Download Carrying out a structured medication review

n MEDICINES OPTIMISATION
Carrying out a structured
medication review
SHARON COANE and ROSALYNE PAYNE
As part of our series on the NICE guideline on
Medicines Optimisation, Sharon Coane and Rosalyne
Payne discuss the NICE recommendations relating to
medication review and how to put these into practice
effectively.
Recommendation 1.4.1. Consider carrying out a structured medication review for
some groups of people when a clear purpose for the review has been identified.
These groups may include:
• adults, children and young people taking multiple medicines (polypharmacy)
• adults, children and young people with chronic or long-term conditions
• older people
Recommendation 1.4.2. Organisations should determine locally the most appropriate health professional to carry out a structured medication review, based on their
knowledge and skills including all of the following:
• technical knowledge of processes for managing medicines
• therapeutic knowledge on medicines use
• effective communication skills
The medication review may be led, for example, by a pharmacist or by an appropriate
health professional who is part of a multidisciplinary team
Recommendation 1.4.3. During a structured medication review, take into account:
• the person’s, and their family members or carers where appropriate, views and
understanding about their medicines
• the person’s, and their family members’ or carers’ where appropriate, concerns,
questions or problems with the medicines
• all prescribed, over-the-counter and complementary medicines that the person is
taking or using, and what these are for
• how safe the medicines are, how well they work for the person, how appropriate
they are, and whether their use is in line with national guidance
• whether the person has had or has any risk factors for developing adverse drug
reactions (report adverse drug reactions in line with the Yellow Card scheme)
• any monitoring that is needed
Table 1. NICE Medicines Optimisation guidance: recommendations relating to medication
review1
I
n March 2015, NICE issued guidance
on Medicines Optimisation (NG5), with
specific recommendations on medication
review (see Table 1).1 NICE states that
the review should be “a structured, critical examination of a person’s medicines
with the objective of reaching an agreement with the person about treatment,
optimising the impact of medicines, min-
22 z Prescriber January 2016
imising the number of medication-related
problems and reducing waste.”1 In this
article, we discuss what these recommendations mean for prescribers and
how they could be applied in practice.
Which patients should be
reviewed?
The NICE guideline suggests that a
structured medication review should be
carried out in the following groups of
patients:
1. Adults, children and young
people taking multiple medicines or
polypharmacy
Polypharmacy can be divided into two
categories:
• Appropriate polypharmacy, which can
extend patients’ life expectancy and
improve quality of life and
• Inappropriate polypharmacy, sometimes called problematic polypharmacy,
which can increase the risk of drug interactions and adverse drug reactions, and
reduce medication adherence and also
quality of life for patients.
It is important that for each medication,
the rationale for treatment choice should
be recorded and reference made to a risk
versus benefit assessment, considering
patient acceptability and choice.2
The NICE guidance does not stipulate
how many medicines constitute “multiple
medicines” or polypharmacy. However,
The King’s Fund suggests a pragmatic
approach, such as focusing on patients
with 10 or more medicines on repeat prescription or those prescribed four to nine
medicines on repeat together with other
unfavourable factors such as contraindicated drugs, potential drug interactions
or where there have been complications with taking medicines in the past.2
Interventions such as the Pharmacistled Information Technology Intervention
prescriber.co.uk
Medication review
for Medication Errors (PINCER) tool can
be used to identify patients at risk from
harm due to prescribing or monitoring
errors.3
2. Adults, children and young people with
chronic or long-term conditions
It has been reported that more than 15
million people in England are living with
a long-term condition, eg hypertension,
depression, dementia and arthritis, and
this accounts for up to 70 per cent of
the healthcare budget. This is expected
to increase over the next 10 years, especially the number of people with three or
more co-existing conditions.4
NHS England’s Five Year Forward
View encourages people to manage their
own health by staying healthy, making
informed treatment choices, managing
their own conditions and avoiding complications.5
Patients with long-term conditions
may have multiple co-morbidities and
see multiple clinicians. Many clinical
trials and guidelines do not take into
account long-term conditions that commonly co-exist (see Figure 1). Primary
care practitioners are in an ideal position to review medication that patients
take for all their long-term conditions and
co-ordinate their care. Given that this is a
large cohort of patients, strategies such
as stratifying patients according to read
codes or hospital admission, or focusing on one or two therapeutic areas per
month, could make this process more
manageable.
