Quality Prescribing for Antidepressants: A Guide for Improvement 2024-2027

6. Examples from practice and case summaries

Lived Experience 1

I am learning that my experience of psychiatric drug prescribing is not an unusual one. In May 2013, I suffered a two-week period of insomnia due to work-related stress and visited my GP. I was prescribed mirtazapine, an antidepressant. Unfortunately, I had a bad reaction to the drug; very increased anxiety within one week, and suicidal thinking within two weeks. I was then prescribed antipsychotics and a benzodiazepine. The benzodiazepine helped with the anxiety, but provided short lived relief, and I realised it was possibly an addictive medicine which I then tried to avoid.

The anxiety remained; I had no relief. I was then prescribed imipramine, a tricyclic antidepressant, and was told I should slowly increase the dose over six weeks when the relief would begin to be felt. After six weeks there was no improvement. My GP told me that I needed to ‘believe in the antidepressant and then it would work’. At this point I began to descend into severe depression.

During periods of depression, the anxiety would lessen, but as the depression eased the anxiety would return – like two sides of the same coin. With no relief from the drugs, I experienced multiple admissions to different mental hospitals over a number of months. First to a mental hospital, where different drug combinations were tried. Then another where a further ten different psychiatric drugs were tried. Then finally two admissions to the same hospital, as a precaution to prevent suicide attempts. During these two admissions I was given 15 courses of electroconvulsive therapy (ECT). These treatments did not work either. There would be a day of hyperactivity and then a plunge back into even deeper depression. I volunteered to stop all ECT treatments. My Hamilton Depression rating was frequently close to the maximum of 45. I was very seriously ill, and the psychiatrist at that time diagnosed me as chronic treatment resistant bi-polar depressed, and promptly put me onto lithium. Before long I was having trouble with shaking hands, acute nervous agitation and unbearable anxiety.

Every day was a struggle to survive. My mind was constantly occupied with ways to kill myself and there were many attempts, which very luckily were not successful. Only time spent with the excellent nurses and other individuals in the hospital garden eased my suffering and despair.

Eight years later, I am fully recovered. How did this happen? I was very lucky to have had psychotherapists visit me every day and talking therapy with a psychotherapist in the health centre once a week. These talking sessions kept me alive. After three and a half years of being prescribed psychiatric drugs of all descriptions, my psychiatrist referred me to a brilliant psychologist. Talking with her helped to keep me alive.

But finally, it was clear to me that the only thing we had not tried was coming off all psychiatric drugs. My psychiatrist eventually agreed to help me do this. Within eight weeks, on a slow reducing dose I was lifted out of depression for the first time in four years. Three months later I was allowed to stop the last drugs. I have never taken a single pill of any description ever since. While coming off the drugs, I started low sugar, low carbohydrate, high fibre diet with some minerals and vitamins to build up my immune system. I lost 3 stone of weight that had accumulated on the antidepressants and restored my physical health as well as my mental health. Before reducing the psychiatric drugs, my wife had enrolled me into an art group. Although I was severely depressed at the time, the simple act of joining a group of people who enjoyed art had a great positive effect on me; I began to enjoy learning to be better at drawing and painting. I found myself looking back at previous art work and being amazed that I had actually achieved something. My wife also enrolled me in the volunteers gardening group where I enjoyed meeting others in the public garden, we would do small jobs that gave us all a sense of achievement and belonging. I then joined a choir. The atmosphere was always friendly, and I began, very slowly, to begin to look forward. My mind was slowly shifting from endless rumination towards normal thought processes of linear continuity. Finally, Tai Chi and weekly walks with the local walking club all helped me to recover full health.

Lived Experience 2

In 2014, my GP prescribed sertraline to help alleviate my anxiety. Following a traumatic experience, and an operation, I was petrified of being left by myself. I was started on 50mg a day which, after an assessment by Psychiatry, was stepped up to 200mg over the course of four months. At the same time, I attended a six-week group CBT course through primary care mental health services and started receiving regular counselling. Concurrently, I was seen and assessed by cardiology, gastroenterology and genetics which ultimately compounded my anxiety and increased the medicine burden to around 20 tablets a day.

