MedicationReview PracticeGuide2011

Clinical Medication Review
A Practice Guide
Overview
NHS Cumbria Medicines Management Team
February 2013
Overview
A definition of medication review is a structured, critical examination of a patients medicines

with the objective of reaching an agreement with the patient about treatment, optimising the
impact of medicines, minimising the number of medication related problems and reducing
waste. (Room for Review, 2002)1
The review should, ideally be with the patient and their current medication to hand but as a
minimum with the full medical notes:
Check that
the medication prescribed is appropriate for the patients needs
the medication is effective for the patient
the medication is a cost effective choice
any required monitoring has been done or arrangements are in place
Consider
drug interactions
side effects
compliance
concordance
over-the-counter and complementary medicines
lifestyle and non-medicinal interventions
unmet need
Record
information pertinent to any decisions made
Read Code appropriate to the review:
Level 2: Treatment Review a review of medicines with the patients full notes 8B314
or 8B3S
Level 3 (also Type 3): Clinical Medication Review a face to face review of medicines
and condition 8B3V or 8B3x
Proposed follow up
The following do not count as a full clinical medication review, but may be useful as part of
the medication review process:
technical check of the medication list or tidying up medication records e.g. removing
unrequested items from repeats or dose optimisation
switching to a formulary item
linking medication to a problem
re-authorising the repeat list or reviewing an individual medication/
disease without reviewing all medication as above
asking the patient is everything else alright? at the end of a
consultation
a DRUM, a Dispensers Review of Use of Medicines by
dispensing doctors or their staff
an MUR, a Medicines Use Review by community pharmacists
The practice should have a Standard Operating Procedure (SOP) for medication review that
provides details of the process e.g. responsibilities of all staff involved; how a regular review
is ensured; prescription duration; formulary adherence and process to be followed if a patient
does not attend for monitoring as requested.
NHS Cumbria Medicines Management Team, February 2013 2

Clinical Medication Review A Practice Guide
Background
Medication is by far the most common form of medical intervention. Four out of five people
over 75 years take a prescription medicine and 36% are taking four or more drugs. 1 However,
we also know that up to 50% of drugs are not taken as prescribed;2,3 many drugs in common
use can cause problems and that adverse reactions to medicines are implicated in 5-17% of
hospital admissions. This leads to difficult decisions, particularly with the frail elderly, whether
to initiate or discontinue medication.
Medication review is increasingly recognised as a cornerstone of medicines

management, preventing unnecessary ill health and avoiding waste.
Involving patients in prescribing decisions and supporting them in taking their medicines is a
key part of improving patient safety, health outcomes and satisfaction with clinical care.
Despite the publication of nationally recognised guidance on medication review in 20021 and
2008 4 there is often still a lack of common understanding of what constitutes a medication
review. Consequently the effectiveness of medication review can vary widely this document
aims to bring consistency to the standard of medication review delivered within NHS Cumbria.
1
Principles of Medication Review
All patients should have a chance to raise questions and highlight problems about their
medicines.
The medication review seeks to improve or optimise impact of treatment for an

individual patient.
The review is undertaken in a systematic and comprehensive way, by a competent

person.
Any changes resulting from the review are agreed with the patient.
The review is documented in the patients notes.
The impact of any change is monitored.
Types and Levels of Medication Review

Medication review was originally a loose term but it has been gradually refined.
Levels of medication review were introduced by Room For Review in 2002 and are
dependent on the level of detail of information used for the review 1
Level 1: Prescription Review a technical review of the list of a patients medicines (8B3h).
Level 2: Treatment Review a review of medicines with the patients full notes (8B314 or
8B3S).
Level 3: Clinical Medication Review a face to face review of medicines and condition (8B3V
or 8B3x).

The face to face element was deemed important because patients views about their
medication will influence whether they take their medicines and non-compliance can cause ill
health and cost to the NHS.
In 2008 the National Prescribing Centre published A Guide to Medication Review. 4 This is a
framework for medication review with practical advice and examples. It describes different
types of review in a less hierarchical manner than previously, as it recognised that different
types of review each have a useful purpose and it is possible to have a useful discussion with
the patient about their medication (face to face) without having the full notes as described as
a level 3 review.
The types are:

Type 1: Prescription review addresses issues relating to the prescription or medicines; the
patient does not need to be present, nor access to full notes.
Type 2: Concordance and compliance review addresses issues relating to the patients
medicine taking behaviour e.g. a DRUM or MUR (Dispensers Review of Use of
Medicines by dispensing doctors or their staff or Medicines Use Review by
community pharmacists).
Type 3: Clinical medication review addresses issues relating to the patients use of
medicines in the context of their clinical condition.
This practice guide is aimed at achieving a good quality Type 3 review, but can also be
applied in part to a Level 2 or 3 review.
QOF requires that medication review is conducted in a systematic way. QOF specifies that at
least a Level 2 medication review will occur 5 and as described in the NPC 2008 briefing
paper. 4
Who to review?
The first element of a systematic approach will be to identify the patients who might benefit
from a review.
The GMS contract advises medication review to be undertaken every 15 months for all
patients being prescribed repeat medicines. The review should be repeated whenever a new
drug is added or a dose changed.
QOF 2012/13 requires 80 % of patients on repeat medication and 80 % of patients on four or

more repeat items to have had a medication review in the past 15 months; however QOF is a
basis for payment, rather than a definitive guide to best practice.
The National Service Framework for Older People stated: By 2002: All people over age of 75
should normally have their medicines reviewed at least annually and those taking four or
more medicines should have a review 6-monthly This is mandatory for NHS organisations. 2
To give all patients an annual medication review is an ideal to strive for, but in the meantime
there is an argument for targeting full clinical medication reviews to those patients who are
likely to benefit most.

