How to conduct a clinical review of a patient’s medicines

The medication review is a well established intervention within UK primary care. There are multiple types of medication review, but they all primarily focus on ensuring safety, monitoring side effects, supporting adherence, managing polypharmacy and optimising medicines use​[1–3]​.

The success of the medication review is heavily influenced by the consultation skills and clinical experience of the clinician, and it has been shown that shared decision making and equal partnership between the clinician and patient can improve outcomes​[1]​.

Medication reviews should aim to identify what is best for the patient’s overall quality of life and include an evidence-based appraisal of the therapeutic benefits of their medicines balanced against the risks and side effect burden. It is essential that pharmacists are well prepared and equipped for these consultations; this article will outline best practice principles alongside practical advice for structuring the review and approaching conversations with patients.

Approaching the consultation

Before the consultation, it is important to consider patient accessibility needs. Vulnerable patients, those with disabilities, or people from marginalised backgrounds often experience inequitable access to services​[4]​. Making suitable adjustments, such as organising interpreters or large-format printed materials, can enable patients to contribute fully and benefit more from the consultation. Reviewing the patient record prior to the consultation will result in better preparedness for the review itself, enabling a more productive conversation. It is also important to ensure sufficient time for the review has been allocated: research suggests that structured medication reviews need to last for a minimum of 30 minutes to be fully effective​[5]​.

Duration and frequency of reviews will vary depending on the complexity of the patient’s needs. For example, in patients with complex polypharmacy, where there is lots of information to discuss, it may be necessary to increase the consultation length or arrange a series of reviews.

It is important that pharmacists ensure that the following points are addressed during a medicines review:

• If the patient still needs to be on all their medicines;
• If the medicines are helping the patient;
• If the medicines are causing harm or risk to the patient;
• If the patient is happy to continue to receive and take the medicines;
• If the patient should be offered any additional medicines for treated or untreated conditions​[6]​.

Useful tips and advice on how this can be achieved in practice are outlined below.

1. Determine what matters to the patient

It is important to build trust and develop rapport with the patient from the outset, and consultations should begin with personal introductions. For example:

“Hello, my name is …. and I am the pharmacist here. You are here to discuss your health and medicines. Can I first confirm your name and date of birth please?”

Pharmacists should seek to understand what matters to the patient and whether they understand the objectives of the prescribed drug therapies, management of existing health problems and the prevention of future health problems.

The ‘ICE’ mnemonic can be used effectively to explore the patient’s ideas, concerns and expectations (ICE), together with simple, open questions​[7]​.

“Before we delve into things more deeply, I’d like to know how you are getting on at home. How are things? How are you managing?”

This is a time for the clinician to be silent and gather information, as well as identification of patient priorities and rapport development: a ‘golden minute’​[8]​. Observation of characteristics such as walking pace and gait when moving into the consultation room, shortness of breath or pallor, or ability to participate in the review process (e.g. cognition) can provide valuable insight into the disease monitoring process. Ask questions such as:

“Tell me, what do you understand about your health?”

“I gather you have COPD; what do you understand by this and how does this affect you day to day?” 

“What matters to you?” — ask this question to identify aims and objectives of drug therapy.

Pharmacists should ask themselves the following questions when considering drug therapies:

• Is the medicine in a form the patient can take?
• Is the dosing schedule convenient?
• What assistance does the patient have and when is this available?
• Can the patient take their medicines as intended?​[6]​

Once the patient’s priorities are identified, it is important to discuss their health needs, disease history and current management. If changes in management (either pharmacological or non-pharmacological) are to be considered, build a shared understanding of this with the patient​[9]​.

“And when you say your breathing ‘has been worse’, can you tell me more about that, and how often it happens?”

Further information may be needed to better understand the patient’s experience:

“Do your symptoms wake you at night? Are you short of breath when resting? How far can you walk before you become breathless?”

It may be necessary to ask about other symptoms that patients may not have mentioned, to build a full clinical picture:

“Have you noticed any ankle swelling or anything else unusual?”