Fast forward to August 2021 and I remain on the same daily dose. I am subject to annual medicines reviews by my GP where the question of lowering the dose is discussed. The first time I panicked, as I hadn’t even considered it, so naturally any adjustment was put on hold. I have never felt pressurised or been made to feel guilty for ‘failing to cut back’. I have a supportive GP who understands I have no desire to ever feel the way I did before I started taking antidepressants. I have done behavioural therapy and learned the tools to change my way of thinking, but for me there has always been a huge physical element to my anxiety, they called it ‘Double Anxiety’ at the time. Add to that the physical health problems, additional drugs, and changes in my personal circumstances. So far, the time has never been right to start cutting back. When the time is right, however, I know I have a GP who is mindful of my reservations and who will let me go at my own pace.

NHS Greater Glasgow and Clyde^[17]

GPs were asked to proactively review a proportion of their practice patients prescribed the same antidepressant continuously long-term (≥2 years), as current guidelines advise up to two years’ treatment for some individuals with depression. Amitriptyline was excluded as it is more commonly used to treat neuropathic pain. Prescribing support pharmacists and technicians created the opportunity for proactive reviews by identifying potential patients for review, using data extraction tools, enabling >150-hour audits to be completed within two to four hours, November 2009 to March 2010. The GPs then decided which of their patients to review.

78 of 96 practices participated. 8.6% (33,312/388,656) of all registered patients were prescribed an antidepressant, 47.1% (15,689) were defined as long-term users and 2,849 (18%) were reviewed. 811 (28.5%) patients reviewed had a change in antidepressant therapy: 7% stopped, 13% reduced dose, 5% increased dose, and 3% changed antidepressant, resulting in 9.5% (95% CI = 9.1% to 9.8% P<0.001) reduction in prescribed daily dose and 8.1% reduction in prescribing costs. 6% were referred onwards, half to NHS mental health services. Pre-review SSRI doses were 10–30% higher than previously reported.

Since 2009, this work has continued as a local prescribing initiative, enabling over 8,000 people in more than 180 general practices to be reviewed between 2009/10 and 2014/15. However, this represents less than 2% (8,000/451,084) of people receiving long-term treatment,^[155] and lacked long-term follow-up to assess relapse and recurrence rates. (Estimate calculated from: previous studies indicate approximately 50% of people receive long-term treatment.^[20] Current medicines use in mental health indicates that 902,168 people received antidepressants in 2017/18. Therefore approximately 451,084 people are receiving long-term treatment in Scotland.)

Strengths: Enabled GPs to proactively review their own patients, enabling more people to be reviewed in a short period of time. Demonstrated use of electronic systems in enabling appropriate people to be identified and called for review. Demonstrated the effectiveness of pharmacy general practice teams in supporting and facilitating proactive GP reviews.

Limitations: Prescribers were asked to use their own clinical judgement for reviewing and reducing antidepressants, however they did not have structured advice as outlined in this guideline which may help overcome some of the barriers outlined in 2.3 above. Limited numbers of people reviewed. Limited resources and long-term follow-up to assess longer-term impact.

Systematic review summary from Maund et al^[23]

Maund et al. have completed a systematic review regarding published studies that focused on reviewing, reducing and stopping antidepressants.

Of the 15 studies outlined, 12 were included in the synthesis (eight randomized controlled trials, two single-arm trials, two retrospective cohort studies). None were rated as having high risk for selection or detection bias.

Two studies prompting primary care clinician discontinuation with antidepressant tapering guidance found 6% and 7% of patients discontinued versus 8% for usual care.

Six studies of psychological or psychiatric treatment plus tapering reported cessation rates of 40% to 95%.

Two studies reported a higher risk of discontinuation symptoms with abrupt termination.

At two years, risk of relapse/recurrence was lower with cognitive behavioural therapy (CBT) plus taper versus clinical management plus taper (15% to 25% vs 35% to 80%: risk ratio = 0.34; 95% CI, 0.18-0.67; two studies).

Relapse/recurrence rates were similar for mindfulness-based cognitive therapy with tapering and maintenance antidepressants (44% to 48% vs 47% to 60%; two studies).

CBT or mindfulness-based cognitive therapy can help patients discontinue antidepressants without increasing the risk of relapse/recurrence but are resource intensive.

Strengths: Included a range of studies with different methodologies and different populations. Highlighted that a complex intervention with tapering and psychological support may be more effective.

