrome: tramadol and trazodone
• Risk of steroid adverse effects: high dose topical steroid
• ACB burden score 4 increases risk of falls, confusion
• Medication Sick Day Guidance: ensure staff have clear information on medicines to withhold if dehydrated (in this case bendroflumethiazide)

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal

Water pollution

• All medicines are formulary choices
• Care home advised to dispose of medicines through community pharmacy and advised to only order what is needed

Does the person understand the outcomes of the review?

• Consider Teach back
• Involve the adult where possible. If deemed to lack capacity, discuss with relevant others, e.g. welfare guardian, power of attorney, nearest relative if one exists. Even if adult lacks capacity, adults with Incapacity Act still requires that the adult’s views are sought. Ensure “Adults with Incapacity Documentation” in place

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?
• 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
• include lifestyle and holistic management goals
• 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

• Stop:

- bendroflumethiazide

- thiamine

- Fucibet® cream

• Reduce trazodone and amisulpride to decrease sedation and falls/fracture risk
• Reduce and review:

- tramadol

- cetirizine

• Review the need to start bisphosphonate and calcium/vitamin D, taking a person-centred approach

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

• Continence
• Burden of medication
• Improvement in function where possible

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)

• Levothyroxine: check thyroid function tests to ensure correct dose

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 and applicability (NNT) table)

• Edoxaban and clopidogrel: no indication for combination. High bleeding risk in combination
• Alendronic acid: completed eight years treatment. Further years of treatment of questionable benefit. Note CrCl 20ml/min, therefore alendronic acid not appropriate. Cognition/frailty will influence choice of other bone protection
• Zopiclone: night sedation, long-term use not recommended
• Mirtazapine: antidepressant with sedative effects
• Atorvastatin: consider ongoing benefit of high dose statin.

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?

• Consider and discuss how medicines are being managed as with such a large list of medicines, adherence may be difficult
• Tolterodine: continence major issue therefore review effectiveness and stop if not beneficial
• Shortness of breath affecting mobility. Consider if uncontrolled heart failure or other treatable cause
• Consider ongoing therapeutic management of osteoporosis in context of frailty

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• High risk combination of edoxaban and clopidogrel: excessive blood thinning
• Edoxaban dose too high. Reduce to 30mg as weight less than 61kg. Note reduced renal function and not licensed when CrCl less than 15 ml/min
• Diabetes:
  • blood glucose control too tight.
  • Hypoglycaemia more likely with gliclazide and could be contributing to episodes of confusion and variable cognitive function.
  • Metformin: low creatinine clearance, therefore not indicated
• Blood pressure control too tight with postural drop, review perindopril and indapamide. Note perindopril indicated for reno-protection in T2DM
• Zopiclone and mirtazapine: risk of falls and sedation
• Levothyroxine without recent TFTs. Check to ensure correct dose
• Digoxin in presence of excessive bradycardia. Reduce dose and consider checking digoxin levels due to impaired renal function
• Alendronic acid: not indicated with eGFR less than 35 ml/min
• Tolterodine: anticholinergic and concern over worsening cognitive function
• Paracetamol: reduce dose as weight less than 50kg

Medication Sick Day Guidance: advice given for perindopril and gliclazide (if continued)

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal

Water pollution

• All medicines are formulary choices
• Advised to dispose of medicines through the community pharmacy
• Advised to only order what is needed, do not stockpile medicines

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
• include lifestyle and holistic management goals
• 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

• Stop:

• alendronic acid
• clopidogrel
• metformin
• perindopril and indapamide. Note before stopping perindopril, ensure symptoms are not due to heart failure. Aggressive treatment of albuminuria outweighed by potential problems with low blood pressure

• Reduce:

• Paracetamol to 500mg four times a day
• Digoxin and check level. Stop if pulse remains less than 65bpm
• Gliclazide or stop with follow up
• Atorvastatin or stop to reduce tablet burden
• Zopiclone. Discuss the risk and benefit of night sedation and option to gradually reduce with an aim to stop

• Review mirtazapine: check indication and efficacy and withdraw if unclear
• Review levothyroxine dose: check TFTs
• Review tolterodine and trial stopping to assess effectiveness
• Discuss oral calcium/vitamin D supplement and option of alternative formulation
• After drug holiday, careful consideration needed of risk and benefit of continuing osteoporosis treatment
• Ask about bowel function as could be affected by medication
• Referral or signposting for management of low body weight and nutritional needs
• Complete falls assessment
• Consider carer stress and support available. Provide detail of local support services

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

• Support and encourage independence and interaction where possible
• Ensure symptoms are well controlled

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)

• No drugs considered essential

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 and applicability (NNT) table)

• Gabapentin: indication not clear and may no longer be needed. Risk of sedation and confusion
• Lisinopril and amlodipine: tight blood pressure control, likely to be over treated. Target BP control should consider comorbidities and frailty using a person-centred approach
• Gliclazide: tight HbA1c, therefore likely over treated
• Sertraline: unclear indication, may be possible to withdraw
• Atorvastatin: likely commenced after possible TIA several years ago, likely limited effect now
• Lorazepam: unclear indication, may be possible to withdraw
• Folic acid: may no longer be needed
• Review indications for all medications in old notes/records

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?

• Recent hip fracture and no investigations recorded for osteoporosis. Consider if life expectancy sufficient for time to benefit from treatment. In this case may be too short. Note: if considering bisphosphonate treatment need to assess dental health
• Assess pain control. Is paracetamol still needed as regularly as four times a day?

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• Risk of hypoglycaemia with tight blood glucose control
• Risk of falls and increased harm with tight blood pressure control
• Risk of sedation and increased confusion with gabapentin
• Risk of sedation and increased falls with lorazepam
• Medication Sick Day Guidance: ensure staff have clear information on medication to withhold (in this case lisinopril and gliclazide if continuing)

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal

Water pollution

• All medicines are formulary choices
• Care home advised to dispose of medicines through community pharmacy and advised to only order what is needed

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
• include lifestyle and holistic management goals
• 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

• Stop lorazepam
• Stop gliclazide. Review HbA1c after three months
• Consider stopping atorvastatin due to limited life expectancy
• Reduce and stop lisinopril and amlodipine
• Reduce gabapentin gradually and assess pain control
• Reduce and stop sertraline, if agreed
• Change calcium/vitamin D supplement to a once daily preparation
• Low BMI and history of acute on chronic poor nutrition. Encourage continued focus on nutrition in care home. Look for old weights in notes/records. Assess Malnutrition Universal Screening Tool (MUST) score
• Potential for improvement in physical and cognition with improved nutrition, encouragement to mobilise and interaction in care home activities.
• Discuss changes with appointed guardian

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

• Sore itchy legs: improve analgesia
• Nausea and vomiting due to number and size of tablets

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)

• No current medication is essential but medicines to relieve symptoms and improve quality of life should be prioritised

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 and applicability (NNT) table)

Review the need for:

• Omeprazole and metoclopramide recently started for nausea and vomiting
• Tramadol: not controlling pain but paracetamol often refused due to the size of the tablets
• Fexofenadine: for itchy sore legs
• Lorazepam: for stress and distress in the context of dementia
• Laxatives: for opioid induced constipation, aggravated by poor mobility and diet

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?