Room for Review and A Guide to Medication Review suggested the following target groups to
prioritise medication review:
Patients at risk of medicines-related problems

taking four or more medicines every day
on a complex medication regimen or more than 12 doses in a day
recently discharged from hospital
recently transferred to care home
frequent hospital admissions
with multiple diseases
receiving medicines from more than one source e.g. specialist and GP
significant changes to the medication regimen in the past 3 months or more than 4
changes in medication in the past 12 months
taking higher risk medicines - those requiring special monitoring e.g. lithium; those
with a wide range of side effects e.g. NSAIDs; or a narrow therapeutic range e.g.
digoxin; or on drugs not commonly used in primary care (red/amber or black list
available from the medicines management intranet site)
symptoms suggestive of an adverse drug reaction
longstanding use of psychotropic medication
where non-compliance is suspected or known
high incidence of self medication
Special needs
older people
residents in care homes
learning difficulties
sensory impairment e.g. sight or hearing
physical problems e.g. arthritis, swallowing difficulties
mental states such as confusion, depression, anxiety, serious mental illness
communication difficulties
literacy or language difficulties
minority ethnic groups
refugees and asylum seekers
living alone or poor carer support
housebound
recent falls
identified by a screening tool (appendix 1)
Opportunities to improve care

new evidence or guidelines
newly diagnosed long term condition
out of date care plan
newly registered patient
Where possible, before a medication review, patients should be provided with written
information about the review including what they can do to prepare for the review. 4 See
appendix 2 for one example of a patient leaflet that may be adapted for use in the practice.
Your prescribing support pharmacist can provide further samples.

Who does the review?
QOF requires a competent person to do the review.
In practice doctors, pharmacists and many nurses have the clinical skills and therapeutic
knowledge to perform all aspects of medication review described here. Other practice staff
may be able to deliver some, but not all of these elements their work can be used to
contribute to the full medication review process but should not be classed as a full medication
review itself.
What should the review cover?
QOF guidance states that at least a level 2 medication review will occur i.e. the minimum
standard is a treatment review of medicines with the full notes but not necessarily with the
patient present. However QOF guidance goes on to say that all patients should have the
chance to raise questions and highlight problems about their medicines and that any
changes resulting from the review are agreed with the patient.
It also states that practices are expected to:

Minimise waste in prescribing and ineffective treatments; and
Engage effectively in the prevention of ill health to avoid the need for costly treatments
by proactively managing patients to recovery through the whole care pathway in acting
as conscientious gatekeepers to services.
For each drug:
Check that
The medication prescribed is appropriate for the patients needs
Following hospital discharge there may be unintentional changes to regular medication

or conversely medication may have been introduced that was appropriate in the
hospital setting, but is not needed at home e.g. hypnotics, enteral nutrition or nebules.
National and local evidence-based guidelines should be considered at this stage.
A medication may be time-limited e.g. clopidogrel and aspirin in combination for one
year.
Drugs of limited clinical value are flagged up in the BNF and the STOPP START
Toolkit suggests medication that might be inappropriate for older people in certain
situations. The dose prescribed should be reconsidered with advancing age or
changing physiology e.g. renal clearance.
It is unlawful for service providers to discriminate on grounds of age however for

medication that has clinical benefit only after use for a number of years or is intended
to prevent events in the distant future it is appropriate to consider the patients life
expectancy when weighing up the benefits versus risks of a treatment. If the answer to
the question Would you be surprised if this patient were to die in the next few months,
weeks or days? is anything other than yes then reference to the Gold Standards
Framework Prognostic Indicator Guidance 6 may clarify this and then the medication

review process should aim to provide the patient with medication that enables them to
live well until they die.
Particular care should be taken with drugs that are poorly tolerated in the frail elderly.
These drugs are listed in the STOPP START Toolkit. (This toolkit and many local
guidelines are available on the Medicines Management section of the NHS Cumbria
intranet at:
http://www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/Home.aspx)
Appendix 3 contains further supporting information such as NNT (numbers needed to
treat).
Consideration should also be given to what might happen if the drug were stopped.
The medication is effective for the patient this may involve objective evidence e.g.
change in HbA1c or discussion with the patient. In frail patients precedence may be
given to drugs that provide symptomatic benefit or those that prevent rapid worsening
of symptoms.
The medication is a cost effective choice - prescribing within NICE guidance and
the local formulary ensures that drug choices are evidence based and cost effective
(NHS Cumbria adopted the Lothian Joint Formulary 7 however this may change with
the creation of the CCG ). The medication should be prescribed generically wherever
appropriate. Specials (unlicensed products, imports and special formulations) are
rarely cost effective. In preference a licensed alternative should be sought, if necessary
used outside the licence. The Medicines Management team can provide advice and a
guide to alternatives.8
Any required monitoring has been done or arrangements are in place e.g. blood
tests specific to a medication or to monitoring a disease. Some guidelines are available
on the Medicines Management section of the NHS Cumbria intranet e.g as part of
shared care protocols. Your prescribing support pharmacist will be able to advise on
medication monitoring.
Consider
Drug interactions also consider the impact of withdrawing an interacting drug e.g.
simvastatin and warfarin.
Contraindications to the drug this status may have changed since the drug was
originally prescribed (either a change in licensing/evidence or a change in patient
factors such as kidney function or co-morbidities) so that the benefit to risk ratio is no
longer favourable. See Appendix 3 for numbers needed to treat and harm for
commonly prescribed drugs.
Side effects adverse reactions are implicated in many hospital admissions; they can
also lead to non-compliance and therefore ineffectual treatment. Some drugs may be
appropriately prescribed to mitigate side-effects, but in many cases the original need
for the original drug can be reconsidered e.g. should a PPI be co-prescribed with an
NSAID, or could the NSAID be replaced with a less toxic option?