Limitations: Variation in study methodologies across different healthcare systems, and small sample numbers. Not always clear how long individuals had been receiving the antidepressant for; ranged from three months to more than nine months for the majority of studies.

Case study 1: Depression

Background (age, sex, occupation, baseline function)

• 54-year-old male
• Recent loss of employment

History of presentation/ reason for review

• Attended for review of his antidepressant started two months ago for first depressive episode
• Attends with a supportive friend who is concerned about him, as the individual has cancelled plans to meet and avoiding contact with others. Appears more socially isolated
• Signs of self-neglect
• Has lost over half a stone in weight due to reduced appetite
• Reports early morning wakening, increased rumination and a loss of motivation

Current medical history and relevant comorbidities

• Depressive episode – started antidepressant therapy two months ago
• Asthma (diagnosed in childhood) currently well controlled

Current medication and drug allergies (include over the counter (OTC) preparation and herbal remedies)

• Citalopram 20mg tablets - one tablet daily
• Clenil® (beclomethasone) 100microgram MDI - two puffs twice a day
• Salbutamol 100microgram MDI - two puffs up to four times a day (two ordered in last 12 months)
• No known drug allergies

Lifestyle and current function (include frailty score for >65yrs), alcohol, smoking, diet, physical activity

• Recent loss of employment
• Supportive friend
• At review:
  • Avoidant of eye contact and when asked becomes tearful reporting fleeting, occasional thoughts of ending his life. Whilst he has no active plan for suicide, he has disclosed he has thought about different ways of ending his life. Is adamant he would not act on these, citing his father and dog as protective factors
  • He reports taking his citalopram as prescribed every day for eight weeks but little/no benefit
  • Does not drink alcohol or use recreational substances

“What matters to me” (ideas, concerns and expectations of treatment)

• When asked about his goals he struggles to identify any, other than he wants to feel better but feels helpless as to how to change his situation
• Invited to complete the Patient Reported Outcome Measures (PROMs) prior to his review to identify any additional areas for discussion

Results e.g. biochemistry, other relevant investigations or monitoring

Note: local lab reference ranges may vary

• Recent bloods within normal range, including thyroid function tests
• During consultation indicates a worsening of symptoms. PHQ-9 score 14/27 eight weeks ago to 18/27 today (moderately severe depression)

Most recent relevant consultations

He is agreeable to a review of his medication and psychological supports are discussed. He was signposted to the NHS inform self-help guide at first presentation to the practice, which he had taken time to explore. He found understanding the links between his thoughts, feelings and behaviours helpful but would feel more comfortable if able to discuss this in person.

Step: 1. Aims

What matters to the individual about their condition(s)?

Process

Review diagnoses and consider:

• Therapeutic objectives of drug therapy
• Management of existing health problems
• Prevention of future health issues, including lifestyle advice
• Ask person to complete PROMs in preparation for their review

Person specific issues to address

• Wants to “feel better”
• Wants to regain motivation and appetite
• Wants to walk his dog more often

Step: 2. Need

Identify essential drug therapy

Process

Identify essential drugs (not to be stopped without specialist advice)

• Drugs that have essential replacement functions (e.g. levothyroxine)
• Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)

Person specific issues to address

• none identified as essential medicines
  
• inhaled corticosteroids required for asthma control
• consider the need for gradual withdrawal/ cross tapering with antidepressants where necessary

Step: 3.

Does the individual take unnecessary drug therapy?

Process

Identify and review the continued need for drugs

• what is medication for?
• with temporary indications
• with higher than usual maintenance doses
• with limited benefit/evidence for use
• with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address

• episode of depression, possibly related to loss of employment. Trial of citalopram 20mg daily – ineffective after two months

Step: 4. Effectiveness

Are therapeutic objectives being achieved?

Process

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

• to achieve symptom control
• to achieve biochemical/clinical targets
• to prevent disease progression/exacerbation
• is there a more appropriate medication to achieve goals?

Person specific issues to address

• Moderate severe depressive episode, worsening signs and symptoms, citalopram ineffective.
• Combination of:
  • switch antidepressant as no effect at eight weeks of therapeutic dose. Should be reviewed two to four weeks after initiation.
  • psychological intervention (e.g. cCBT)
  • lifestyle interventions e.g. exercise such as walking
• Asthma well controlled

Step: 5. Safety

Does the individual have or is at risk of ADR/ Side effects?