• Review pain management
• Reduce peripheral oedema
• Improve mood
• HbA1c to be checked three months after starting metformin

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

Review need for:

• Metoclopramide: risk of adverse effects e.g. extra-pyramidal
• Omeprazole: increased risk of electrolyte disturbance
• Tramadol: increased risk of falls
• Lorazepam: increased risk of falls, potential to reduce from regular to as required use if less agitated once pain is managed
• Furosemide: review dose of and its effect on renal function
• Nausea: consider metformin as probable cause. A switch to MR preparation is not an option as she chews large tablets such as paracetamol and metformin. Option for liquid preparations
• Medication Sick Day Guidance: ensure staff have clear information on drugs to withhold (in this case prescription of furosemide and metformin) 

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal
• Water pollution

• Metformin liquid more expensive than tablets but clinically justified
• Paracetamol capsules are less expensive than oral suspension, however still large capsules. Once pain is managed, could try capsules, however crunching capsules may cause nausea again
• Care home advised to dispose of medicines through community pharmacy and advised to only order what is needed

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
• include lifestyle and holistic management goals
• 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

• The proposed changes to medication were discussed and agreed with her welfare power of attorney
• Care staff will administer medication, monitor effect and her ability to take medication
• Stop metoclopramide, omeprazole once nausea resolves
• Reduce tramadol as regular paracetamol used
• Reduce lorazepam with aim to withdraw
• Change paracetamol, and metformin to liquid preparations
• Review furosemide, dose could reduce if increased mobility improves oedema
• Review fexofenadine, stop if itch resolves with oedema, or trial without
• Review laxatives, as mobility improves and tramadol reduced
• Medication dosing remained four times a day, this could be reviewed once leg pain has been managed to trial reduction in paracetamol frequency

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

• Improving quality of life: over sedation potentiates poorer/recurrent physical health issues
• To review polypharmacy and potential interactions

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)

• All antiseizure medications (ASM) require specialist input. Rufinamide requires enhanced specialist consideration and referral
• Legislative requirements met for ongoing use of sodium valproate
• Changes to non-ASM could destabilise physical health and thus create additional provoking factors for increased seizures

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 and applicability (NNT) table)

• Mirtazapine – confirm indication. Are there sufficient signs of mood disorder/moderate depression to balance the risk of over-sedation (with clobazam). Consider if signs of low mood caused by frequency of seizures
• Consider sedation profile

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?

• Seizures and respiratory conditions have known linear connection. Sedation can contribute to overall poorer outcome
• Assess effectiveness by combination of:

• Review drug history and consider cautious reduction in overall drug load

• Review for evidence of neurotoxicity from ASM and consider pharmacokinetic and pharmacodynamic interactions
• Increase sensory and interactive activities to monitor improved cognitive response

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• Risk of inappropriate palliation
• Risk of over-sedation and worsening of chest health, leading to risk of morbidity/mortality
• Mirtazapine has the potential to increase seizure frequency
• ASM TDM to monitor for potential toxicity, then ongoing to monitor variance in levels
• Note phenytoin has non-linear pharmacokinetics and will need at least 21 days following dose changes to reach steady state again
• Ongoing consideration of potential for reactive neurotoxicity when prescribing, deprescribing, or alterations of dose
• Metoclopramide contra-indicated in epilepsy and ADRs may cause misdiagnosis/inappropriate prescribing (see note below)
• Care staff should be trained in the administration of any rescue medication
• Staff education on identification of likely symptoms of non-convulsive status epilepticus and neurotoxicity
• Include pro-forma / symptom checklist to support when to escalate

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal
• Water pollution

• Medicines should be prescribed by brand for epilepsy
• Clear rationale for non-tablet formulation
• Care staff advised to dispose of medicines through community pharmacy and advised to only order what is needed

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
• include lifestyle and holistic management goals
• 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

• Phenytoin: implement two weekly serum level check – most unpredictable pharmacokinetic (non-linear) and highly interactive and highly protein bound
• If changes to medication do not resolve altered consciousness and CT/ MRI alongside blood tests (U&Es, calcium, etc) are clear, consider EEG to exclude neurological basis of deterioration (non-convulsive status epilepticus NCSE)
• ASM: referral to neurology and joint working with epilepsy and intellectual disability team to rationalise current ASM
• Use of formal care/support structures (Care Programme Approach) to potentiate inter-professional collaboration and mapping of outcomes
• Share information to support parents/family/carers e.g. local carers centre, Epilepsy Scotland website, Quarriers fieldworker service (this should have occurred via epilepsy specialist services input).

Outcomes

• Blood tests showed severe neurotoxic levels of phenytoin 33mg/L (normal range: 10-20mg/L)
• Phenytoin cautiously reduced in 25mg increments every four weeks and levels returned to baseline

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

• Wants to be on the best medication for all her current conditions as does not want them to worsen. However, she does wonder if she needs all the medication to achieve this

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)

• Levothyroxine: for hypothyroidism

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 and applicability (NNT) table)

• Gabapentin in pain management check indication - neuropathic pain or mechanical back pain. Query co-codamol or paracetamol and need for NSAID
• Citalopram : check ongoing indication
• Omeprazole: high dose, check indication, e.g. active peptic ulcer, oesophagitis, GI protection (clopidogrel, aspirin, diclofenac, citalopram)

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?

• Secondary prevention of coronary events: likely to derive macrovascular benefit from tight glycaemic control; consider statin and BP control
• Stroke prevention in AF: CHA2DS2-VASc score 4, consider replacing aspirin with anticoagulant; check rate control
• COPD management: check symptom control (including exacerbation rate) and inhaler technique. Review ICS (single ICS not licensed in COPD) and/or escalate bronchodilation
• Pain management: review symptoms, pain score and expectations. If gabapentin prescribed for back pain, then consider withdrawal; review NSAID
• Depression: review duration of treatment and ongoing need
• Hypothyroidism: check TFT result
• CKD: check and monitor for proteinuria
• Diabetes: HbA1c high despite three antidiabetics; check adherence.
• Pioglitazone use is cautioned in those with CVD, consider stopping and starting an SGLT-2i

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• Ankle swelling: potential ADR of amlodipine or pioglitazone. Query if furosemide still indicated.
• GI bleeding risk: NSAID, citalopram and aspirin (or anticoagulant if added)
• Acute kidney injury risk:
  • NSAID with CKD (eGFR 55ml/min), consider stopping NSAID
  • co-prescribed diuretic, ACE inhibitor/ARB and NSAID (‘triple whammy’)
  • co-prescribed thiazide and loop diuretic, thiazide and ACEI not appropriate
• Metformin: reduce to maximum daily dose of 2g
• Increase U&E monitoring
• Cardiac events risk: NSAID and CVD – diclofenac (ibuprofen and naproxen preferred); pioglitazone (ankle swelling and ischaemic heart disease)
• Risk of arrhythmia: QTc prolongation: omeprazole, citalopram and gabapentin
• Medication Sick Day Guidance given for metformin, furosemide, bendroflumethiazide, lisinopril, gliclazide, diclofenac and SGLT-2i

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal
• Water pollution

• Opportunities for cost minimisation by changing liquid levothyroxine to tablets
• Change ICS MDI (no exacerbations recently) to long-acting bronchodilator in a lower carbon emission formulation e.g. tiotropium soft mist inhaler (Respimat®)
• Advised to dispose of medicines through the community pharmacy
• Advised to only order what is needed, do not stockpile medicines

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
• include lifestyle and holistic management goals
• 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

• Stop: aspirin, diclofenac, gabapentin, Clenil® MDI, pioglitazone
• Start: statin, DOAC for AF; tiotropium Respimat®, SGLT-2i (counsel accordingly)
• Reduce: metformin dose to 2g daily
• Change: co-codamol to paracetamol; levothyroxine liquid to tablets
• COPD management: check they understand how to monitor breathlessness score, advise regarding use of new inhaler and check inhaler technique and suitability
• Lifestyle management: smoking cessation, weight reduction, increased physical activity
• Non-medication interventions: signpost to social support, e.g. Alzheimer’s Scotland
• Pulmonary rehabilitation may be appropriate depending on breathlessness score
• Ensure regular review: diabetes, COPD, CVD, BP, pain management

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

• Reduce falls risk
• Maintain independence
• Reduce risk of further cardiovascular events
• Reduce risk of stroke
• Simplify medication if possible

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)

• Levothyroxine

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 and applicability (NNT) table)

• Citalopram check ongoing need
• No indication for combination of clopidogrel and edoxaban

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?