Compliance it is estimated that 50% of medicines are not taken as prescribed. The
history of prescription issues can indicate non-compliance but cannot be relied upon
due to possible hoarding. The patient may have practical issues such as swallowing
difficulties or remembering to take medication in a complex regimen. For patients that
struggle to manage ordering repeat medication in time, repeat dispensing and/or the
electronic transfer of prescriptions might help. The patient could also be encouraged to
see the community pharmacist for an MUR or for provision of large labels, easy-open
containers etc.
Concordance if the patient understands the rationale behind their treatment, they
are more likely to take the medication as prescribed and adopt other non-medical
measures.
NICE now recognises this patient-centred approach as a key part of the medication
review process and has issued specific guidance to support improved adherence. 9
This may be particularly important in the very elderly who may no longer be interested
in medication that prolongs life, but be more willing to take medication that allows them
to live without pain or discomfort. Patient decision aids can be used to inform patients
about the risks and benefits of treatment e.g. available from www.npc.nhs.uk
Over-the-counter and complementary medicines many potent medicines can now

be purchased by the patient; these may have side effects, antagonise or augment
prescribed medication or affect the course of the disease. e.g. St Johns Wort reducing
contraceptive effect or decongestants in cough and cold remedies elevating blood
pressure.
Lifestyle and non-medicinal interventions the patient may be more willing to adopt
a lifestyle change than take medication or have made a lifestyle change that negates
the need for treatment e.g. weight loss to control hypertension. Lifestyle interventions
that complement pharmacological therapy should also be promoted as appropriate.
Unmet need - this is an opportunity to identify and treat new conditions, particularly
those that increase in prevalence with age e.g. atrial fibrillation, heart failure and
dementia. Some conditions are frequently under-treated e.g. warfarin could be more
widely used to prevent stroke in atrial fibrillation. The STOPP START Toolkit is a
detailed aid to medication that might be either inappropriate or worth starting in the
elderly.
Tools to support medication review

Prescribing software medication review templates can be used to prompt key points to
address during a review. An NHS Cumbria developed medication review template is available
for EMIS LV and Vision. Please contact your prescribing support pharmacist for more
information.
The NO TEARS tool is a mnemonic designed to prompt consideration of the key areas above
during a ten minute consultation (Appendix 5). 10
The STOPP START Toolkit is a detailed aid to medication that might be either inappropriate
or worth starting in the elderly. It is available on the Medicines Management section of the
NHS Cumbria intranet at:
http://www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/Home.aspx

Appendix 3 contains further supporting information such as NNT (numbers needed to treat)
and NNH (numbers needed to harm).
Prescribers still need to use their clinical judgement when adjusting a patients medication
the NNTs and NNHs can only be a guide as they are limited by the original study limitations
(e.g. frail elderly excluded from trials) and may not take into account the combination of
therapy given to an individual patient.
Appendix 4 gives a sample paper based medication review template designed for pharmacist
use but that can be adapted for other clinicians.
Implementing changes
Medication changes may be implemented during medication review by a prescriber.
However, if the reviewer is not a prescriber then any recommendation for change must be
discussed with/communicated to the prescriber using an agreed method. The prescriber
should then record any changes, or reasons for not implementing recommended changes, in
the patients records.
Documentation
Record
Information pertinent to any decisions made
Recommendations (if the reviewer is not a prescriber)
Read Code appropriate to the review
Level 2: Treatment Review a review of medicines with the patients full
notes 8B314 or 8B3S
Level 3 (also Type 3): Clinical Medication Review a face to face review
of medicines and condition 8B3V or 8B3x
A review undertaken by a medicines management pharmacist should be
Read coded as 8BMY
If an MUR has been undertaken by a community pharmacist this should
be Read coded as 8BMF
Proposed follow up.
QOF guidance states that the review should be documented in the patients notes.
Medication review templates can be used to prompt key points to address and improve Read
coding as well as allow free text recording of the review. An NHS Cumbria developed
medication review template is available for EMIS LV and Vision.
Communication of changes
The patient and/or carer must be informed of changes and have the opportunity to discuss or
be involved in the decision making.
If the patient is resident in a care home, uses a monitored dose system or uses the repeat
dispensing service the community pharmacy should also be informed of medication changes.

Follow up
If the reviewer is not a prescriber then any urgent recommendation for change must be
followed up in a reasonable timescale.
The practice SOP should state mechanisms for follow up e.g. by defining amended
medication as acute or resetting medication review diary dates for one month, six months or
a year.
QOF requires that the impact of any change is monitored.
The medication review SOP should demonstrate how the system works and in particular how
regular review (e.g. annual) is ensured. This in turn will provide evidence for part of the QOF
assessment.
Optimising resources
Although a clinical medication review with a patient is seen as the ideal form of review, they
will be the most resource intensive form of review. This can be mediated by
deploying the skills of a range of personnel to fulfil different elements of the review or
to supplement periodic clinical medication review with other forms of review e.g.
through MURs and/or DRUMs
focussing in the first instance on patients in greatest need - typically elderly patients
on polypharmacy or those recently discharged from hospital
following a clear structure as described in the overview.