Not all illnesses are life-limiting and many patients live well with disease if managed appropriately. Some patients attending reviews will be living with the symptoms of their comorbidities, despite pharmacotherapy​[10]​. By establishing early in the review process what patients want from the management of their conditions and their expectations for the future, the clinician can encourage their active participation. For example, the progression of COPD will require the patient’s treatment aims to be re-established at each review as the disease advances​[11]​. A patient-led approach should be taken, with the aim being to maximise their quality of life, with the management of the condition tailored around the things most important to them.

2. Identify essential and non-essential drug therapies

Once the patient’s experience, expectations and understanding of their health has been established, it is important to link this with prescribed medicines​[6]​.

Examine the patient’s comorbidities alongside their listed medicines; consider if all diseases have relevant prescribed medicines (if appropriate), and if all medicines prescribed have an appropriately matched diagnosis or indication​[6]​. Asking the patient to confirm how medicines are administered at home will offer insight into compliance and will reconcile home use with clinician records:

“I can see you are regularly using a steroid nasal spray. What do you use this for?”

A cross-matching approach to linking diagnosis with prescription might identify opportunities for deprescribing and medicines optimisation. The STOPP/START tool can be effectively implemented within the ageing population, in whom polypharmacy is particularly problematic​[12]​.

Patient education is essential, to ensure understanding of the purpose of prescribed therapies, and should be linked to the patient’s established aims.

The use of over-the-counter (OTC) medicines, herbal remedies and non-traditional approaches (such as illicit drug use) to managing patient health should also be explored, since OTC medicines can also be a significant contributor to inappropriate and/or excessive polypharmacy​[13]​. Ask the patient:

“Do you take any other medicines or use any other products that are not prescribed by your GP? This may include creams, inhalers, powders, gels, or sprays.”

Where medicines deprescribing is considered, research has shown that communicating risks of side effects as a rationale for making changes is preferred, and that shared-decision making ensures both patient and clinician are better informed, with better outcomes on reducing overprescribing​[14,15]​. Patient education should therefore focus on discussion of both risks and benefits of medicines to facilitate informed decision making:

“This group of medicines is well known to increase your risk of falling, as well as affect what we might call ‘cognitive function’; this may mean it makes you more likely to fall and/or become confused or notice memory changes.”

Once any deprescribing discussions have taken place, all remaining medicines should be verified as having appropriate functions that align with the patient’s therapeutic goals. Indeed, medicines that are indicated as to be continued may not remain that way, and if a specified duration of therapy is necessary to achieve intended benefit (e.g. statins), it may be that medicines lose their necessity or purpose as time progresses, and can be deprescribed in future reviews​[16]​.

It is important to note that drug therapy may not always be the solution to illness, with lifestyle changes and/or referral to non-pharmacological services an option. Mental health can also be significantly improved through exercise and talking therapies, and dietary management of type 2 diabetes mellitus plays a huge factor in the success of treatment​[17,18]​. Patients should be offered the opportunity to explore all options, while being aware that they should seek advice before stopping any medicines.

3. Determine the effectiveness of prescribed therapies

The patient’s remaining drug regime, although now synchronised with therapeutic objectives, may not have optimised doses to minimise risk but maximise outcomes. It may be necessary to taper or intensify drug therapy through titration of doses to achieve tighter symptomatic control or reach biochemical or clinical targets.

Current treatment choice may not be as effective as other options and, if not already established, patient adherence must be investigated before changing or optimising current therapy. With a purported 40–50% of patients with chronic conditions not taking their medicines as prescribed, the challenge of encouraging adherence is significant​[19]​.

Disease monitoring, including any pathology and/or microbiology results, may also inform the outcome of the review. The presence or absence of these results may prompt further requests for testing or inform medicines prescribing/deprescribing. Prior available laboratory markers and pathology results must also be considered, as studies show these can lead to the provision of useful advice from pharmacists and may also identify a need for referral or changes to current treatment plans​[20]​.

Initiation of statins is a good example here:

“We use a risk scoring system to identify the percentage risk that people have for experiencing a heart attack or a stroke in the next ten years. To better allow us to calculate your risk, it would be useful for you to have a blood test to check your cholesterol levels.”

It may also be necessary to review thyroid status and adjust existing medicines:

“I notice your TSH, a measure we use to monitor your thyroid function, has been particularly low on your last two tests. This suggests we need to reduce the amount of levothyroxine that you are taking.”

Readers may find this article on how to provide patients with the right information to make informed decisions useful.