• Co-codamol 30/500mg high strength. Check pain control adequate and well managed. High dose codeine so consider constipation

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• · drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• High risk combination Clopidogrel not stopped when edoxaban started – increased bleeding risk (also citalopram) Stop clopidogrel
• Omeprazole may reduce efficacy of clopidogrel – change to lansoprazole 15mg if remaining on clopidogrel
• Citalopram 30mg is above the recommended dose for over 65s. Risk of QT prolongation at this dose in this group. Reduce dose if ongoing need
• Variable blood pressure readings. Check postural BP. Consider medication adherence. Watch for potential steep blood pressure drop if adherence improves
• Consider if blood pressure over treated
• Edoxaban: creatinine clearance 27ml/min and weight less than 61kg therefore reduce to 30mg
• Zopiclone is a sedative and increases falls risk. High risk, advise stopping

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal

Water pollution

• All medicines are formulary choices
• Advised to dispose of medicines through the community pharmacy
• Advised to only order what is needed, do not stockpile medicines

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
• include lifestyle and holistic management goals
• 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

• Stop clopidogrel
• Stop zopiclone combined with advice on sleep hygiene and normal sleep patterns in older age
• Reduce edoxaban to 30mg
• Reduce citalopram to 20mg and consider non-pharmacological options for mood (e.g. restarting social activities) with a view to stopping
• Change co-codamol to paracetamol regularly with as required codeine, and review pain management
• Postural blood pressure check and ongoing review of blood pressure
• Discuss compliance aids including medication charts
• Weight borderline - discuss whether nutrition adequate and compare with previous weights
• Signpost to options to increase physical activity
• Possible episode of delirium recently. Check baseline cognitive function
• Prompt regarding power of attorney

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

• Does not want to stop any medication, reports all are effective despite pain 10/10. “If it’s not broke, don’t fix it”
• Wants to go out to bingo/shops
• Challenge of matching her expectations of remaining on all medicines versus reducing risks of ADR/side effects. Suspicious of reviews due to past experiences.
• Discuss realistic expectations of pain management
• Discuss non-pharmacological ways of managing pain
• Develop a therapeutic relationship

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)

• Essential – none

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 and applicability (NNT) table)

• Nitrofurantoin: complains of UTI despite continuous nitrofurantoin. CrCl 33ml/min, so should be avoided and no evidence to support prophylactic use beyond six months. Trial without
• Mirtazapine, zopiclone and diazepam: contributing to anticholinergic burden (ACB). Review and rationalise if possible after opioid reduction. Reassess GAD. Not keen to engage with mental health teams currently, has tried before, with no benefit
• Zopiclone: trial reduction after opioids have been reduced
• Amlodipine: BP adequately controlled, with no postural drop

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?

• Bone protection: awaiting DXA, receives vitamin D but no calcium, however her diet is calcium rich with full fat milk, cream and cheese

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• Quinine sulfate: still reports leg cramps, therefore trial without
• Oxybutynin: high ACB. She reports previous catheterisation because of urinary retention. Trial discontinuation to reduce ACB, then assess urinary frequency
• Opioids: she reports 10/10 for pain despite 240mg MED dose.

Discuss ADR and potential harm, increasing risk of falls, hyperalgesia, impact on cognition, sedation, immune suppression, query a factor in recurrent UTIs

• Plan: reduce oxycodone by 7-10% every two to four weeks to achieve lowest possible dose
• Paracetamol: Reduce dose to one tablet as weight less than 50kg
• Reassess BP after medicines are deprescribed with potential to reduce ramipril

Medication Sick Day Guidance given for ramipril

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal

Water pollution

• Check local formulary choices for sustained-release oxycodone and if necessary, switch to a more cost-effective preparation when a stable dose is reached
• Advised to dispose of medicines through the community pharmacy
• Advised to only order what is needed, do not stockpile medicines

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
• include lifestyle and holistic management goals
• 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

• Unwilling to change pain medicines at first but willing to ‘trial’ reduction of therapy at subsequent consultations
• Gradual changes in medicines discussed and agreed
• Stop: nitrofurantoin, oxybutynin, quinine sulfate
• Reduce: opioids, then zopiclone
• Reduce: paracetamol dose
• Option to include functional assessment scores before and after medication changes, along with the pain score
• Refer to community link worker for social prescribing and community support options
• Attitude to smoking explored and reports reducing her cigarette smoking to less than eight a day

After four months follow-up, she had reduced to 45mg oxycodone (90 MED). Pain still 9/10, but now going out with carer one day a week and visiting shops

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

• Concerned regarding side effects and possible ‘addiction’
• She feels original pain improved
• Gaining weight despite healthy diet

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)

• Essential - none

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 and applicability (NNT) table)

• Pain improved. May not need higher dose gabapentin or full dose tramadol, both would need slowly reduced to avoid adverse effects of withdrawal. Reduce one at a time

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?

• Pain improved overall
• Consider therapeutic paracetamol, if evidence of benefit. May need tramadol as required

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• · drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• Gabapentinoid and opioid both central nervous system depressant with risk of dependency
• Weight gain: gabapentin adverse effect includes abnormal appetite, therefore although diet is healthy may be consuming more. Previous pain and sedation could result in less physical activity. Increased weight can lead to joint pain
• Counsel and agreed shared decision to gradually reduce to lowest effective dose or stop

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal

Water pollution

• Consider non-pharmacological ways to manage pain
• Advised to dispose of medicines through the community pharmacy
• Advised to only order what is needed, do not stockpile medicines

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
• include lifestyle and holistic management goals
• 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

• Discuss reduction plan advising that it may take several weeks or months to gradually reduce
• Discuss likely side effects of withdrawal and how to mitigate
• Explain the need to monitor pain, and stop at lowest effective dose if needed
• Could consider when required NSAID to help manage any flare up
• Additional steps: signpost to supported self-management and other allied team members to support activity management and pacing

Steps

Process

Person specific issues to address

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

• Assess pain control and function as states struggling with pain during the day and at work
• Biopsychosocial assessment to determine if other factors worsening pain
• Diabetes well controlled

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)

• Essential - none

3.

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 and applicability (NNT) table)

• Duloxetine and amitriptyline: review effectiveness of these, determining which has been the most beneficial. Optimise the dose and gradually reduce the other
• Tramadol not recommended as treatment for neuropathic pain, consider stopping

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?

• Diabetes well controlled, continue with treatment and lifestyle measures
• Pain poorly controlled, optimise medicines and encourage use of self-management strategies

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 e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• Duloxetine, tramadol and amitriptyline: all serotonergic, review for signs and symptoms of serotonin syndrome and rationalise therapy
• On several psychoactive substances including cannabis. Educate on cannabis use in pain, and use health behaviour change techniques to encourage stopping
• Assess for other ADR
• Counsel on potential long-term issues with regular opioids. Advise gradual dose reduction of tramadol with aim to stop

6.

Sustainability

Is drug therapy cost-effective and environmentally sustainable?

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal

Water pollution

• All medicines are formulary choices
• Advised to dispose of medicines through the community pharmacy
• Advised to only order what is needed, do not stockpile medicines

7.

Person-centredness

Is the person 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
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

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

Agreed plan

• He is happy to take less medication and does not want to take medicines that are “doing more harm than good”
• Stop: agreed to reduce amitriptyline and then stop
• Increase: duloxetine could be increased up to a maximum of 120mg daily
• Review: tramadol could be reduced and stopped once other pain management strategies are in place
• Signposted to NHS Inform and pain management websites for information on self-management

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

• Reducing risk of falls “I don’t want to be in hospital”
• “Can I take less tablets? Do I need them all?”

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)

• Essential – levothyroxine, Note: insulin for symptom control, not essential in T2DM

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 and applicability (NNT) table)

• FBC and folate in range: stop ferrous fumarate and folic acid
• Hypertension: BP well controlled, severe frailty, history of falls – stop doxazosin
• Furosemide: 80mg twice daily for fluid overload, oedema controlled, reduce dose
• Solifenacin: still incontinent, risk of anticholinergic effects, trial stop
• Ascorbic acid: no longer indicated and recently omitted with no difference in symptoms – stop

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?