References
1. Room for Review: A guide to medication review: the agenda for patients, practitioners and managers.
Task Force on Medicines Partnership and The National Collaborative medicines Management Services
Programme. 2002
2. Department of Health. National Service Framework for Older People 2001. www.dh.gov.uk
3. From Compliance to Concordance 1997. Royal Pharmaceutical Society of Great Britain.
4. A Guide to Medication Review 2008. National Prescribing Centre. A framework for medication review
with practical advice.
5. Quality and Outcomes Framework guidance for GMS contract 2012/13

http://www.nhsemployers.org/PayAndContracts/GeneralMedicalServicesContract/QOF/Pages/QualityOu
tcomesFramework.aspx
6. Prognostic Indicator guidance

http://www.goldstandardsframework.org.uk/Resources/Gold%20Standards%20Framework/General/Prog
nostic%20Indicator%20Guidance%20October%202011.pdf
7. The Lothian Joint Formulary www.ljf.scot.nhs.uk
8. NHS Cumbria Medicines Management Information available from:

http://www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/Home.aspx
9. National Institute for Health and Clinical Excellence. NICE clinical guideline 76. Medicines Adherence
January 2009
10. Tessa Lewis. Using the NO TEARS tool for medication review. BMJ 2004 Vol 329, 433-434

Appendices
Appendix 1
Medication Review Screening Tool
Do you understand what your medicines are for? Y/N
Do you understand when to take your medicines? Y/N
Do you find it easy to take your medicines? Y/N
Do you always remember to take your medicines? Y/N
Are you always able to order all your medications at the same time? Y/N
Are the medicines currently prescribed by your GP the only medication you take? Y/N
Do you return excess, unwanted or leftover medicines to the pharmacy? Y/N
Are you comfortable with your current medication? Y/N
Any No answer prioritises the patient for medication review
(from Morecambe Bay PCT Medication Review for patients aged over 75 years)

Appendix 2
Sample Patient Information Leaflet
Practice Address and contact details
LOGOS/ PICTURES
MEDICATION REVIEW
Information for patients
WHAT IS A MEDICATION REVIEW?

A medication review is a meeting to discuss your medicines with a healthcare professional.
The meeting is free and is an opportunity to check that your medicines are the best ones for
you. It is also an opportunity for you to ask questions and find out more about your medicines.
Its purpose is to check that you are getting the best from your medicines.
The meeting is confidential. Whoever you talk to, the details will be kept private. You can speak
openly about any worries you may have about your medicines and the person conducting the
medication review will listen to you. A record of the meeting will be added to your medical notes. No
medicines will be altered without agreement with you and your doctor.
BENEFITS OF ATTENDING A MEDICATION REVIEW

You will have the opportunity to:
Find out more about your condition(s) and medicine(s)
Tell a health professional how you feel about your treatment
Ask if you are taking the most appropriate medicines for your illness and how best to
take your medicines.

HOW TO PREPARE FOR YOUR MEDICATION REVIEW
When attending for your medication review please bring along:
a list of all the medicines that are prescribed for you including liquid medicines, creams
and ointments, inhalers or other devices, eye and ear drops
any medicines you buy from the pharmacy, health shop or supermarket such as
painkillers, vitamins, herbal products or other supplements
Any medicines you no longer take. You can keep hold of them if you wish, or you can take
them to your nearest pharmacy and they will dispose of them safely.
Before your appointment: think about any questions, concerns and suggestions you have
about your medicines and write them down to bring with you.
Make sure you know when, where and who you are meeting. You can make an
appointment at reception. If you have difficulty getting to the surgery please ask as it
may be possible to visit you at home.
If you have special concerns about a medicine jot this down and bring it along.
Otherwise, making a list of medicines you are taking is usually enough.
If there is someone who helps you manage your medicine, such as a family member,
you may find it helpful to bring them with you to your review.
QUESTIONS YOU COULD ASK AT YOUR MEDICATION REVIEW

Here is a list of questions that you could ask at your review. These are only suggestions;
you can write your own questions down in the space provided below.
What does this medicine do?
Why is it important to take the medicine?
What other treatment options are available?
When and how should my medicine be taken?
How long should I take my medicine for?
What medicines, drinks, foods or activities should I be aware of when taking my
medicine?
What should I do if I dont feel well when taking my medicine?
How can I tell if my medicine is helping?
How can I be sure that it is safe to take my medicine?

What are the possible risks or side effects of taking my medicine and what should
I do if I get one of the side effects?
What will happen to me if I miss a dose of my medicine or if I stop taking it
altogether?
Is there anything that could help me to take my medicine more easily or help me to
remember when to take them?
Where can I go for more information about my medicine?
Write your own questions and concerns here:
WHAT HAPPENS AFTER A MEDICATION REVIEW?

Your regular doctor will be informed of any changes agreed to at the medication
review.
The medicines you are prescribed may change; but only with your agreement.
A summary of the meeting will be entered into your medical record.
You can agree any future treatment requirements, (tests, referrals to other health
professionals etc.) and a date for your next medication review at the end of the
meeting.
Contact details for surgery.
NHS Choices
http://www.nhs.uk/Pages/HomePage.aspx

Appendix 3
Further information to support review
The information in this appendix is designed to supplement that found in the BNF and the
STOPP START Toolkit. Drug interactions, contraindications and dosage adjustments
necessary for renal and hepatic impairment are covered in the BNF so not all repeated here.
The number needed to treat (NNT) is an estimate, based on clinical trial data of the number
of patients who need to receive a drug (usually at a defined dose for a defined duration) for
one patient to show the desired benefit e.g. prevent death. Unless stated NNTs are given
here per annum. Number needed to harm (NNH) is similarly an estimate of how many
patients need to be treated with the drug for just one to have an adverse effect. Usually minor
side-effects are excluded.
Prescribers still need to use their clinical judgement when adjusting a patients medication
the NNTs and NNHs can only be a guide as they are limited by the original study limitations
(e.g. frail elderly excluded from trials) and may not take into account the combination of
therapy given to an individual patient.
There is no absolute formula for deciding how close NNT and NNH need to be to decide that
the benefits no longer outweigh the risks. This will vary from patient to patient as their
perceptions of what they are willing to put up with and what they want to achieve varies.
(Many of the NNTs are taken from an NHS Highland document1 please consult this for the
original study references if no reference is given).
The ACB score (anticholinergic burden2) is included here because anticholinergic