3. Older people
In the UK, 45 per cent of prescriptions
are dispensed to patients over the age of
65 years although they represent only 17
per cent of the population.7 The higher
prevalence of multiple co-morbidities in
older people and the corresponding prescribing of multiple medicines (managed
by multiple physicians) to treat these conditions, coupled with pharmacokinetics
and pharmacodynamic changes associated with ageing and disease, greatly
increases their risk of adverse drug
reactions (ADR) and drug/drug interactions.7,8 In 2012, one person aged over
65 years in the UK died as a result of a
fall every three hours9 and it has been
prescriber.co.uk
Type 2 diabetes
Type 2 diabetes
l MEDICINES OPTIMISATION n
Depression
7
Heart failure
20
Depression
18
Heart failure
7
2
Myocardial infarction
11
4
36
Chronic kidney disease
14
4
23
Atrial fibrillation
7
2
25
COPD
9
7
18
Painful condition
23
27
23
Rheumatoid arthritis
1
1
1
Dementia
2
3
1
Hypertension
61
23
57
17
Figure 1. Percentage of people with three index conditions (type 2 diabetes, depression,
heart failure) who also have each of the other named conditions. Morbidity data were not
available for osteoarthritis or neuropathic pain; “painful condition” data shown are defined
by receipt of four or more prescriptions for non-over-the-counter analgesics in previous 12
months. Reproduced with permission from Dumbreck S, et al. BMJ 2015;350:h9496
reported that in older patients taking four
or more medicines, there is a 14 per cent
increased risk of a fall with each additional medicine prescribed.10 Therefore,
it is important to assess the benefit versus risk of medicines prescribed for this
age group and rationalise their use; a
medication that may have been appropriate when a patient was 40 years old may
not be so when they are in their 80s or
90s. A review of the medication should
be individualised, as with all different age
groups.
Which healthcare professionals
should be involved?
NICE states that organisations must
determine locally the most appropriate
healthcare professional to conduct the
review. They must have the following
skills:
• Therapeutic knowledge of the processes for managing medicines
• Therapeutic knowledge on medicines use
• Effective communication skills.
In Coventry, pharmacists have been
commissioned to review the patient
either at the surgery or by calling the
patient at their home. Comparing medicine reviews conducted by a GP alone
with those conducted by a pharmacist
and GP collaboratively, showed that
more drugs were stopped when working
together (see Figure 2), minimising the
potential for medication-related problems. 11 Pharmacists were chosen for
this role, as working within the multidisciplinary team utilises their professional
skills, therapeutic knowledge on medicines use and technical knowledge of
managing medicine. Although being an
independent prescriber is not essential
to conduct medication reviews, having
this additional skill means that the pharmacist can easily correct any doses or
make appropriate changes to a patient’s
therapy.
Taking a patient-centred
approach
In order to undertake an effective medication review, the patient and/or their
Prescriber January 2016 z 23
n MEDICINES OPTIMISATION l Medication review
encourage the patient to disclose the
regular medicines they are taking to the
pharmacist before they purchase a medicine over the counter.
In the USA, it has been reported that
more than 50 per cent of patients with
chronic diseases or cancer use complementary medicines and nearly one-fifth
500
of patients take these products concomitantly with prescribed medicines.12 In one
study, it was estimated that only 30 per
cent of patients disclosed to their healthcare provider that they had taken complementary or herbal medicines. Some
ingredients in complementary/herbal
medicines, such as St John’s wort, mag-
before the review
10% discontinued
400
Number of items
carer needs to be fully engaged in the
process and their views and opinions
sought throughout the consultation. This
will give the reviewer more insight as to
how the patient actually takes their medicine, help identify nonadherence and
enable them to work with the patient to
agree a management plan for their condition.