• T2DM: HbA1c 57– Consider individual treatment in relation to frailty and therapeutic aims. Receives short and long-acting insulin, metformin and GLP-1RA (liraglutide): reduce metformin (renal impairment); discuss with diabetes specialist nurse to review liraglutide, rationalise insulins
• Analgesia: oxycodone MR used regularly, pregabalin not indicated for cancer pain – started for sciatica, now resolved, trial stopping
• COPD: poor inspiratory flow and on LTOT. Has both pressurised MDI and dry powder inhaler. Check inhaler technique and if required change Trelegy® to Trimbow® with spacer

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• Solifenacin: anticholinergic side effects
• Metformin: eGFR 44ml/min, therefore, reduce dose
• Oxycodone MR: side effect constipation (Bristol stool chart 2). Essential for cancer, therefore, optimise therapy and change when required lactulose to regular macrogol sachets
• Mental health – takes both venlafaxine and mirtazapine - increased risk of serotonin syndrome – under care of mental health team but lost contact, and will follow up for review

Medication Sick Day Guidance given for furosemide and metformin

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal
• Water pollution

• Carbocisteine - could be switched to acetylcysteine effervescent tablets which will reduce tablet burden
• Advised to dispose of medicines through the community pharmacy
• Advised to only order what is needed, do not stockpile medicines

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
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

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

Agreed plan

• Stop ascorbic acid, doxazosin, ferrous fumarate, folic acid, pregabalin, solifenacin
• Reduce furosemide, metformin
• Change lactulose to macrogols, carbocisteine to acetylcysteine
• Community pharmacy contacted regarding immediate changes
• Follow-up with mental health team, diabetes specialist nurses

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

• Reduce number of medicines where possible
• Provide education on medicines
• Reduce constipation: education about lifestyle e.g. increased fibre intake, physical activity
• Referral to local weight management services
• Long-term out of work – check entitlement to benefits- refer to community link worker

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)

• No drugs considered essential
• Amiodarone, apixaban, bisoprolol, spironolactone and bumetanide have valid indications and therefore continue (diuretic could be contributing to constipation)

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 and applicability (NNT) table)

• Gabapentin, Oxypro®, Shortec® prescribed for chronic back pain with no recent review. He reports pain is no longer an issue but concerned that reducing Oxypro and/or gabapentin may exacerbate pain. Reduce Oxypro and gabapentin dose gradually
• self-report version of the Leeds Assessment of Neuropathic Symptoms and Signs pain scale (S-LANSS) score = 0 does not suggest he is experiencing neuropathic pain and therefore gabapentin not indicated^[318]
• Ferrous fumarate has been prescribed for several years. Current FBCs normal. Stop iron and repeat FBCs and serum ferritin in three months. If needs to restart, current guidance recommends once daily treatment only
• Solifenacin prescribed for urinary incontinence five years ago. No benefit perceived. ACB score 3. Complains of constipation and sometimes dry mouth. Stop and review in four weeks.
• Trelegy – review symptoms and exacerbation rate and consider stepping down to LABA/LAMA

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?

• BP, AF and T2DM well controlled.
• T2DM and age over 40 with hypercholesterolemia - atorvastatin indicated
• Analgesia: add in regular paracetamol to help offset need for Oxypro® and/or gabapentin

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• AF: Risk of gastrointestinal (GI) bleeding with aspirin and apixaban. Indication for aspirin not clear- stop. Continue apixaban for AF as per clinic letters.
• Apixaban dose checked with creatinine clearance - >60ml/min. Continue current dose and check urea and electrolytes annually
• Ensure he has regular monitoring scheduled for U&Es for spironolactone
• Gabapentinoids can increase the risk of respiratory depression (has sleep apnoea). Manufacturers advise dose reduction in those with impaired respiratory function (caution)
• Ensure TFTs and LFTs and U&Es are being monitored every six months as prescribed amiodarone (hypothyroidism may cause constipation).
• Medication Sick Day Guidance given for spironolactone and bumetanide. Seek advice from community pharmacy to identify these tablets in the dosette box

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal

Water pollution

• Consider streamlining inhaler devices so that both are dry powder inhalers
• Advised to dispose of medicines through the community pharmacy
• Advised to only order what is needed, do not stockpile medicines

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
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

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

Agreed plan

• Provided with a list of medication, explaining the indication of each drug
• Start atorvastatin 20mg daily
• Stop aspirin, ferrous fumarate, solifenacin
• Monitoring required:
  • check LFTs and lipids after four weeks
  • FBC and serum ferritin in three months
• Reduce: Oxypro dose gradually with a view to stop
• Gabapentin reduction. Initially he did not agree to this. Following discussion about risk of respiratory depression and lack of clinical indication, he agrees to a gradual reduction after opioid has been stopped/reduced in the first instance (individual preference)
• Constipation should decrease with medication changes, so there may be scope to stop senna
  • Importance of adequate fluid, physical activity and dietary fibre intake reinforced
• Change salbutamol MDI to salbutamol Accuhaler®
• Choice of MDS discussed and alternatives explored e.g. prompt chart, but he would like to continue with “dosette box”
• Inform community pharmacy of changes to medicines
• Agrees to lifestyle changes and referral to local weight management services
• Agrees to community link worker referral for advice on benefits

Review diagnoses and consider:

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

Ask person to complete PROMs (questions to prepare for my review) before their review

• Wants to reduce side effects of sedation and ensure able to swallow necessary medication

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)

• Co-beneldopa for PD

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 and applicability (NNT) table)

• Pregabalin: review as may aggravate motor symptoms of PD
• Co-codamol: review as may aggravate non-motor symptoms of PD (constipation) – consider paracetamol alone if needed for pain
• Sertraline: review mood and continued need. Reduce dose to 50mg if ongoing indication (see Quality Prescribing for Antidepressants guidance)
• Consider non-pharmacological management of depression

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?

• Suggestions to discuss with PD team include:
• Review formulation and timings as dispersible tablet may be easier in the morning, as that is when swallowing is most difficult
• First dose should ideally be on waking, which is before the carers visit at breakfast time
• Ensure speech and language therapy (SALT) referral for swallowing assessment and advice

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

• Ensure discussion and clear information on which medicines to withhold at times of dehydrating illness.

• Potential for interaction between pregabalin, sertraline, codeine (in co-codamol) and co-beneldopa, increasing sedation. Review ongoing need for the non-PD medication
• Due to importance of timing of medication, if the person is acutely ill, e.g. vomiting which may affect absorption of medication, seek specialist advice on antiparkinsonian medication dose replacement/alternatives (e.g. transdermal)

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal

Water pollution

• All medicines are formulary choices
• Advised to dispose of medicines through the community pharmacy
• Advised to only order what is needed, do not stockpile medicines

Does the person understand the outcomes of the review?

• Consider Teach back
• Involve the adult where possible. If deemed to lack capacity, discuss with relevant others, e.g. welfare guardian, power of attorney, nearest relative if one exists. Even if adult lacks capacity, adults with Incapacity Act still requires that the adult’s views are sought. Ensure “Adults with Incapacity Documentation” in place

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
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Ask person or carer to complete the post-review PROMs questions after their review

Agreed plan

• If agreed with PD team, change co-beneldopa dispersible to early morning, to be taken on waking. Remaining co-beneldopa to be given at breakfast, lunchtime, teatime and bedtime
• Ensure timing of medication is specified in dose instructions (for transfer to ECS/KIS)
• Trial reduction of pregabalin, by 25mg every two weeks and monitor pain and sedation
• Trial paracetamol alone, in place of co-codamol for chronic pain. Monitor pain and constipation side effects
• Reduce sertraline to 50mg, and review mood and continued need at next appointment
• There is an Anticipatory Care Plan in place, the individual wishes to remain at home for as long as possible. Welfare POA arrangements are in place and relevant clinical systems (e.g. KIS) are updated with individual’s wishes
• Referral to SALT is made to highlight the increased swallowing difficulties

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

• “Wants to feel better”
• PHQ-9 score increased

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)

• Essential medication: Clenil®
• Folic acid replacement recommended

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 and applicability (NNT) table)

• Episode of depression, possibly related to loss of employment. Trial of citalopram 20mg daily – ineffective
• Asthma well controlled

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?