(antimuscarinic) side effects are well documented from constipation to confusion. Many drugs
have some degree of anticholinergic effect so combining them will increase the risk of a
serious problem, particularly in the elderly, such as cognitive impairment or falls.
If the total drug score adds up to three or more this is considered to be clinically relevant. A
study of patients over 65 found that 20% of participants who scored four or more had died by
the end of the two year study period compared with 7% of patients with a score of zero. The
risk of dying increased by 26% for every point scored.
The list is not exhaustive so it is reasonable to assume that drugs of the same class have the
same score unless stated.
Considerations to optimise medicines use given in each section are adapted from The
PrescQIPP Workstream Bulletin3 please consult that for the original references. It is assumed
that the guidance given earlier in this guide on what the review should cover (e.g. valid
indication for prescribing) will also be followed so is not re-iterated here.
Drugs stated as being in the PrescQIPP DROP List have been taken from The PrescQIPP
Workstream Bulletin4 which lists twenty drugs that are poor value for money or have safer
alternatives. The drugs are identified here as a prompt for review, the bulletin gives further
details on the rationale for their inclusion in the list, suggested alternatives and scenarios
where the drug may be appropriate, please also consult it for the original references.

BNF Chapter 1 Gastro-intestinal System
ACB Score 1 ACB Score 2 ACB Score 3

Alverine Belladonna alkaloids Atropine
Cimetidine Prochlorperazine * Dicyclomine
Loperamide Hyoscine
Ranitidine Propantheline
*From NHS Scotland Polypharmacy Guidance Oct 2012
Considerations to optimise medicines use
H2 antagonists/PPIs: check if there has been no proven peptic ulcer, GI bleeding or

dyspepsia for 1 year. Continued use may contribute to C difficile infection.
Laxatives: check if previous use of opioid analgesics has been reduced or stopped; if regular
bowel movements are occurring without difficulty; if the patient is eating and drinking and has
an adequate fluid intake.
If more than one laxative is used, reduce and stop one at a time reducing the stimulant
laxative first and increasing the dose of the osmotic laxative if necessary.
PrescQIPP DROP List

Esomeprazole isomer of omeprazole.
BNF Chapter 2 Cardiovascular System

Atenolol
Captopril
Chlorthalidone
Digoxin
Dipyridamole
Disopyramide
Furosemide
Hydralazine
Isosorbide
Metoprolol
Nifedipine
Quinidine
Timolol
Triamterene
Warfarin
Antihypertensives: check if the BP is too low; if the risks outweigh the benefits stop one
antihypertensive at a time restart if BP increases above NICE target (140/90 for under 80
years, 150/90 for over 80 years).

In the over 80s with BP>140/90 but otherwise low cardiovascular risk NNT 80 and with high
cardiovascular risk (diabetes, vascular disease) NNT 32 to avoid one cardiovascular event
(two years to see effect); NNT 122 to avoid one cerebrovascular event. In the over 60s with
otherwise low cardiovascular risk NNT 107 and with high cardiovascular risk NNT 40 to avoid
one cardiovascular event (4.5 years to see effect); NNT 225 to avoid one cerebrovascular
event.
In diabetes standard BP control (systolic < 140) NNT 57 to prevent one stroke, major diabetes
event or death but tight control (systolic 120) v standard (systolic 134) NNT 500 to prevent
one stroke (4 years for effect) and NNH 50.
ACEIs in elevated vascular risk NNT 280 and in impaired LV function NNT 30 to prevent one
death (all cause mortality).
ACEI plus indapamide NNT 55 to prevent one stroke.
Nitrates: check if the patient has had no chest pain for six months or has reduced mobility.
Lipid lowering drugs: re-evaluate the patient risk profile; stop in metastatic disease. (It is
impossible to give evidence based guidance on whether to continue or stop statins in the over
80s due to the paucity of trial data however in primary prevention they may increase all cause
mortality)5
Post MI or angina NNT 80 to 170 with statins to prevent one major coronary event (no
difference in mortality to 5 years). More specifically, post stroke with atorvastatin 80mg NNT
165 to prevent one cardiovascular event (no difference in mortality to 5 years).
Aspirin: if used in primary prevention re-evaluate need (massive NNT); query doses above
150mg for cardiovascular indication and its use in dizziness which is not clearly attributable to
cerebrovascular disease. Post stroke/TIA NNT 100 to prevent one stroke, MI or vascular
death. Stopping aspirin prescribed for secondary prevention has NNH 250.
Dipyridamole: clopidogrel is now preferred over dipyridamole in ischaemic stroke and

peripheral artery disease. However post stroke/TIA the combination of dipyridamole plus
aspirin has similar NNT to clopidogrel NNT 100 to prevent one vascular event.
Anticoagulants: if started following hip or knee surgery are they still required? Consider if
long term warfarin use is still required e.g. if VTE provoked by surgery, other trigger factors or
below knee.
Warfarin may be indicated e.g. in AF with another risk factor NNT with warfarin instead of
aspirin 40 to prevent one stroke (no difference in mortality).
Relative risk of bleeding compared to warfarin alone: REF Highland
RR v warfarin Confidence interval