If patients are requested to attend
the surgery for a medicine review, an
invitation letter should be sent or, at the
start of the review, the reason for the
review explained. Medication reviews
can be a source of anxiety for patients:
it is important to explain that guidance
may have changed since their medicines
were first started while avoiding worrying
a patient about potential side-effects of a
drug, which they have been taking happily
with no adverse effects.
A suggested model for conducting a
patient-centred polypharmacy review is
shown in Figure 3).12 To understand the
patient perspective, it is helpful to begin
a review with open questions such as:
“How are you getting on with your medicines?”
“What is important to you about your
medicines?” or
“How do you feel about taking your medicine?”
In Coventry, we found that many older
people did not want to take as many medicines as they were currently taking and
welcomed the opportunity to discuss
stopping some if they were considered
inappropriate.
after the review
21% discontinued
300
200
100
0
GP alone
With pharmacist support
Figure 2. Comparison of the effect of polypharmacy reviews in two similar practices (GP alone
or with medicines management team pharmacist support) on number of items prescribed
Assess patient
Monitor and adjust regularly
Define context and overall
goals
Communicate actions with
all relevant parties
Identify medicines with
potential risks
Agree actions to stop,
reduce dose, continue or
start medication
Assess risks and benefits in
context of individual patient
What to include in the
medication review
• Ask about all prescribed, over-thecounter and complimentary medicines
that the person is taking or using, and
what these are for
Many medicines bought over the counter
may be contraindicated, be used to treat
the same condition as the prescribed
medication or interact with prescribed
medication. To prevent this, it is important that the practitioner reviews all the
medication that the patient is taking.
As more medicines become available to
buy over the counter, it is important to
ascertain what the patient is taking to
give advice on its appropriateness and
24 z Prescriber January 2016
Figure 3. A patient-centred approach to managing polypharmacy in practice. Taken from
Barnett N, et al. 201512
prescriber.co.uk
Medication review
nesium, calcium, iron and gingko biloba,
could lead to potentially serious drug
interactions.13
The NICE guidance does not mention
asking about the use of recreational drugs
or advising on drug/food interactions.
Prior to the consultation, identify
questions about the medicines currently
prescribed including:
1. How safe are the medicines? For example, have there been any MHRA reports,
such as for domperidone, metoclopramide and mirabegron? Are there any
contraindications/cautions, eg NSAIDS
in patients with renal impairment or heart
failure?
2. How well do the medicines work for the
person? Some medications should be
reviewed periodically to assess whether
they are still working such as anticholinergics, eg solifenacin and tolterodine
for urinary incontinence. These can be
assessed using a treatment break. Has
the patient’s renal function been reviewed
and the dose adjusted or changed
accordingly? For example, thiazides are
no longer effective if their eGFR is <30ml
per min. If they are taking analgesia, is
it still effective and is it still required?
If the patient is taking a laxative, is this
still required? These issues can then be
discussed within the consultation.
3. How appropriate are the medicines? Is
the patient requiring end-of-life care? Do
they still need to take a statin for primary
prevention? Are they an older person on
antihypertensives? Is their blood pressure too low and are they at risk of a fall?
4. Is the use of the medicine in line with
national guidance? Have any recent
guidelines been published? For example, avoiding aspirin as monotherapy in
atrial fibrillation, prescribing clopidogrel
instead of dipyridamole and aspirin for
the secondary prevention of cerebrovascular events.