• Moderate depressive episode with worsening signs and symptoms, citalopram ineffective

Management with combination of:

• Switch antidepressant as no effect at eight weeks of therapeutic dose
• Psychological intervention (e.g. CBT)
• Non-medicalised interventions e.g. exercise such as walking
• Given history of harmful alcohol use when anxiety/insomnia, supportive general discussion re negative impact of alcohol on sleep and mood (and also increases risk of gastrointestinal side effects/GI bleeding with antidepressants)

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• Discuss worsening symptoms and possible increasing self-harm/suicide risk. Worsening symptom advice and out of hours telephone numbers (e.g. Breathing Space)
• Follow up review within two to four weeks, or sooner if considered appropriate
• Current medicines have low overdose fatality risk
• Try and ensure continuity of care with the same HCP where possible. Offer in-person appointments rather than telephone-based. Caution re digital exclusion given financial situation
• Discussion about potential harmful effects of cannabis on mental health (paranoid thoughts, anxiety) and lung health. General sleep hygiene advice given

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal
• Water pollution

• Dry powder inhalers are more environmentally sustainable than metered dose inhalers. Once mental health improved consider inhaler device
• Advised to dispose of medicines through the community pharmacy
• Advised to only order what is needed, do not stockpile medicines

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
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

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

Agreed plan

• Switch antidepressants: last dose of citalopram today, start sertraline 50mg daily tomorrow
• Onset of action: sertraline likely to show effect in two to four weeks, review four to six weeks
• Safety information: suicide prevention advice, contact telephone numbers
• Low intensity exercise such as walking may help
• Friend attending with him is supportive, safety information provided as above
• Try and ensure continuity of care with the same HCP where possible. Offer in-person appointments rather than telephone-based. Caution re digital exclusion given financial situation
• Social interventions – link with practice-based welfare advisor for money advice (fuel poverty, food poverty, rent arrears); link with practice-based community link worker to explore options for community supports (e.g. gym pass, walking group, address social isolation)

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

• Reduce anxiety
• Improve sleep
• Keen to explore non-medicalised and non-pharmacological approaches, including lifestyle interventions

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)

• No current medication

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 and applicability (NNT) table)

• None

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?

• Pharmacological option not appropriate at present
• Computerised cognitive behavioural therapy (cCBT) non-pharmacological preferred option

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• Prefers non-pharmacological treatment to start with

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal
• Water pollution

• No medication necessary currently

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
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

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

Agreed plan

• Very motivated to explore non-pharmacological options
• Medication options will not be commenced at this stage
• Referral to National Wellbeing Hub
• Comfortable using computers, she sees this as a flexible way to receive support around her work and social commitments
• Signposted to a cCBT package for anxiety
• Sleep hygiene discussed and signposted to cCBT app
• Alcohol: discussed the effects of alcohol and potential to worsen pre-existing anxiety
• Caffeine intake assessed and discussed - with advice to reduce and use non-caffeine alternatives
• Review in four to six weeks and contact the GP practice if her mood worsens

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

• Reduce avoidable harms from street drugs, OTC medicines and alcohol use
• Manage pain from previous assault-consider trauma informed approach

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)

• No drugs considered essential
• Although not essential, street benzodiazepines, alcohol and OTC co-codamol should not be stopped suddenly – see below for risks. He requires support to safely reduce his use. Referral to specialist service and/or third sector partner

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 and applicability (NNT) table)

• Having checked his understanding of the current risks, he is offered further harm reduction advice in relation to his benzodiazepine, alcohol and co-codamol use

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?

• Work with specialist service to develop a shared care plan for him which may include prescribing for alcohol detox, relapse prevention and appropriate vitamins, diazepam detox and opioid substitution therapy (OST)
• Pain to be discussed in greater detail at follow up appointment, explaining the difference between acute and chronic pain

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• Discuss increased overdose risk with the combination of benzodiazepines, alcohol and opiate (co-codamol)
• Need for appropriate harm reduction strategies including dose reduction. Advice includes:
  • avoid buying larger quantities of benzodiazepines to limit the risk of an overdose
  • splitting doses throughout the day to avoid withdrawal symptoms
  • keep a note of how much and how often he takes
• Opioids: supply take home naloxone kit
• Benzodiazepines: discuss risk associated with street supply - purity and strength are unknown
• Alcohol: discuss risk associated with alcohol consumption. AUDIT score of 20 indicates specialist referral required
• Paracetamol: discuss the possible effects on his liver from co-codamol use above recommended doses for a prolonged period of time
• He must not drive if he is unfit to do so, because he has taken medication or street drugs

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal

Water pollution

• No prescribed medication

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
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

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

Agreed plan

• Gradual reduction of street benzodiazepines, OTC co-codamol, alcohol intake whilst considering specialist input
• Referral offered to specialist drug and alcohol service, discussed and encouraged, but reluctant to engage at this time. He agrees to attend a local third sector drop-in
• Naloxone trained and has a kit. Advise where friends and family can obtain a kit
• Discuss worsening symptoms and possible increasing self-harm/suicide risk. Give out of hours telephone numbers, e.g. Breathing Space, Samaritans, NHS 24
• Written information provided to support discussions
• Follow-up appointment in seven days’ time for ongoing pain management, and check if attended third sector drop-in. Discuss specialist referral again

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

• Continued stability of Bipolar type 1 disorder
• Reduction of risk of cardiovascular events

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)

• Lithium - Stopping lithium therapy could cause a relapse in bipolar symptoms and significantly increase suicide risk – do not stop without specialist advice

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 and applicability (NNT) table)

• Quinine - assess ongoing benefit. Individual at risk of side effects including QTc prolongation

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?

• No changes required

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• Lithium – despite the level being in therapeutic range, it is rising and appears to be higher than required to manage bipolar type 1 disorder (see key concepts below)
• Interaction with ibuprofen: occasionally buys OTC
• Interaction with ramipril could influence lithium level. Option to change to other medication e.g. amlodipine
• Alcohol consumption and lithium combined can impair psychomotor skills – this varies significantly between individuals
• Dehydration can influence development of lithium toxicity. This can be exacerbated by alcohol
• Lithium and quinine could both prolong QTc interval. Risk increases in females and increases with age. Consider ECG to assess QTc
• Medication Sick Day Guidance: ensure clear information provided on medicines to withhold if dehydrated (in this case ramipril) 

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal

Water pollution

• All medicines are formulary choices
• Advised to dispose of medicines through the community pharmacy
• Advised to only order what is needed, do not stockpile medicines

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
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

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

Agreed plan

• Stop: ibuprofen and quinine sulfate
• Change: ramipril to amlodipine
• Individual re-counselled on lithium including signs and symptoms of toxicity and how medication/diet can influence this.
• Lithium levels (and blood pressure) to be repeated in two weeks and if still elevated, lithium to be reduced by 100-200mg. Individual’s mental state to be monitored at each review – also advised to report any deterioration in mental state
• Education on importance of presenting National Patient Safety Agency (NPSA) purple lithium warning card to community pharmacy when purchasing any OTC medicines (see key concepts)
• Advise on the avoidance of dehydration e.g. when drinking alcohol and the importance of drinking other fluids

Review diagnoses and consider:

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

• Patient with incapacity: authority from power of attorney sought
• Investigate cause of fall
• Management of deterioration of cognition and function
• Management of sudden confusion, agitation and aggression
• Refusing medications

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)

• None

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 and applicability (NNT) table)

• Atorvastatin: stop, currently non-essential
• Donepezil: withhold due to low pulse. Investigate cause; if bradycardia due to donepezil then stop. Refer to psychiatry
• Aspirin: CT head normal
• Perindopril: BP tightly controlled, withhold until stable and re-assess. No past medical history of LVSD
• Solifenacin: started one month ago, no improvement in urinary frequency. Stop as increased risk of anticholinergic adverse effects. Consider mirabegron as has no recorded anticholinergic activity
• Hydroxyzine: rash now resolved. Stop as can increase risk of anticholinergic adverse effects
• Risperidone: stop as past medical history of cerebrovascular disease. Risperidone can increase QTc. Treat underlying cause of agitation, use non-pharmacological approach as first line

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?