Does the person know what to do if they’re ill?

Process

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• drug-disease interactions
• drug-drug interactions (see ADR table)
• monitoring mechanisms for high-risk drugs
• risk of accidental overdosing

Identify adverse drug effects by checking for

• specific symptoms/laboratory markers (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Ensure discussion and clear information on which medicines to withhold at times of dehydrating illness

Person specific issues to address

• Worsening symptoms and possible increasing self-harm/suicide risk
• Worsening symptom advice and out-of-hours numbers provided (e.g. NHS 24, Breathing Space).
• Follow-up review within one to two weeks, or sooner if considered appropriate
• Current medicines have low overdose fatality risk

Step: 6. Sustainability

Is drug therapy cost-effective and environmentally sustainable?

Process

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, safety, convenience

Consider the environmental impact of

• inhaler use
• single use plastics
• medicines waste
• water pollution

Person specific issues to address

• Formulary preferred options being prescribed
• Asthma well controlled, salbutamol ordering/use appropriate and inhaler technique checked
• Consider option of dry powder inhalers at a later consultation if suitable (prioritise depression management)
• Dispose of unwanted and expired medicines at community pharmacy
• Advised not to dispose of medicine via household or water waste

Step: 7. Person-centredness

Is the person willing and able to take drug therapy as intended?

Process

Does the person understand the outcomes of the review?

• Consider Teach back
• Involve the adult where possible. If deemed to lack capacity, discuss with relevant others, e.g. welfare guardian, power of attorney, nearest relative if one exists. Even if adult lacks capacity, adults with Incapacity Act still requires that the adult’s views are sought. Ensure “Adults with Incapacity Documentation” in place

Ensure drug therapy changes are tailored to individual’s preferences. Consider

• is the medication in a form they can take?
• is the dosing schedule convenient?
• are they able to take medicines as intended?

Agree and communicate plan

• discuss and agree with the individual/ carer/welfare proxy therapeutic objectives and treatment priorities
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Ask person to complete the post-review PROMs questions after their review

Person specific issues to address

Agreed plan

• Switch antidepressants: last dose of citalopram today, start sertraline 50mg daily tomorrow.
• Referral to adult mental health services for high intensity psychological interventions
• Safety information - suicide prevention advice, provide emergency contact telephone numbers for out-of-hours services for crisis support if required.
• Low intensity exercise recommended – e.g. walking his dog may help
• Friend attending with him is supportive, safety information provided as above

Key concepts in this case

• Ensure timely review of new antidepressant treatment to assess effectiveness
• Review following changes to antidepressant therapy to ensure effectiveness
• Potential medication side-effects: loss of appetite could be caused by both depression and/or antidepressants
• Ongoing symptoms of depression including suicidal thoughts, despite antidepressant, indicates the need for review of therapy
• Importance of non-pharmacological therapies, such as psychological interventions, cCBT, exercise
• Holistic review could include inhaler use and environmental sustainability. However, these may be more suitable for future discussions when depression has stabilised

Case study 2: Anxiety

Background (age, sex, occupation, baseline function)

• 24-year-old female
• Office administrator

History of presentation/ reason for review

• Reports a 12-week history of increasing anxiety including worry, mild irritability, difficulties concentrating and marked sleep disturbance
• Increasingly difficult to control her worries which is having an impact on her work. She has been going in early and staying late as taking extra time to both complete and then check over her work due to concerns she may make a mistake
• Parents have noticed she is more on edge, restless and seems tired all the time

Current medical history and relevant comorbidities

• No mental or physical health comorbidities

Current medication and drug allergies (include over the counter (OTC) preparation and herbal remedies)

• None

Lifestyle and current function (include frailty score for >65yrs), alcohol, smoking, diet, physical activity

• Single, no dependents
• Lives at home with her parents
• Social drinker
• Non-smoker
• Very supportive close group of friends, parents, and older brother that she has been able to talk to about her anxiety

“What matters to me” (ideas, concerns and expectations of treatment)

• Keen to reduce the time she spends worrying, improve sleep, and feel less tense
• Although she is experiencing some difficulties at work, she is keen to avoid time off and is still managing to go to the gym
• Keen to avoid medication
• Invite individual to complete questions to prepare for the review (PROMs)

