Applying 7 Steps

Review diagnoses and identify therapeutic objectives

• Patient reports: pain control is her main priority while minimising side effects. Patient wonders whether she can begin using buprenorphine patches again as these worked really well
  • Constipation and Drowsiness
• Therapeutic objectives: include minimising GI Symptom and managing hypertension

Review need for essential drugs (stop only on expert advice)

• Levothyroxine: to treat hypothyroidism

Review need for non-essential drugs – consider stopping or reducing dose (deprescribe)

• Pain control: is the NSAID really required. Consider stopping with follow up and review
• Hypertension management: is hypertension still an issue? Normotensive whilst sitting, and is dizzy on standing. Consider stopping bendroflumethiazide (deprescribe)
• Lipid management: does patient need a statin? No indication is recorded so consider stopping (deprescribe)

Identify if therapeutic objectives are being met and whether therapy should be added or intensified

• Pain control: is relatively good and not interfering with function too much and she felt that she was coping well. Realistic expectation of pain control discussed as well as self-management. Is ibuprofen required?
• Tiredness: review hypothyroidism control. Is on a low dose with fatigue, so check TFTs

Identify patient safety risks

Identify adverse drug effects

• Actual ADR: sedation and constipation due to co-codamol. Consider for dose reduction (deprescribe)
• Actual ADR: dyspepsia due to ibuprofen. Consider stopping or dose reduction (deprescribe)
• Actual ADR: Postural hypotension due to bendroflumethiazide. Normotensive so consider stopping (deprescribe).
• Sick Day Rules Guidance: Check that patient is aware of what medication to stop with dehydration, however no longer an issue if stops diuretic

Opportunities for cost minimisation (e.g. generic substitution) should be explored

Ensure prescribing in keeping with current formulary recommendations

Does the patient understand the outcomes of the review?

Ensure drug therapy changes are tailored to patient preferences

Agree and Communicate Plan

• Preferences and understanding to form action plan:
• Pill burden: keen to reduce tablet burden and try alternatives, including non-pharmacological interventions
• Pain management: pain is under control so side effects can be minimised by reducing current medication rather than adding any additional medication. Explore non-medication interventions to maintain function
• ADR reduction: keen to reduce or stop co-codamol 30/500 because of side effects, risks and limited effectiveness
• ADR reduction: keen to reduce or stop ibuprofen as she felt it was making her indigestion worse
• Discussion: benefits and risks of medication reduction
• Co-codamol 30/500 reduced from 2 four times a day to 1 four times a day with paracetamol added 1 four times a day with plan to review and further reduce if possible
• Flexibility of increased dose of co-codamol during flare-up of pain
• Antihypertensive stopped and reviewed 1/12
• Statin stopped
• NSAID stopped
• Plan to review GI side effect and stop omeprazole at next consultation