• Low folate: Folic acid prescribed
• Low vitamin B12: B12 injection prescribed
• Constipation: Laxatives prescribed

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• Monitor bowels (use bowel chart)
• Monitor blood pressure
• Monitor pulse
• Monitor haemoglobin, MCV, vitamin B12 and folate levels

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal
• Water pollution

• All medicines are formulary choices
• Ensure appropriate disposal of medicines as per hospital standard operating procedures
• Advised to dispose of medicines no longer required through the community pharmacy
• Advised to only order what is needed, do not stockpile medicines

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
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Agreed plan

Delirium:

• Agreed treatment of underlying medical causes
• Stop risperidone. Agreed to treat underlying cause of delirium and use non-pharmacological options in the first instance. Review regularly, if no improvement following non-pharmacological management and symptoms causing significant distress to patient, or if threat to patient, carers or others, consider pharmacological options. Refer to local guidance
• Stop: solifenacin, hydroxyzine, atorvastatin, perindopril, donepezil
• Start: laxatives; folic acid/vitamin B12
• Covert administration in place for one week. Review need regularly
• Aspirin, folic acid and laxatives are currently being given covertly as per agreements within signed policy
• Worsening cognition and function over past three months: discussion of benefit and risks of cholinesterase inhibitors, if to restart (stopped due to potential cause of bradycardia)

Review diagnoses and consider:

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

• Currently functioning at below her normal physical and cognitive baseline, and would like to return to that

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)

• No drugs considered essential

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 and applicability (NNT) table)

• Risperidone - added as an inpatient and likely no longer needed, and potentially causing side effects (sedation). When used in delirium, antipsychotics must be at the lowest possible dose for the shortest possible time
• Oxybutynin - strong anticholinergic, can increase confusion. No clear indication, consider deprescribing
• Amitriptyline - strong anticholinergic and risk of sedation and increased confusion. If no clear indication, consider deprescribing

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?

• Blood pressure now high. Amlodipine and bendroflumethiazide stopped in hospital. Due to concurrent diabetes consider ACE inhibitor, e.g. ramipril
• Type 2 diabetes: may be appropriate to consider statin, requires baseline LFTs with monitoring

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• Diabetes: HbA1c checked some months ago. Discuss appropriate target level with her when recovered considering age and frailty
• On several agents that can lead to sedation, cognitive impairment and increased falls risk. Consider need for risperidone, oxybutynin and amitriptyline; and deprescribe where appropriate
• Antipsychotics (risperidone) associated with increased cardiovascular risk and use. Need to be at lowest possible dose for shortest possible time. Consider deprescribing
• Consider further investigations if confusion worsens or persists
• Ensure Medication Sick Day Guidance for metformin and/or ACE inhibitor

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal
• Water pollution

• All medicines are formulary choices
• Advised to dispose of medicines through the community pharmacy
• Advised to only order what is needed, do not stockpile medicines

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
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Agreed plan

• Stop oxybutynin and risperidone
• Reduce amitriptyline
• Follow up blood pressure, HbA1c
• Check care needs have been met including adequate fluid and nutrition
• Refer to local community team for assessment of needs and rehabilitation
• Medical review if physical and cognitive function not improving

Review diagnoses and consider:

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

• She wishes to maintain independence as long as possible and return home as soon as able
• Focus is on symptom relief - breathlessness, pain from osteoarthritis and maintaining cognition

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)

• As she has a UTI and delirium, antibiotic treatment is essential
• Donepezil can delay progression to 24-hour care (priority for her)

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 and applicability (NNT) table)

• Review the continued need for IV antibiotics
• Lisinopril of limited benefit as preserved ejection fraction so stop
• She has had fewer than two exacerbations of COPD in the last year - step down to LAMA/ LABA inhaler (Anoro Ellipta®)
• Discuss need for laxatives: could be used when required

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?

• Judged to be very low probability of immediate penicillin hypersensitivity reaction, and so after discussion with her and next of kin, proceeded to amoxicillin oral challenge
• Given single dose of oral amoxicillin and monitored at 10, 20, 40 and 60 minutes. Experienced no symptoms of nausea, no rash or lip/tongue tingling or swelling, no tachycardia or hypotension
• Proceeded to a course of amoxicillin for seven days for a suspected upper UTI. Antibiotics were completed without any adverse effect
• Monitor breathlessness (also review inhalers)

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• Medication Sick Day Guidance for furosemide and lisinopril
• Donepezil caution in COPD but control is good
• Paracetamol dose in individual weighing less than 50kg: reduce dose and consider adding ibuprofen gel for painful joints

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal

Water pollution

• Consider use of oral rather than IV antibiotic (e.g. individual acceptability and sustainability)
• After assessment by a pharmacy technician, she is struggling to use dry powder devices. She cannot “feel” the dose being taken and therefore orders more inhalers every month, presuming that it is empty. After discussion about how the dry powder device works, she felt more confident she was receiving the required dose.
• Advised to dispose of medicines through the community pharmacy
• Advised to only order what is needed, do not stockpile medicines

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
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Agreed plan

• On discharge the GP was informed that the penicillin allergy was de-labelled and her GP records were updated and discussed with family so that they were aware for future episodes
• Stop lisinopril. Clear note on discharge to GP about reason for this
• Reduce paracetamol dose to 500mg up to four times a day
• Change Trelegy® to Anoro Ellipta® device
• Referred to the GP practice pharmacy technician to assess ways of supporting medicines management at home and remove unnecessary medicines
• Ensure a written copy of the plan made for future reference by individual, family and carers

Review diagnoses and consider:

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

Anticipatory care plan in place includes desire for

• comfort at the end of life
• end-of-life care to be in nursing home

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)

• Parkinson’s medicines are essential. Specialist input on replacement for oral formulations. Options include:

• dispersible medication if easier to swallow
• nasogastric to deliver medication (unlikely to be useful here due to agitation)
• switch to rotigotine patches to control distressing PD symptoms and potentially improve swallowing. See notes below

• Antibiotics can be essential but need to be reviewed regularly

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 and applicability (NNT) table)

• Majority of medicines should be stopped: amlodipine, aspirin, quinine, simvastatin, thiamine are of no benefit in short-term and should be stopped rather than converted to non-oral forms.
• Macrogol and senna should be stopped due to diarrhoea

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

• Failure to improve with IV antibiotics and fluids in the context of very advanced malignancy, is not unexpected
• Advanced care directive specified the wish to die at nursing home, and to be comfortable at the end of life
• Management of agitation and pain control need to be considered

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• IV access and blood monitoring are painful and potentially distressing which needs balancing against benefits and risks such as Staphylococcus aureus bacteraemia (SAB)
• Oral candidiasis can be caused /worsened by antibiotics
• Diarrhoea and C. diff infection are risks secondary to antibiotics and exacerbated by laxatives. Stool sample sent to assess for C. diff infection

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal
• Water pollution

• Whilst there are associated financial and environmental costs with IV antibiotics and use of vascular devices, there is also “opportunity cost”: IV treatment preparation, administration and monitoring diverts nursing time away from delivering direct care to the individual at end-of-life
• Care home advised to dispose of medicines no longer required through community pharmacy

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
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Agreed plan

• The individual’s wishes made when they were capable remain the core factor guiding management decisions
• Adult now lacks capacity and incapacity certificate required
• Failure to improve on antibiotic treatment should prompt consideration of discontinuation
• The ongoing benefit of fluids and treatment to lower calcium need to be considered, and whether to stop
• Consider whether replacement needed for co-beneldopa and involve local Parkinson’s service
• Stop non-essential medication
• Pain is a cause of agitation and appropriate pain relief should be considered to address this.
• Treat oral candidiasis with topical or systemic therapy
• Consider involving local palliative care service

Review diagnoses and consider:

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

• Wants to have medication restarted as soon as possible

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)

• None

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 and applicability (NNT) table)

• Mirtazapine: clarify date of last review and need for continued therapy. Increased risk of ADRs including sedation and falls
• Co-codamol: no known indication. Increased risk of ADRs in frailty. Consider paracetamol alone, reducing risk of constipation and need for laxative. If only taking one tablet, subtherapeutic dose of paracetamol

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?

