What medication review considerations and practical tips should be applied to optimize a patient's regimen?

Medication Review: A Systematic 8-Step Approach

Conduct medication reviews using a structured stepwise process that prioritizes medication reconciliation, adherence assessment, and identification of drug-drug and drug-disease interactions, followed by systematic screening for high-risk medications using validated tools like the Beers criteria and STOPP/START criteria 1.

Core Algorithm for Medication Optimization

Step 1: Medication Reconciliation

• Create an accurate list of what the patient actually takes (not just what's prescribed)
• Identify discontinued medications still being taken, missing medications, or medications taken incorrectly
• This is a Joint Commission patient safety priority and reduces errors at care transitions 1

Step 2: Adherence Assessment

Use validated tools like the Morisky Medication Adherence Scale 1 to identify:

• Complex dosing schedules (3-4 times daily dosing)
• Cost barriers (unfilled prescriptions)
• Side effects causing non-adherence
• Action: Simplify to once or twice daily dosing whenever possible 2

Step 3: Drug-Drug Interaction Screening

Use interaction databases to identify:

• QT prolongation risks
• Anticoagulant combinations increasing bleeding risk
• NSAIDs with anticoagulants
• Serotonin syndrome potential
• Action: Select non-interacting alternatives or monitor closely if unavoidable 1

Step 4: Drug-Disease Interaction Screen

Identify high-risk combinations:

• NSAIDs in heart failure, chronic kidney disease, or hypertension
• Sulfonylureas in kidney disease (hypoglycemia risk)
• Anticholinergics in dementia
• Action: Choose alternative therapy that doesn't exacerbate the underlying condition 1

Step 5: Identify Overtreatment and Duplication

• Look for duplicate therapy classes
• Identify medications with additive side effects
• Action: Taper or eliminate duplicates; adjust doses 1

Step 6: High-Risk Drug Screening in Older Adults

Apply Beers criteria and STOPP/START criteria 1 to identify:

• Sedative/hypnotics
• Opioids
• Anticholinergics (including over-the-counter products)
• Benzodiazepines
• Hypoglycemic agents
• Action: Reduce or eliminate these medications; educate patients about OTC anticholinergic avoidance 1

Step 7: Identify Undertreated Conditions

Use START criteria to find missed therapy:

• CAD without statin
• Missing antiplatelet after coronary stenting
• Osteoporosis without treatment
• Action: Initiate indicated medications within patient's goals of care 1

Step 8: Monitoring Plan

Establish monitoring for:

• Efficacy (is the medication working?)
• Safety (routine labs like TSH, INR, drug levels)
• Kidney and liver function
• Glucose monitoring for insulin users
• Action: Schedule specific follow-up intervals for each high-risk medication 1

Practical Simplification Strategies

After completing the 8-step assessment, simplify the regimen by 2:

• Consolidating dosing times (move all morning meds to same time)
• Standardizing routes (prefer oral over multiple routes)
• Using long-acting formulations instead of short-acting
• Switching to combination products (e.g., single pill with two drugs instead of two separate pills)

Critical Tools for Implementation

The Medication Appropriateness Index (MAI) uses 10 criteria worded as questions 3:

1. Is there an indication for the drug?
2. Is the medication effective?
3. Is the dosage correct?
4. Are the directions correct?
5. Are there drug-drug interactions?
6. Are there drug-disease interactions?
7. Are the practical directions clear?
8. Is the cost reasonable?
9. Is there duplication?
10. Is the duration appropriate?

Common Pitfalls to Avoid

• Don't assume the prescription list matches what patients actually take - always verify with pill bottles and patient demonstration 1
• Don't overlook over-the-counter medications - particularly anticholinergics in sleep aids and cold medications 1
• Don't continue medications indefinitely without reassessing indication - many medications started in hospital continue unnecessarily 1
• Don't ignore cost as a barrier - unaffordable medications lead to non-adherence and partial filling 1

Deprescribing Considerations

Purposefully stop or taper medications where patients no longer derive reasonable benefit 1. This reduces:

• Mortality rates
• Potentially inappropriate medications by 36.4% 1
• Cost and complexity

Target medications for deprescribing when:

• The indication no longer exists
• Risks outweigh benefits
• The medication contributes to high-risk combinations
• Time to benefit exceeds life expectancy

Implementation Framework

Create an actionable therapeutic plan that:

• Communicates changes clearly to all providers
• Obtains patient and caregiver acceptance
• Includes specific monitoring intervals
• Aligns with patient's goals of care 1

The evidence consistently shows that medication reviews improve prescribing appropriateness and reduce polypharmacy 4, though robust evidence for reducing mortality or hospitalizations remains limited. However, cost-effectiveness analyses consistently show benefits exceed intervention costs 4.