Results e.g. biochemistry, other relevant investigations or monitoring

Note: local lab reference ranges may vary

• GAD-7 score 8 (mild-moderate anxiety). However, as the anxiety is affecting her daily tasks of living, she is experiencing moderate anxiety

Most recent relevant consultations

• Presents as very motivated, has clear goals that including reducing the time she spends worrying, improved sleep, and feeling less tense
• Caffeine intake assessed and discussed
• Medication options are explored alongside psychological options. Has avoided coming into the practice as she is keen to avoid medication however expresses an interest in accessing CBT which she has looked up online. Comfortable using computers, see this as a flexible way to receive support that she can manage around her work and social commitments
• Reports no family history of suicide. No plans or intent to harm herself or others
• Agreed plan:
  • Medication options will not be commenced at this stage. Sleep hygiene discussed and written information given
  • Referral to Daylight, a cCBT package for Generalised Anxiety Disorder (GAD) with a review in the practice in four to six weeks’ time or if symptoms worsen

Step: 1. Aims

What matters to the individual about their condition(s)?

Process

Review diagnoses and consider:

• Therapeutic objectives of drug therapy
• Management of existing health problems
• Prevention of future health issues, including lifestyle advice
• Ask individual to complete PROMs to prepare for the review

Person specific issues to address

• Motivated and keen to reduce anxiety and time spent worrying
• Improve focus at work
• Improve sleep
• Prefers to avoid medication

Step: 2. Need

Identify essential drug therapy

Process

Identify essential drugs (not to be stopped without specialist advice)

• Drugs that have essential replacement functions (e.g. levothyroxine)
• Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)

Person specific issues to address

• None

Step: 3.

Does the individual take unnecessary drug therapy?

Process

Identify and review the continued need for drugs

• what is medication for?
• with temporary indications
• with higher than usual maintenance doses
• with limited benefit/evidence for use
• with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address

• None

Step: 4. Effectiveness

Are therapeutic objectives being achieved?

Process

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

• to achieve symptom control
• to achieve biochemical/clinical targets
• to prevent disease progression/exacerbation
• is there a more appropriate medication to achieve goals?

Person specific issues to address

• Medication options explored but not appropriate at present, interested and preference for cCBT and non-pharmacological management (e.g. sleep hygiene, physical activity, caffeine reduction)

Step: 5. Safety

Does the individual have or is at risk of ADR/ Side effects?

Does the person know what to do if they’re ill?

Process

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• drug-disease interactions
• drug-drug interactions (see ADR table)
• monitoring mechanisms for high-risk drugs
• risk of accidental overdosing

Identify adverse drug effects by checking for

• specific symptoms/ laboratory markers (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Ensure discussion and clear information on which medicines to withhold at times of dehydrating illness

Person specific issues to address

• No current plans or intent to harm herself or others
• No family history of suicide
• Has good family and friends support network
• Prefers non-pharmacological treatment to start with
• Reducing the use of medicines that are not indicated or appropriate avoids the risk of ADRs

Step: 6. Sustainability

Is drug therapy cost-effective and environmentally sustainable?

Process

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, safety, convenience

Consider the environmental impact of

• inhaler use
• single use plastics
• medicines waste
• water pollution

Person specific issues to address

• No medicines prescribed. Reducing the use of medicines that are not indicated or appropriate reduces the environmental impact from medicines

Step: 7. Person-centredness

Is the person willing and able to take drug therapy as intended?

Process

Does the person understand the outcomes of the review?

• Consider Teach back
• Involve the adult where possible. If deemed to lack capacity, discuss with relevant others, e.g. welfare guardian, power of attorney, nearest relative if one exists. Even if adult lacks capacity, adults with Incapacity Act still requires that the adult’s views are sought. Ensure “Adults with Incapacity Documentation” in place

Ensure drug therapy changes are tailored to individual’s preferences. Consider

• is the medication in a form they can take?
• is the dosing schedule convenient?
• are they able to take medicines as intended?