Warfarin 1
Aspirin 0.93 0.88 0.98
Clopidogrel 1.06 0.87 1.29
Aspirin + clopidogrel 1.66 1.34 2.04
Warfarin + aspirin 1.83 1.72 1.96
Warfarin + clopidogrel 3.08 2.32 3.91
Warfarin + aspirin + 3.70 2.89 4.76
clopidogrel

Peripheral vasodilators: clinical effectiveness not established (NICE do state you can give
naftidofuryl for leg pain).
Digoxin: long term digoxin at over 125 mcg per day in patients with impaired renal function
can lead to an increased risk of toxicity.
Cardiovascular drug combinations:

In secondary prevention post MI in the over 80s the combination of ACEI plus beta-blocker
plus aspirin plus a statin NNT 33 to prevent one death.
In impaired LV function treating with ACEI and beta-blocker NNT 14 to prevent one death (for
mild to moderate impairment NNT is 15). In severe impairment the combination of ACEI plus
beta-blocker plus spironolactone NNT 7 to prevent one death.
PrescQIPP DROP List

Doxazosin MR no benefit over immediate release.
Omega-3 fish oils encourage patient to obtain fish oils from their diet evidence re
supplementation is weak.
Perindopril arginine no benefit over generic perindopril erbumine.
Aliskiren limited evidence of benefit.
BNF Chapter 3 Respiratory System

Alimemazine Cetirizine* Brompheniramine
Theophylline Cyproheptadine Chlorphenamine
Loratadine* Clemastine
Diphenhydramine
Hydroxyzine
Promethazine

Theophylline: monotherapy in COPD is not appropriate
Oral corticosteroids: prednisolone maintenance in COPD is not usually recommended. (NB

gradual withdrawal)
Inhaled corticosteroids: in asthma review every three months and if control achieved reduce
dose slowly e.g. by 50% every three months.
PrescQIPP DROP List

Desloratadine no advantage over loratadine.

BNF Chapter 4 Central Nervous System

Alprazolam Amantadine Amitriptyline
Bupropion Carbamazepine Chlorpromazine
Codeine Methotromeprazine (Levomepromazine) Clomipramine
Dextropropoxyphene Oxcarbazepine Clozapine
Diazepam Pethidine Dimenhydrinate
Fentanyl Pimozide Doxepin
Fluvoxamine Prochlorperazine * Hyoscine
Haloperidol Imipramine
Morphine Nortriptyline
Risperidone Olanzapine
Trazodone Orphenadrine
Paroxetine
Perphenazine
Procyclidine
Promazine
Quetiapine
Trifluoperazine
Trihexyphenidyl
Trimipramine
Benzodiazepines: check if physical and psychological health and personal circumstances

are stable and consider withdrawal which should be gradual.
Antipsychotics: in dementia patients with BPSD review and discontinue unless there is
extreme risk or distress for the patient. Standardised symptom evaluations and drug
cessation attempts should be undertaken at regular intervals. Withdrawal after long term
therapy should be gradual and closely monitored.
Antidepressants: for a single episode of depression treat for six to nine months; for multiple
episodes treat for at least two years; do not use dosulepin; consider ACB score and potential
to worsen dementia, glaucoma, constipation and urinary retention; SSRIs can induce
hyponatraemia; withdrawal should be gradual.
Drugs for dementia: review according to NICE guidance they can be continued if having a
worthwhile effect but usually the MMSE should be over 10 for AChEIs. Memantine may be
used in severe dementia (MMSE<10).
Opioid analgesics: check if pain is still severe enough to warrant a regular opioid as the risk
of falls/constipation can out weigh the benefits; consider non-drug options e.g. regular
paracetamol; review laxatives.
Opioid analgesics further information

Treat stepwise according to the World Health Organisation pain ladder6 although developed
for cancer pain relief it can be applied to chronic pain.

Prescribe regular paracetamol (opioid sparing)
Step 1 & 2:
The Oxford league table of analgesic efficacy7
Number Needed to Treat (NNT) for at least 50% pain relief over 4-6 hours in patients
with moderate to severe pain.
Paracetamol 1g + Codeine 60mg NNT 2.2

Diclofenac 50mg NNT 2.3
Ibuprofen 400mg, 600mg NNT 2.4
Paracetamol 1g NNT 3.8
Tramadol 100mg NNT 4.8
Codeine 60mg NNT 16.7
Patients should be given the individual components where possible to allow titration of
dose.
Codeine (plus paracetamol) is the step 2 opioid of choice, however 10% of Caucasians
cannot metabolise codeine to active metabolites so if very little response, consider tramadol.
Step 2 opioids that you may want to switch away from include:
Co-proxamol license withdrawn due to toxicity and relative inefficacy - on the PrescQIPP
DROP List.
Dihydrocodeine or dipipanone locally abused
Co-dydramol, co-codamol 8/500 &15/500mg and Tramacet low strength opioids so little
pain killing benefit but with the opioid side effects.
Morphine is the step 3 opioid of choice (Zomorph brand). Oxycodone and fentanyl (Matrifen)
have no advantage except where morphine is not tolerated or the oral route cannot be used.
Consider the need for laxatives: stool softener plus stimulant or osmotic.
Step 3 opioids that you may want to switch away from include:
Fentanyl buccal or intranasal on the PrescQIPP DROP List and APC black list8 (other drugs
preferred). Buprenorphine patches and oxycodone/naloxone are also APC black (not
accepted by the SMC).
PrescQIPP DROP List

Escitalopram isomer of citalopram.
Co-proxamol more toxic in overdose than paracetamol.
Fentanyl immediate release limited evidence compared to morphine.
Lidocaine patch expensive product with limited evidence of benefit.
Tramadol with paracetamol fixed low dose paracetamol (325mg) no more effective than
established analgesics and more expensive.
Oxycodone/naloxone uncertain clinical benefit and more costly than oxycodone plus a
laxative.
BNF Chapter 5 Infections

Antibacterials: inappropriate uses include that a bacterial infection has resolved; a viral
infection has been diagnosed; prophylactic treatment prescribed but no pathogen isolated;
treatment of asymptomatic bacteriuria in older patients, diabetes patients or catheterised
patients. Check if fluid intake is adequate.

