During a practice audit of patients over 75 years taking 10 or more regular medications, you identify several patients who would benefit from structured medication reviews. You are prioritising which patients to review first based on risk stratification. According to best practice guidance on medication reviews in primary care, which patient characteristic indicates HIGHEST priority for urgent structured medication review?

A patient recently discharged from hospital with five new medications added to their existing regimen

A patient taking 15 medications who has been stable on the same regimen for 3 years with no recent adverse events

A patient taking multiple high-risk medications including warfarin, methotrexate, and lithium who attends regular monitoring

A patient who has reached the age of 75 and is now eligible for routine medication review under the Quality and Outcomes Framework

A patient with declining renal function (eGFR decreased from 68 to 54 over 12 months) taking eight regular medications

A 75-year-old man with COPD (post-bronchodilator FEV1 42% predicted), ischaemic heart disease, atrial fibrillation, and type 2 diabetes attends for medication review. He is on multiple inhalers: tiotropium, salmeterol/fluticasone 25/250 twice daily, and salbutamol as needed. Other medications include apixaban, bisoprolol, ramipril, atorvastatin, and metformin. He has had two exacerbations requiring oral steroids in the past year, the last one being 8 months ago. His current COPD symptoms are well-controlled with no exacerbations recently. Sputum cultures from his last exacerbation grew Pseudomonas aeruginosa. Which change to his inhaler therapy is MOST appropriate?

Switch from salmeterol/fluticasone to a triple therapy inhaler (LABA/LAMA/ICS combination)

Add a regular azithromycin prophylaxis regimen due to previous Pseudomonas infection

Stop inhaled corticosteroids and continue bronchodilators only, given limited recent exacerbations

Reduce fluticasone dose to minimise steroid-related adverse effects including pneumonia risk

Add regular nebulised colistin for Pseudomonas suppression in COPD

You are conducting a structured medication review for an 80-year-old man with heart failure (NYHA class II), type 2 diabetes, chronic kidney disease stage 3b (eGFR 38 ml/min/1.73m²), and benign prostatic hyperplasia. He lives alone and manages his medications independently using a dosette box filled by his daughter. He takes 13 different medications at various times throughout the day. He mentions he sometimes forgets his evening doses and finds the regimen 'complicated'. Which approach BEST addresses medication adherence in this context according to principles of medicines optimisation?

Simplify the regimen by switching to once-daily preparations where possible and aligning administration times

Arrange for a district nurse to visit twice daily to supervise medication administration

Provide detailed written instructions about each medication and the importance of adherence

Reduce the total number of medications by stopping those not providing immediate symptom relief

Arrange urgent assessment of his cognitive function as non-adherence suggests early dementia

A 70-year-old woman with rheumatoid arthritis, osteoporosis, hypertension, and gastro-oesophageal reflux disease attends for review. She takes: methotrexate 15mg weekly, folic acid 5mg weekly (taken day after methotrexate), prednisolone 5mg daily, alendronic acid 70mg weekly, omeprazole 20mg daily, amlodipine 10mg daily, and calcium/vitamin D daily. Blood tests show: Hb 102 g/L (MCV 88 fL), WCC 3.8 × 10⁹/L, platelets 156 × 10⁹/L, ALT 68 U/L (previously 32), eGFR 58 ml/min/1.73m². Which aspect of her medication regimen requires MOST urgent attention?

The elevated ALT indicating methotrexate hepatotoxicity requiring dose reduction or cessation

The alendronic acid and omeprazole combination reducing bisphosphonate absorption

The low haemoglobin suggesting methotrexate-induced bone marrow suppression requiring urgent cessation

The combination of prednisolone and alendronic acid requiring additional osteoporosis monitoring

The declining renal function requiring methotrexate dose adjustment or alternative DMARD

A practice pharmacist is conducting a quality improvement project on anticholinergic burden in elderly patients with multimorbidity. She identifies a 73-year-old man taking 12 medications with a total Anticholinergic Cognitive Burden (ACB) score of 6. His medications include amitriptyline 50mg nocte for neuropathic pain, tolterodine 4mg for overactive bladder, lansoprazole 30mg, co-codamol 30/500, atorvastatin, ramipril, bisoprolol, aspirin, and metformin. He reports feeling 'foggy-headed' and has had two falls. Which intervention would have the GREATEST impact on reducing anticholinergic burden?