• Prochlorperazine: commenced for treatment of nausea and vomiting only
• Blood pressure: at target, could reduce ramipril
• HbA1C: at target, potential to reduce metformin

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• Medication Sick Day Guidance followed: dapagliflozin, furosemide, metformin and ramipril temporarily paused during intercurrent illness
• Macrogol and senna also withheld
• Reason for temporary suspension of medicines explained and understood by individual and POA

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal

Water pollution

• All medicines are formulary choices
• Care home advised to dispose of medicines through community pharmacy and advised to only order what is needed

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
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Agreed plan

• Nursing home staff ensured correct medicines were temporarily withheld
• Restart: medicines once nausea and vomiting resolved, and the individual is eating and drinking normally for 48 hours
• Stop: prochlorperazine when acute illness resolved
• Change: co-codamol tablets to paracetamol tablets
• Reduce: ramipril to 5mg once daily and metformin to 500mg once daily. Monitor response and adjust accordingly
• Review: continued need for mirtazapine and laxatives at next consultation

Review diagnoses and consider:

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

• Reducing risk of falls and associated fractures
• Provide adequate analgesia

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)

• No essential drugs

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 and applicability (NNT) table)

• Check adherence with all therapy as substantial polypharmacy load
• Osteoporosis: alendronic acid taken for over 10 years, could assess the possibility of a treatment pause for two years given the volume of medication and possible GI side effects. Thereafter review again for most suitable bone protection treatment (e.g. parenteral). Establish whether there has been considerable height loss recently to indicate possibility of vertebral fracture and requirement for spinal imaging
• AF: warfarin should be reviewed considering falls risk. A DOAC may be a more suitable option and reduce monitoring requirements
• Hypertension: consider stopping indapamide. May reduce dose of ramipril based on BP target to minimise falls risk. No issues with statin
• Dyspepsia: may benefit from reduction and withdrawal of lansoprazole, use Peptac® symptomatically. Dyspepsia symptoms may be helped by pausing alendronic acid
• Continue calcium and vitamin D supplementation, especially as limited time outdoors
• Review need for zopiclone as this may cause drowsiness the next day, affecting mobility

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?

• Analgesia: use paracetamol regularly for pain rather than when required. Reduce the dose to 500mg four times a day, as weight less than 50kg
• Ensure chair-based programme of exercises appropriate to need (physiotherapy input) and look at feasibility of weight bearing exercise
• Review diet with potential for dietitian input

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• Risk of bleeds when falling – review warfarin choice for AF
• Hypertension target may need to be reviewed to reduce risk of falls. Stop indapamide and review. May also be able to reduce or stop ramipril
• Stop zopiclone as increased risk of sedation and falls risk (phased reduction suggested: reduce to 3.75mg tablets for two weeks then alternate nights for two weeks)
• Potential for interactions (warfarin, lansoprazole, ramipril) with the herbal remedy devil’s claw as interferes with cytochrome p450 metabolism. Advise to stop taking as no known benefit in OA

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal
• Water pollution

• Salbutamol MDI could be changed to a dry powder inhaler (DPI) to streamline devices. She has sufficient inspiratory flow to manage DPI and this reduces environmental impact
• Diclofenac gel is one of the most polluting pharmaceutical agents and has the potential to interact/interfere with other medication. Discuss continued need or use paracetamol regularly instead
• Ramipril capsules are more cost-effective than tablets
• Advised to dispose of medicines through the community pharmacy
• Advised to only order what is needed, do not stockpile medicines

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
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Agreed plan

• Conduct falls risk assessment (including vision, cognitive function, balance, muscle strength and footwear)
• Exercise plan and dietitian input to encourage muscle bulk and nutrition
• Pause alendronic acid for two years. After two years, review risk and potential benefit of bone protection, where IV bisphosphonate or denosumab may be options
• Change warfarin to a DOAC (refer to local guidance for management of change and formulary choice)
• Stop indapamide and review BP in four weeks. May subsequently be able to reduce ramipril to 5mg daily, monitor BP
• Change ramipril tablets to capsules
• Stop diclofenac gel and take 500mg paracetamol four times a day regularly
• Phased reduction of zopiclone and advise on sleep hygiene methods and resources
• Stop Devil’s claw (herbal remedy)
• Change salbutamol to a DPI (Salbutamol Easyhaler®) for use when needed

Review diagnoses and consider:

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

• Pain control
• Bowel function
• Burden of medication
• Improvement in mobility where possible
• Shortness of breath
• Current smoker

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)

• Levothyroxine: essential replacement 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 and applicability (NNT) table)

• Edoxaban: Increased risk of gastrointestinal bleeding in combination with dexamethasone. Consider risks versus benefit of continued anticoagulation for atrial fibrillation in context of metastatic cancer and steroid use.
• Solifenacin and amitriptyline: two anticholinergic drugs prescribed with cumulative risk of adverse effects. Anticholinergics.
• Folic acid: Limited benefit in context of advanced malignancy
• Alogliptin and metformin: Reduced oral intake
• Diazepam: Indication unclear; falls risk due to concomitant sedatives
• Dexamethasone: significant impact on blood glucose control
• Atorvastatin: long-term survival benefit of statin therapy not relevant for patients with prognosis of less than 12 months
• Lidocaine: Limited comparative data and clinical effectiveness remains unclear. Ensure prescribing in line with palliative care guidelines.
• Trelegy Ellipta^®: Difficulty administering dose; dry powder formulation

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?

• Consider and discuss compliance in context of polypharmacy and mouth discomfort. Can all medicines be swallowed as prescribed?
• Analgesics: assess effectiveness and tolerability; check requirement of breakthrough doses of morphine
• Omeprazole: gastroprotection whilst taking dexamethasone
• Solifenacin/ amitriptyline: Stop if not beneficial, cumulative risk of anticholinergic effects
• Shortness of breath affecting mobility, may cause anxiety. Check inhaler compliance and assess technique. Alternative devices may be required.
• Consider ongoing therapeutic management of diabetes in context of reduced oral intake and steroid therapy
• Monitor bowel function. Adjust laxatives if required, rectal preparations may be necessary
• Assess oral pain and whether prescribed medications are contributing factors and/or oral thrush evident. Encourage to rinse mouth out with water and brush teeth after using inhaler

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

• Bleeding risk increased with edoxaban, dexamethasone and sertraline:
• Edoxaban: dose reduction required (if continued): 30mg once daily if creatinine clearance 15–50 mL/minute.
• Diabetes: review blood glucose targets, control potentially too tight, accounting for reduced oral intake
• Dexamethasone. Monitor for hyperglycaemia. Administer as a single dose in the morning
• If troublesome symptoms associated with high blood glucose, consider gliclazide or appropriate insulin. Administer once daily in the morning to reduce the risk of nocturnal hypoglycaemia
• Ramipril: No current hypertension. Long-term renal protective effect not relevant due to limited prognosis. Risk of hyperkalaemia in renal impairment and symptomatic hypotension as general condition declines
• Diazepam, opioids, amitriptyline and pregabalin: risk of falls, sedation and respiratory depression
• Morphine: opioid effects increased and prolonged in renal impairment: risk of opioid toxicity
• Pregabalin: dose reduction required: maximum 300mg daily in 2–3 divided doses if creatinine clearance 30–60mL/minute
• Solifenacin and amitriptyline: risk of anticholinergic side-effects, complaining of a dry mouth

Medication sick day guidance:

• Metformin: dehydration increases the risk of lactic acidosis
• Ramipril: dehydration can impair kidney function

Dexamethasone: ensure aware of steroid sick day guidance and ensure they have a steroid emergency card

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal

Water pollution

• If other formulations are required, consult local guidance
• Advised to dispose of medicines through the community pharmacy
• Advised to only order what is needed, do not stockpile medicines

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
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Agreed plan

• Stop:
  • alogliptin
  • atorvastatin
  • folic acid
  • metformin
  • ramipril
  • solifenacin (and assess symptoms)
• Reduce pregabalin dose
• Reduce edoxaban dose, if continuing
• Review amitriptyline and trial reducing dose or stopping
• Review diazepam: consider reducing dose with aim to stop
• Review lidocaine plasters; trial stoppage and stop if no benefit
• Dexamethasone: check dosing plan, ensure changes made by specialist team are implemented promptly. Review need for blood glucose monitoring
• Review laxatives; consider more palatable formulations
• Consider different inhaler device/ spacer
• Discuss possibility of changing opioids due to renal impairment and/or swallowing difficulties (e.g. oxycodone or transdermal fentanyl)
• Check if willing to stop smoking and start nicotine replacement therapy.
• Referral for management of nutritional needs, if appropriate
• Consider carer stress and support available. Provide details of local support services

Review diagnoses and consider:

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

• Pain control
• Control of other symptoms such as nausea, constipation, sore mouth, breathlessness and fatigue
• Struggling to swallow medications
• Diabetic control
• Desire for cigarettes

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)

• Insulin- should not be stopped in those known to have type 1 diabetes
• Analgesics (fentanyl, morphine, paracetamol, ibuprofen)- assess effectiveness and tolerability of each analgesic, check requirement of breakthrough doses of morphine
• Metoclopramide- switch to antiemetic with longer half-life that can be given once daily or administer via Continuous Subcutaneous Infusion (CSCI)
• Omeprazole: gastric protection whilst taking non-steroidal anti-inflammatory drug (NSAID); indicated for oesophagitis.