PrescQIPP DROP List
Amorolfine nail laquer and tioconazole cutaneous solution systemic treatments more
effective if antifungal treatment indicated.
BNF Chapter 6 Endocrine System

Hydrocortisone
Prednisolone
Tight HbA1c control in type 2 diabetes can increase mortality in one study HbA1c of
around 7.5% had the lowest mortality, with risk of death rising significantly either side of this.9
NNT 200-333 to prevent one microvascular event (predominantly retinal). No difference in
macrovascular risk.
Metformin in overweight diabetics NNT 50 to prevent one MI, diabetes related event or death.
Bisphosphonates: review if the treatment has been taken for five years or over; if the risk of
falls is low they may be no longer needed but prolonged immobility is a risk factor for low
BMD.
These NNTs are for treatment with alendronate plus calcium and vitamin D supplementation,
used for secondary prevention of osteoporotic fractures normally two years treatment is
needed to see effect:
Age NNT vertebral # NNT Prevent Hip #

70-74 years 65 430
75-79 years 45 180
80-84 years 60 105
85-89 years 55 45
90+ 40 40
PrescQIPP DROP List

Ibandronic acid tablets/injection no advantage over alendronate and more expensive.
Gliclazide modified release formulations Glicazide MR 30mg is approximately
therapeutically equivalent to gliclazide 80mg.
BNF Chapter 7 Obstetrics, Gynaecology and Urinary Tract Disorders

Darifenacin
Flavoxate
Oxybutynin
Propantheline
Tolterodine

Alpha blockers: not generally indicated if patient has a long term catheter.
Antimuscarinics: review effectiveness after 3-6 months; check if continence pads are used
(making the antimuscarinic unnecessary); consider the potential side effects (postural
hypotension, urinary retention, constipation, reduction in MMSE); check ACB score.
Tadalafil once a day not cost effective compared to on demand in most patients.
The Lothian Joint Formulary has a useful section on HRT which gives the NNTs and NNHs at
http://www.ljf.scot.nhs.uk/LothianJointFormularies/Adult/6.0/6.4/6.4.1/Pages/default.aspx
PrescQIPP DROP List

None listed although some work has been done locally on rationalising the prescribing of
erectile dysfunction drugs.
BNF Chapter 8 Malignant Disease and Immunosuppression

Cytotoxics and immunosuppressants: consider the expected outcome do possible
adverse drug reactions out weigh the possible benefit; consider referring the patient back to
the doctor who initiated treatment.
BNF Chapter 9 Nutrition and Blood
Sodium, potassium and iron supplements: check if indication still current.
Vitamins: check for valid indication
Calcium and vit D: check if the patient might have adequate levels through diet/sunlight
exposure or if still otherwise indicated.
Sip feeds: check if there has been a recent dietician review; might the patient be able to have
fortified food?
PrescQIPP DROP List

Calcium and ergocalciferol (or vitamin D without strengths stated) for prevention of
osteoporotic fractures insufficient dose.
There is local guidance available on the prescribing of vitamin D and baby milks available at
http://www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/Guidelines/Home.aspx

BNF Chapter 10 Musculoskeletal and Joint Diseases

Colchicine Baclofen* Propantheline

NSAIDs: possible adverse drug reactions might outweigh the benefits in mild osteoarthritis
(>3 months use), hypertension, heart failure, renal failure. Review the need for long term use
of topical NSAIDs.
DMARDs/TNF inhibitors: refer to doctor who initiated treatment if no improvement.
PrescQIPP DROP List

Glucosamine/chrondroitin not recommended by NICE for osteoarthritis.
BNF Chapter 11 Eye

Eye drops/ointments: check need for preservative free formulations; eye drops used more
than four times a day; long term antibiotic preparations.
BNF Chapter 12 Ear, Nose and Oropharynx

Drops,sprays, solutions: have antibiotic/steroid/sympathomimetic preparations been
continued without a review or stop date?
BNF Chapter 13 Skin

Creams, ointments: has the condition resolved or could continued use exacerbate the
condition? Is the patient using sufficient emollient?
PrescQIPP DROP List

Minocycline for acne increased risk of side effects compared to oxytetracycline, lymecycline
or doxycycline.
Eflornithine cream for hirsutism continuous use needed.

References for Appendix 3
1. Polypharmacy Action Group. NHS Highland; Polypharmacy:Guidance for prescribing in frail adults. Nov
11
2. Fox C. Anticholinergic Medication Use and cognitive Impairment in the Older Population: The Medical
Research Council Cognitive Function and Ageing Study. Journal of the American Geriatrics Society
2011; 59:8
3. UKMI. The PrescQIPP Workstream Bulletin 8 Sept 2011
4. UKMI. The PrescQIPP Workstream Bulletin 10 Feb 2012
5. REF Petersen L et al Age and Aging: 2010; 39: 674-680 Lipid-lowering treatment to the end? A review of
observational studies and RCTs on cholesterol and mortality in 80+ year olds.
6. WHO pain ladder available at http://www.who.int/cancer/palliative/painladder/en/
7. The Oxford league table of analgesic efficacy:

http://www.medicine.ox.ac.uk/bandolier/booth/painpag/Acutrev/Analgesics/Leagtab.html
8. http://www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/TrafficLight/Home.aspx
9. Currie et al. Survival as a function of HbA1c in people with type 2 diabetes: a retrospective cohort study.
The Lancet, 2010 volume 375: 9713; 481-489.