Address both amitriptyline and tolterodine simultaneously by switching to alternatives

Switch tolterodine to mirabegron, a beta-3 agonist with no anticholinergic activity

Replace amitriptyline with duloxetine for neuropathic pain management

Stop lansoprazole as proton pump inhibitors contribute to cognitive impairment

Reduce co-codamol dose as opioids can contribute to cognitive impairment

A 76-year-old woman with dementia (MMSE 18/30), Parkinson's disease, type 2 diabetes, and recurrent falls is brought by her daughter for medication review. Current medications include: co-careldopa 25/100 three times daily, ropinirole 8mg three times daily, quetiapine 25mg twice daily, metformin 500mg twice daily, gliclazide 40mg twice daily, alendronic acid 70mg weekly, calcium/vitamin D, and PRN paracetamol. She has had three falls in the past two months. Her daughter reports increasing confusion and hallucinations. Blood glucose monitoring shows values between 4.8-8.2 mmol/L. Which medication intervention should be prioritised?

Reduce ropinirole as dopamine agonists cause hallucinations and should be withdrawn first

Reduce co-careldopa dose as dopaminergic medications contribute to hallucinations and falls

Stop quetiapine immediately as antipsychotics worsen Parkinson's disease motor symptoms

Review and rationalise diabetes medications given risk of hypoglycaemia contributing to falls

Stop alendronic acid as bisphosphonates increase fall risk in elderly patients

A 68-year-old man with ischaemic heart disease, permanent atrial fibrillation, type 2 diabetes, and osteoarthritis takes: aspirin 75mg, apixaban 5mg twice daily, bisoprolol 5mg, atorvastatin 80mg, metformin 1g twice daily, gliclazide 80mg twice daily, and paracetamol as required. He has no history of stenting or acute coronary syndrome in the past 12 months. His most recent echocardiogram shows LVEF 55% with no wall motion abnormalities. His CHA₂DS₂-VASc score is 5. Which medication change is MOST appropriate?

Stop aspirin as dual antiplatelet and anticoagulation increases bleeding risk without additional benefit

Stop apixaban and continue aspirin alone for cardiovascular protection

Continue both medications as dual therapy is indicated in atrial fibrillation with ischaemic heart disease

Stop both aspirin and apixaban and commence warfarin for better control

Reduce apixaban to 2.5mg twice daily when used in combination with aspirin

During a structured medication review using the STOPP/START criteria for a 71-year-old woman, you identify she takes co-codamol 30/500 four times daily for chronic lower back pain, alongside atorvastatin, ramipril, and bisoprolol. She mentions she has been constipated for several weeks and also takes senna tablets daily. She has no history of major surgery or inflammatory spinal disease, and her back pain has been present for 18 months. Her renal function and liver function are normal. Which action represents BEST practice according to deprescribing principles?

Gradually reduce and stop codeine while optimising non-opioid analgesia and addressing pain holistically

Switch co-codamol to tramadol to reduce constipation while maintaining analgesia

Add a stimulant laxative such as sodium picosulfate to manage opioid-induced constipation

Continue current regimen but refer for specialist pain management assessment

Switch to modified-release morphine for more consistent pain control

A 74-year-old man attends for medication review. He has heart failure (LVEF 32%), atrial fibrillation, type 2 diabetes, stage 3b CKD (eGFR 36 ml/min/1.73m²), and benign prostatic hyperplasia. Current medications: bisoprolol 10mg, ramipril 10mg, furosemide 40mg, spironolactone 25mg, apixaban 5mg twice daily, metformin 1g twice daily, empagliflozin 10mg, finasteride 5mg, tamsulosin 400mcg, atorvastatin 80mg. Blood tests show potassium 5.4 mmol/L, sodium 134 mmol/L, urea 12.8 mmol/L, creatinine 168 μmol/L (stable). He reports good symptom control but occasional dizziness on standing. Which represents the BEST management approach?

Continue current regimen with close monitoring as benefits outweigh risks

Stop spironolactone due to hyperkalaemia risk and continue other heart failure medications

Reduce ramipril to 5mg daily to decrease potassium and improve renal function

Stop empagliflozin as it may be contributing to hyperkalaemia and renal impairment

Stop tamsulosin as it may be causing orthostatic hypotension and reduce polypharmacy

According to the Beers Criteria for potentially inappropriate medication use in older adults, which of the following medications should be avoided in elderly patients regardless of diagnosis or condition?

Long-acting benzodiazepines such as diazepam and chlordiazepoxide

Non-selective beta-blockers in patients with peripheral vascular disease

First-generation antihistamines in patients with cognitive impairment

Proton pump inhibitors when used for longer than 8 weeks

Thiazide diuretics in patients with a history of gout

Medication reviews - Free UK Medical PG Review

Quick Overview

Structured medication reviews are systematic evaluations of a patient's medicines to optimize treatment, reduce polypharmacy, and minimize adverse effects. NICE NG5 recommends regular reviews for patients on multiple medications, particularly those with multimorbidity. This process balances therapeutic benefit against harm, incorporating shared decision-making and deprescribing where appropriate.