5. Does the person have any risk factors
for developing an ADR? (report ADRs to
the Yellow Card scheme) Five per cent of
hospital admissions are thought to be
due to adverse drug reactions (ADRs),
which increases to 10 per cent in the
older patient.14 A patient on one or two
medicines has a 5 per cent chance of
experiencing an ADR whereas a patient
on five or more medicines has a 20 per
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l MEDICINES OPTIMISATION n
Healthcare professionals are asked to help improve medicines safety by reporting all
suspected ADRs to the Yellow Card scheme that are:
• associated with newer drugs and vaccines – identified by the black triangle t
symbol: mhra.gov.uk/blacktriangle
• s erious, medically significant or result in harm from established vaccines and
medicines, including unlicensed medicines, herbal remedies and medicines used
off-label. Serious events are fatal, life-threatening, disabling or incapacitating, or
result in or prolong hospitalisation
• If you are unsure, please report anyway
Table 2. Reporting adverse drug reactions (ADRs) to the Yellow Card scheme15
cent chance of experiencing an ADR.8,9 A
study undertaken in two large UK hospitals analysed hospital admissions over a
six-month period; 6.5 per cent of admissions were thought to be due to an ADR
(at an estimated cost of £466 million
to the NHS) of which 72 per cent were
considered to be preventable.8 In clinical
trials it is usual for between 2500–3000
patients to be exposed to a medication
before it is licensed. If a reaction is
rare and occurs in less than 1 in 1000
patients, it might not be detected during
trials; this is one of the reasons why it is
so important that reactions are reported
to the Yellow Card scheme (see Tables
2 and 3).15
6. Are there any monitoring requirements?
Many of the medicines used in primary
care require different tests when initiated or regular tests throughout treatment. A useful document produced by
the UK Medicines Information (UKMi)
service – Suggestions for Drug Monitoring
in Adults in Primary Care – can be used
as guidance16 or you could refer to local
guidelines or the Summary of Product
Characteristics (available from www.
medicines.org.uk/emc) for more information on monitoring requirements.
What relevant information is
missing from the guideline?
While NICE guidance focuses more on
deprescribing, medicine reviews are
about working with the patient to optimise their medicines. This may include
reducing or changing existing medication
and initiating new medication as well as
deprescribing.
The guidance includes some information about medication adherence
but does not highlight the importance of
medication review as an opportunity to
establish patient adherence to their medication or identify and help the patient
Year
Drug
Reason
2004
Rofecoxib
Myocardial infarction/stroke
2005
Co-proxamol (paracetamol/
dextropropoxyphene)
Suicide
2008
Rimonabant
Suicide and depression
2009
Efalizumab
Progressive multifocal
leukoencephalopathy (PML)
2010
Sibutramine, rosiglitazone
Cardiovascular effects
2013
Tredaptive/Pelzont/Trevaclyn
(nicotinic acid/laropiprant)
Benefit does not outweigh risks with no
additional benefit when taken in addition
to statin compared to statin alone plus
increased risk of bleeding, myopathy,
infections and new onset diabetes
Table 3. Examples of drug withdrawals following Yellow Card reports15
Prescriber January 2016 z 25
n MEDICINES OPTIMISATION l Medication review
resolve any barriers they may have to taking them. It has been reported that up to
50 per cent of patients do not take their
medicines as intended.17
The STOPP START toolkit18 is mentioned as a potential screening tool earlier in the guidance for older people in
general but tools are not discussed in
detail and there is merit in exploring this
when creating a medication review service. The issue of cost-effectiveness of
medicines and adherence to formularies
is not included. Finally, medication review
is an opportunity to discuss appropriate
ordering with the patient to avoid medicine waste, which is also not mentioned
in the guidance.
Barriers to conducting an
effective medication review
1. Time
For the review to be effective, we suggest at least 20 minutes patient-facing
time is needed. Additional preparation
time is needed and having a dedicated
healthcare professional, such as a
practice-based pharmacist, undertaking
the reviews means that the GP is still
available for their daily case load. Time
invested now can save time later as
fewer prescriptions may be needed. The
investment in time is usually compensated for in drug cost savings.