Appendix 4
Sample Medication Review Form
Name DOB
Doctor Pharmacist
Date
Past medical history Allergies
Reason for review.Patient present/not present..Read code
Medication Date Indication Previous therapy for this Compliance Monitoring Value
Good/Poor Add/tick
started (Contraindicated?) indication/notes/interactions Date OK
1. BP
2. Chol
3. HDL/LDL/TG
4. U&Es
5. LFTs
6. FBC
7. BG/HBA1C
8. TFTs
9. Pulse
10. Other
11.
Understands purpose of Buying any meds OTC? Any difficulties taking meds?
meds?
Believes meds working? Experiencing side effects? Any difficulties obtaining meds?
Any untreated problems? Make one thing better? Reminder chart issued?
Smoking status Diet advice given Alcohol advice given

Medication Review Action Plan
Name DOB
Doctor Pharmacist
Date
Medication problem Action proposed Action by Implementation
identified authorised/refused -
comments
1
Signed (GP)..
Please return to

Appendix 5
10
The NO TEARS Mnemonic to Aid Medication Review in a 10 Minute Consultation
N Need and Indication

O Open Questions
T Tests and Monitoring
E Evidence and Guidelines
A Adverse Events
R Risk reduction or prevention
S Simplification and switches
Need and indication
Does the patient know why they take each drug?
Is each drug still needed?
Is the diagnosis refuted?
Is the dose appropriate?
Was long term therapy intended?
Would non-pharmacological treatments be better?
Open questions
Allows patients to express views,
Helps to reveal any problems they may have.
Test and Monitoring
Assess disease control.
Any conditions under-treated?
Use appropriate reference for monitoring advice e.g. BNF
Evidence and Guidelines
Has the evidence base changed since initiating drug?
Are any drugs now deemed less suitable?
Is dose appropriate? (Over or under-treatment, extreme old age)
Are other investigations now advised e.g. echocardiography?
Adverse Events
Any side effects?
Any over the counter or complementary medicines?
Check interaction, duplications or contra-indications.
Dont misinterpret an adverse reaction as a new medical condition.
Risk Reduction or Prevention
Opportunistic screening.
Risk reduction e.g. Falls are drugs optimized to reduce the risks?
Simplification and Switches
Can treatment be simplified?
Does patient know which treatments are important?
Explain any cost effective switches.

Contact details:
Name: Sue Hawker
Address: Medicines Management Team, NHS Cumbria, 4 Wavell Drive, Rosehill Industrial Estate, Carlisle,
CA1 2SE
Tel: 01228 608316 or 07909 888017
Email: [email protected]


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Clinical Medication Review

A definition of medication review is a structured, critical examination of a patients medicines

NHS Cumbria Medicines Management Team, February 2013 2

Medication review is increasingly recognised as a cornerstone of medicines

The medication review seeks to improve or optimise impact of treatment for an

The review is undertaken in a systematic and comprehensive way, by a competent

The review is documented in the patients notes.

The impact of any change is monitored.

Types and Levels of Medication Review

NHS Cumbria Medicines Management Team, February 2013 3

The types are:

QOF 2012/13 requires 80 % of patients on repeat medication and 80 % of patients on four or

NHS Cumbria Medicines Management Team, February 2013 4

Patients at risk of medicines-related problems

Opportunities to improve care

NHS Cumbria Medicines Management Team, February 2013 5

QOF requires a competent person to do the review.

What should the review cover?

It also states that practices are expected to:

For each drug:

The medication prescribed is appropriate for the patients needs

Following hospital discharge there may be unintentional changes to regular medication

National and local evidence-based guidelines should be considered at this stage.

It is unlawful for service providers to discriminate on grounds of age however for

NHS Cumbria Medicines Management Team, February 2013 6

NHS Cumbria Medicines Management Team, February 2013 7

Over-the-counter and complementary medicines many potent medicines can now

Tools to support medication review

NHS Cumbria Medicines Management Team, February 2013 8

NHS Cumbria Medicines Management Team, February 2013 9

QOF requires that the impact of any change is monitored.

following a clear structure as described in the overview.

NHS Cumbria Medicines Management Team, February 2013 10

3. From Compliance to Concordance 1997. Royal Pharmaceutical Society of Great Britain.

5. Quality and Outcomes Framework guidance for GMS contract 2012/13

6. Prognostic Indicator guidance

7. The Lothian Joint Formulary www.ljf.scot.nhs.uk

8. NHS Cumbria Medicines Management Information available from:

NHS Cumbria Medicines Management Team, February 2013 11

Medication Review Screening Tool

Do you understand what your medicines are for? Y/N

Do you understand when to take your medicines? Y/N

Do you find it easy to take your medicines? Y/N

Do you always remember to take your medicines? Y/N

Do you return excess, unwanted or leftover medicines to the pharmacy? Y/N

Are you comfortable with your current medication? Y/N

Any No answer prioritises the patient for medication review

NHS Cumbria Medicines Management Team, February 2013 12

WHAT IS A MEDICATION REVIEW?

BENEFITS OF ATTENDING A MEDICATION REVIEW

NHS Cumbria Medicines Management Team, February 2013 13

QUESTIONS YOU COULD ASK AT YOUR MEDICATION REVIEW

NHS Cumbria Medicines Management Team, February 2013 14

Write your own questions and concerns here:

WHAT HAPPENS AFTER A MEDICATION REVIEW?

Contact details for surgery.

NHS Cumbria Medicines Management Team, February 2013 15

The ACB score (anticholinergic burden2) is included here because anticholinergic