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 and applicability (NNT) table)

• Antihypertensive - Stop as hypotensive. Low BP is common near the end of life
• NSAID - indicated for bone pain but patient at risk of gastrointestinal complications, especially if unable to take gastric protectant. Assess risk versus benefit
• Antidepressant - Stop at a pace he can manage. Fluoxetine has long half-life. Benzodiazepine (e.g. midazolam) may be needed to counteract anxiety/ withdrawal symptoms
• Oral care - be aware of fluconazole drug interactions but of less relevance near end of life
• Laxative-stop. Likely to struggle to swallow volume of macrogol laxative in the last days of life due to poor fluid intake. Rectal laxatives can be considered if needed for comfort measures

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?

• Prescribe as required medicines in anticipation of need for distressing symptoms (analgesic, antiemetic, anxiolytic sedative, anti-secretory). Prescribe subcutaneous (SC) route in addition to any existing oral (PO) route.
• Consider likelihood of catastrophic haemorrhage; Prescribe anxiolytic sedative by the intramuscular (IM) route in anticipation of need (e.g. midazolam 5mg to 10mg)
• Switch to a simpler insulin regimen aiming to prevent symptomatic diabetic ketoacidosis (e.g. once daily insulin glargine - Lantus^® is often used). Reduce the dose as appetite decreases, seeking advice from diabetic team on a case-by-case basis. Review dose daily
• If unable to swallow, switch oral medication to subcutaneous administration via a syringe pump (CSCI) if possible. Alternative medications may need to be considered
• Do not switch opioid patch to alternative opioid/route in a dying patient; continue the fentanyl patch and administer any additional opioid required via CSCI.
• Ensure breakthrough opioid dose is calculated as 1/6^th to 1/10^th of total oral morphine daily equivalent. Contact specialist palliative care team for advice if uncertain.
• Consider benefit of nicotine replacement therapy (NRT) if unable to smoke to avoid effects of nicotine withdrawal
• Assess need for oxygen therapy if oxygen saturations <88-92%. Manage respiratory distress first line with opioids / benzodiazepines. Oxygen may help alleviate refractory symptoms, or lessen hypoxic related delirium

Identify individual safety risks by checking for:

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

• NSAID - manage the risks and benefits of continuing treatment, particularly if gastric protection cannot be administered
• Antidepressant - increased risk of bleeding with SSRI/SSNRI
• PPI - Switch capsules to orodispersible tablets. Alternatively, open capsules and mix the contents with water, fruit juice or sprinkle on soft food
• Fluconazole - may increase the plasma concentration of all drugs metabolized by CYP3A4 (e.g. fentanyl, midazolam). Review requirement
• Insulin - preventing distressing symptoms of diabetes is the goal towards the end of life; a range of 6-20mmol/l is generally accepted, although 6-15mmol/l may to necessary to prevent distressing thirst, particularly in younger patients
• Monitor for signs of gastrointestinal (GI) toxicity (bleeding)

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal
• Water pollution

• Prescribe the advised number of ampoules for anticipatory ‘Just in Case’ medicines
• Utilise the person’s own medication supply wherever possible
• Advised to dispose of medicines no longer required through the community pharmacy

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
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Agreed plan

• Stop: Antidepressant, antihypertensive, fluconazole, laxative, zopiclone, paracetamol (tablet burden)
• Switch: Symptom focused medications to liquid/ orodispersible formulations or oral to CSCI/SC (SC appropriate for antiemetic and opioid titration).
• Consider: NSAID can be continued until end of life if helpful for symptom control and benefits are considered to outweigh risks. Seek SPC advice if parenteral NSAID is required
• Simplify:

Ensure patient and /or family/POA (depending on capacity) understand and agree with goals of care

Communicate that comfort is paramount as patient is nearing end of life

Review diagnoses and consider:

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

• Wishes to manage her pain
• Wishes to reduce her need for out of hours contacts and find ways to better manage her condition

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)

• Methadone maintenance is essential as substance dependence therapy and should not be stopped abruptly. Methadone is normally initiated by specialist services and the risks of prescribing in OOH services is high. Individuals presenting with opioid withdrawal symptoms during the OOH period should be signposted to the emergency department for assessment and management of their symptoms. Consider elimination half-life of medication requested (see below) and risk of harm from prescribing without access to daytime medical records
• If prescribing, prescribe the smallest quantity needed to allow follow up in daytime GP services and clearly document in case records the strength and quantity supplied

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 and applicability (NNT) table)

• Multiple medications prescribed for pain, all associated with a risk of dependency and which would require support to withdraw safely in daytime practice:
• Amitriptyline
• Co-codamol
• Gabapentin
• Pregabalin
• Tramadol

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?

• Be aware of any local or national policies around prescribing of medicines with risk of dependency during the OOH period
• Take a person-centred approach to management and prescription request in OOH services. Review any management advice on case records/ ECS from daytime GP and discuss the benefits, risks and alternatives to prescribing. Where prescribing in the OOH period, use the smallest quantity to allow daytime GP practice follow up and document clearly in records
• During daytime follow up discuss effective pain management options for chronic pain considering physical function, mental health, social and emotional factors. Record clear instructions on patients ECS with indication for use and management of prescription requests during the OOH period
• Tolerance to opioids occurs therefore higher doses are required to maintain the same level of pain relief
• Good practice not to combine opioids
• During daytime follow up target tramadol first for gradual reduction
• Work with individual to develop a plan to gradually deprescribe gabapentinoids (gabapentin and pregabalin separately) and opioids (tramadol first, then codeine in co-codamol). Agree a plan to communicate to OOH services using ECS
• Explain potential for withdrawal symptoms and that the tapering may take months. Leave clear instructions for OOH management and prescription requests during this time ensuring safety across transitions of care

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• 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 (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• · drugs used to treat side effects caused by other drugs

Medication Sick Day Guidance

• Constipation possibly a side effect of opioid use
• Increased risk of adverse effects such as drowsiness, respiratory depression and interactions with multiple opioids and gabapentinoids (see MHRA alert)
• Ensure awareness of need for contraception to reduce teratogenic effects with gabapentin
• Potentially increased risk of drug-related death due to use of multiple opioids, gabapentinoids and street drugs

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

• Inhaler use
• Single use plastics
• Medicines waste
  • over-ordering
  • disposal

Water pollution

• During daytime practice review, consider reducing ineffective pain medication and introducing non-pharmacological therapy such as physiotherapy, yoga, CBT. Support may be available from a community link worker to identify the best plan for the individual

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
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Agreed plan

• In OOH establish what pain medication is requested and take a person-centred, risk/ benefit approach to management in line with local and national policies, until reopening of daytime GP services
• Recommend follow up with regular GP practice in a suitable time frame
• In daytime practice recommend stepwise reduction plan for any ineffective medicines in agreement with the individual. Record indication for medicine, any reduction plans and management options for prescription requests during the OOH period on the individual’s ECS
• Consider option of physiotherapist and community link worker support
• Signpost to National Wellbeing Hub
• Alcohol: discussed the effects of alcohol and potential to worsen symptoms related to pain and depression and signpost to local support if available
• Smoking: recommend smoking cessation services and reduction/cessation of cannabis

25

125 (5 days)

6

30

1.5-4.5

7.5-22.5

5-7

25-35

6.3

31.5