While medicines will form a significant topic within the medicines review, lifestyle factors should also be discussed to form a more patient-centred picture (e.g. smoking habits, diet and/or exercise, alcohol use), as this provides opportunity for intervention and higher levels of care, particularly in chronic disease​[21]​. Outcomes of these discussions may prompt referrals to smoking cessation services and/or drug and alcohol addiction and recovery hubs.

4. Ensure the safety of the prescribed therapies and associated patient understanding

Patients may present their concerns relating to side effects or adverse drug reactions in the ‘golden minute’ at the beginning of the consultation, or describe symptoms that may be associated with a prescribed medicine (e.g. leg swelling and amlodipine)​[22,23]​. Other patients may be less forthcoming, in which case, this information needs to be elicited.

Drug–drug, drug–food and drug–disease interactions must also be considered and/or, if relevant, discussed in detail with patients​[24,25]​. It is essential to understand patients’ prior adverse reactions or allergies before prescribing any new medicines, as well as any relevant Medicines and Healthcare products Regulatory Agency’s safety alerts, which may indicate the need for dose adjustments or drug changes (e.g. concomitant use of simvastatin and amlodipine)​[26]​. Questions asked will be influenced by the current drug regimen, but important areas include drug combinations with a high anticholinergic burden; significant opiate prescribing; drugs which may increase risk of falls (e.g overprescribing of antihypertensives or benzodiazepines); and drugs with a narrow therapeutic index (e.g warfarin or lithium). Highlighting risks to patients to support ideas for change may be necessary, to reduce excessive polypharmacy and ensure patients can make informed decisions about continuation of medicines use.

5. Determine cost effectiveness

Medicines choice is affected by several factors and, aside from patient preference, it also relates to national guidelines and local formularies. While opportunities to minimise cost may occur, decisions should ensure that clinical effectiveness, safety and adherence are not compromised​[6]​.

Pharmacists should consider whether a prescribing decision is cost effective and falls in line with regional formularies and communicate any possible options to change with patients. Any potential improvement in cost effectiveness needs to be balanced against therapeutic needs and the patients’ specific circumstances. If a change in medicines results in loss of disease control and/or hospital admission then the initial cost savings will quickly be negated.

6. Develop and approve a management plan

At this point in the consultation it would be expected that a management plan has been formulated; further discussion from this point will be more clinician-led, describing options for medicines, monitoring, referrals or follow-up, until a shared agreement is reached:

“Given what we have discussed about the risks and benefits of this medicine, how would you feel about working together on a process for reducing your dose, perhaps even stopping altogether?”​[9]​

Seeking patient opinion and approval on a proposed management plan should facilitate transition into the final part of the review: summarising the issues identified, agreed methods for management or resolution, and a clear follow up plan.

If referrals are necessary, it is important to provide adequate safety-netting, should circumstances change or if new symptoms occur; this helps patients identify the need to seek more urgent medical attention​[27]​.

7. Ensure the patient is willing and can take their medicines as intended

Asking the patient to recap what has been discussed facilitates a final check on their understanding:

“So, having discussed everything, shall we recap the plan that we have agreed so that I know we haven’t missed anything?” 

Reassessing whether the patient’s ideas, concerns and expectations have been met is essential to maintain rapport and determine the patient’s perceived success of the medication review:

“We have discussed a lot of things; do you feel we have covered everything you wanted to discuss?”.

If things have been missed, it may be necessary to spend more time to re-evaluate the patient’s priorities, reconsider medicines prescribed and their safety, and re-establish a management plan​[9]​.

Effective use of the ‘Teach back’ method can be used to confirm that the patient has understood the outcomes of the review, and reinforce the points outlined during the consultation​[28]​.

A clear, factual account of the review should be documented in the patient’s records, including shared agreements and agreed follow-up actions, so that other healthcare professionals who may access it understand the information gathered​[29]​.

After the review

Following the medicines review, the pharmacist should take time to reflect on what they have learnt, including opportunities for development and any learning needs that may have emerged as part of the review process​[9]​. Although the skills of the clinician conducting medication reviews have been noted as a determinant for the effectiveness of the consultation, it is important to note that consultation skill evolves with experience, and patients will benefit from a shared connection and opportunity to talk about their experience of managing their medicines at home​[30]​.