Core Facts & Concepts

Review Frequency (NICE NG5)

High-risk patients: Every 6 months (≥10 medications, care homes, recent hospital discharge)
Moderate complexity: Annually (4-9 medications, stable chronic conditions)
Low complexity: Opportunistically or when clinically indicated

Seven-Step Medication Optimization Approach

Aim: Identify treatment objectives with patient
Need: Check indication for each medication (current & continuing)
Effectiveness: Review if achieving therapeutic goals
Safety: Assess adverse effects, interactions, monitoring requirements
Cost-effectiveness: Consider therapeutic alternatives
Adherence: Explore barriers to compliance
Patient perspective: Incorporate preferences and concerns

Deprescribing Principles

Target medications: Anticholinergics, benzodiazepines, PPIs >8 weeks, medications with no clear indication
Prescribing cascade: Stop medication causing adverse effect before adding another drug
Taper when required: Benzodiazepines, beta-blockers, corticosteroids, antidepressants
Monitor post-deprescribing: 1-4 weeks for withdrawal effects or disease recurrence

Figure 1: Structured medication review template showing seven-step framework

Key Numbers

📊 6.5% of hospital admissions due to adverse drug reactions
📊 50% of patients on ≥5 medications have adherence issues
📊 21% reduction in potentially inappropriate prescribing with structured reviews

Problem-Solving Approach

Conducting a Structured Medication Review

Preparation phase
- Access full medication history (GP records, hospital letters, patient's own drugs)
- Review recent blood results (renal/hepatic function, therapeutic drug levels)
- Check allergy status and previous adverse reactions
Patient consultation (15-20 minutes)
- What medications are you actually taking? (identify non-adherence)
- What concerns do you have about your medicines?
- Any side effects or new symptoms?
Clinical assessment
- Indication check: Is each drug still needed?
- Dose appropriateness: Adjust for age, renal function (eGFR), weight
- Drug interactions: Use interaction checker for ≥5 medications
- Monitoring requirements: Are they up to date?
Shared decision-making
- Discuss benefits vs. burdens of each medication
- Prioritize patient's quality of life goals
- Agree on trial deprescribing if appropriate
Safety netting
- Provide written plan of medication changes
- Book follow-up (2-4 weeks for deprescribing, 3 months for optimization)
- Alert to withdrawal symptoms or disease recurrence

🚩 Red Flags Requiring Immediate Action

Medications without documented indication
Duplicate therapy (e.g., two NSAIDs)
Contraindicated combinations (e.g., NSAID + SSRI + aspirin)
Doses inappropriate for renal function
Missing essential monitoring (e.g., lithium levels >3 months overdue)

⚠️ Warning: Always check renal function before continuing renally-excreted drugs (metformin, digoxin, lithium, gabapentin)

Analysis Framework

Deprescribing Priority Tool

Priority Level	Medication Examples	Action Timeline
High (stop/reduce urgently)	Anticholinergics in dementia, benzodiazepines >4 weeks, PPIs without indication	Within 1-2 weeks
Medium (review benefit)	Statins in limited life expectancy, antihypertensives causing falls	Within 1-3 months
Low (monitor)	Vitamins without deficiency, low-dose aspirin in primary prevention <10% CVD risk	Next routine review

Medication Complexity Assessment

Factor	Low Risk	High Risk
Number of medications	<4	≥10
Dosing frequency	Once daily	Multiple times daily
Special administration	Standard oral	Inhalers, injections, complex timing
Monitoring requirements	None/annual	Monthly or more frequent
Renal/hepatic impairment	Normal function	eGFR <30 or Child-Pugh B/C

Adherence Assessment Questions

"How many doses did you miss in the last week?" (non-judgmental)
"What makes it difficult to take your medications?"
"Do you understand what each medication is for?"

Visual Aid

Documentation Requirements (NICE NG5)

Date of review and reviewer name
Medications reviewed (including OTC, supplements)
Clinical rationale for changes
Patient agreement documented
Follow-up plan with specific timeframe
Information shared with patient (written)

Key Points Summary

✓ Structured reviews reduce adverse drug events by 21% and improve adherence in polypharmacy (≥5 medications)

✓ Seven-step approach: Aim → Need → Effectiveness → Safety → Cost → Adherence → Patient perspective (NICE NG5 framework)

✓ Review frequency: Every 6 months for high-risk (≥10 drugs, care homes), annually for moderate complexity (4-9 drugs)

✓ Priority deprescribing targets: Anticholinergics, benzodiazepines >4 weeks, PPIs without indication, prescribing cascades

✓ Essential checks: Renal function for dose adjustment, drug interactions (≥5 medications), monitoring compliance (lithium, warfarin, methotrexate)

✓ Shared decision-making: Balance therapeutic benefit against treatment burden, align with patient's quality of life goals

✓ Documentation must include: Clinical rationale, patient agreement, written plan, specific follow-up timeframe (2-4 weeks post-deprescribing)

📌 Remember: REVIEW - Rationale check, Effectiveness assess, Verify safety, Interaction screen, Engage patient, Write plan