2. Identifying patients
The practice will need to prioritise
which patients to review first. Common
systems are based on the number of
medicines prescribed and/or age of
the patient, eg targeting all patients
aged over 80 years and taking eight
or more medicines. The target group
can be identified using a search on the
practice system. Alternatively a patient
group could be identified, eg patients
with diabetes.
3. Patient perceptions
Clinicians may fear that reducing the
number of medicines being taken by
a patient could be seen as a cost-cutting exercise or there may be a concern that the patient will feel that their
medicines are being reduced because
their health and wellbeing are no longer
worth investing in. In Coventry, talking
26 z Prescriber January 2016
to patients after polypharmacy reviews
showed that these concerns were generally unfounded; patients wanted to take
fewer medicines and many felt better for
doing so.
Conclusion
NICE recommends medication reviews
as part of its guidance on Medicines
Optimisation. Medicine reviews can be
a positive experience for the patient,
enhancing their understanding of the
medicines they are taking and decreasing the number of unnecessary prescriptions.
References
1. NICE. Medicines optimisation. NG5. Section
1.4: Medication review. March 2015.
2. Duerden M, et al. Polypharmacy and medicines optimisation: making it safe and sound.
The King’s Fund, 2013. www.kingsfund.
org.uk/sites/files/kf/field/field_publication_file/polypharmacy-and-medicines-optimisation-kingsfund-nov13.pdf [accessed 3
November 2015]
3. The University of Nottingham. PINCER audit
tool. www.nottingham.ac.uk/primis/tools-audits/tools-audits/pincer.aspx
4. Department of Health. 2010 to 2015 government policy: long term health conditions.
Policy paper. May 2015. https://www.gov.
uk/government/publications/2010-to-2015g ov e r n m e n t - p o l i c y - l o n g - t e r m - h e a l t h conditions/2010-to-2015-governmentpolicy-long-term-health-conditions [accessed
13 November 2015]
5. NHS England. Five year forward view.
October 2014. https://www.england.nhs.uk/
wp-content/uploads/2014/10/5yfv-web.pdf
[accessed 13 November 2015]
6. Dumbreck S, et al. Drug-disease and drug
interactions: systemic examination of recommendations of 12 UK national clinic guidelines. BMJ 2015;350:h949.
7. Kavanagh S. Prescribing for the older
patient. Patient UK. August 2014. http://
patient.info/doctor/prescribing-for-theolder-patient [accessed 11 December 2015]
8. Beard K. Drug treatment as a cause of
hospital admission. J R Coll Physicians Edinb
2005;35:35–6.
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UK_factsheet.pdf [accessed 11 December
2015]
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polypharmacy burden”. Pharm J
2015;294(786819):705.
12. Barnett N, et al. A patient-centred approach
to polypharmacy: a process for practice. July
2015. Available at: www.medicinesresources.
nhs.uk/en/Communities/NHS/SPS-E-andSE-England/Meds-use-and-safety/Servicedeliv-and-devel/Older-people-care-homes/
Polypharmacy-oligopharmacy--deprescribingresources-to-support-local-delivery [accessed
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mhra.gov.uk/the-yellow-card-scheme/
[accessed 16 November 2015]
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suppor ting medication review. Februar y
2013. Available at: www.cumbria.nhs.uk/
ProfessionalZone/MedicinesManagement/
Guidelines/StopstartToolkit2011.pdf
Declaration of interests
Sharon Coane has received an honorarium from Danone Nutricia for taking part
in a Pharmacy Advisory Board.
Sharon Coane is an HIV lead
pharmacist at Heartlands Hospital,
Birmingham, but previously a prescribing support pharmacist at Coventry
and Rugby CCG and Rosalyne Payne
is a care home support pharmacist at
Coventry and Rugby CCG. They were
the winners of the RPS Pharmaceutical
Care Awards 2015 for their work on
polypharmacy reviews
prescriber.co.uk