Agree and communicate plan

• discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Ask person to complete the post-review PROMs questions after their review

Person specific issues to address

Agreed plan

• Medication options will not be commenced at this stage
• Sleep hygiene and non-pharmacological options discussed. Written information given with links to self-help resources
• Referral made to a cCBT program (e.g. Daylight) for GAD. Review in the practice planned for four to six weeks’ time

Key concepts in this case

• Moderate GAD
• Non-pharmacological option preferred by patient, and matches with stepped-care model as per NICE guidelines
• Online computerised CBT fits with individual’s preference, needs and ease of access

Case study 3: Falls with osteoporosis

Background (age, sex, occupation, baseline function)

• 74-year-old female
• Retired

History of presentation/ reason for review

• Falls – no dizziness or light headedness. Has experienced a number of falls over the years. Main cause is balance and mobility. Has been referred to falls team
• At review:
  • Pains in feet. States that ‘lack of feeling in feet possibly to do with plantar fasciitis’
  • Higher dose of sertraline (100mg daily) ‘made no difference’ Depression resolved
  • Sometimes forgets to take alendronate – due to timing of dose

Current medical history and relevant comorbidities

• Osteoporosis – one year
• Fractured neck of femur (right). Total hip replacement – two years ago
• Depression – three years. Related to death of husband after long illness
• Plantar fasciitis – four years
• Acne rosacea
• High blood pressure – five years
• Chronic kidney disease stage three to seven years
• Lower back and knee pain – chronic
• Dyspepsia – eight years
• Cerebral lacunar infarct – seven years

Current medication and drug allergies (include over the counter (OTC) preparation and herbal remedies)

• Aspirin 75mg tablets - one tablet daily
• Alendronate 70mg tablets – one tablet once weekly (takes before breakfast)
• Co-codamol 30/500mg tablets - two tablets up to four times a day if needed
• Co-codamol 8/500mg tablets - two tablets up to four times a day if needed
• Fludrocortisone 50mcg tablets – one tablet daily
• Salicylic acid 2.0%, mucopolysaccharide polysulfate (MPS) 0.2% gel (Movelat®) - apply up to three times a day if needed
• Omeprazole 20mg capsules – one capsule daily
• Senna 7.5mg tablets – two tablets at night (last ordered 12 months ago)
• Sertraline 100mg tablets – one tablet daily (initiated two years ago after death of husband)
• Simvastatin 40mg tablets - one tablet at night
• Colecalciferol 1000 unit tablets – one tablet daily

Lifestyle and current function (include frailty score for >65yrs), alcohol, smoking, diet, physical activity

• Lives alone
• Supportive family and neighbours. Contact with sister and brother regularly
• Ex-smoker
• Does not drink alcohol
• Walks with stick

“What matters to me” (ideas, concerns and expectations of treatment)

• Reducing frequency of falls
• Invite individual to complete questions to prepare for the review (PROMs)

Results e.g. biochemistry, other relevant investigations or monitoring

Note: local lab reference ranges may vary

• U&Es, LFTs, bone profile, HbA1c and FBC – all within normal range. eGFR = 45ml/min - over estimating renal function
• Weight 65kg, Height 1.62m IBW 54.2kg. Estimated creatinine clearance 35ml/min (CKD G3b)
• DEXA scan – one year ago, severe osteoporosis
• BP 143/91 mmHg sitting, 116/78 mmHg standing. No symptoms of postural BP drop
• Pulse 74 bpm, regular

Most recent relevant consultations

• Fall in garden one week ago. Laceration to forehead. Six stitches in situ. Wound closed and dry with large black scab. No signs of infection. Six stitches removed, no issues. Care advice given. No dressing.

Step: 1. Aims

What matters to the individual about their condition(s)?

Process

Review diagnoses and consider:

• Therapeutic objectives of drug therapy
• Management of existing health problems
• Prevention of future health issues, including lifestyle advice
• Ask person to complete PROMs to prepare for the review

Person specific issues to address

• Reduce frequency of falls
• Where appropriate reduce/minimise prescribed medicines that may add to the risk of falls

Step: 2. Need

Identify essential drug therapy

Process

Identify essential drugs (not to be stopped without specialist advice)

• Drugs that have essential replacement functions (e.g. levothyroxine)
• Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)

Person specific issues to address

• None considered essential

Step: 3.

Does the individual take unnecessary drug therapy?

Process

Identify and review the continued need for drugs

• what is medication for?
• with temporary indications
• with higher than usual maintenance doses
• with limited benefit/evidence for use
• with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address

• First episode of depression after death of husband – states ‘higher dose sertraline not made much difference’. Consider a tapered reduction. SSRIs and higher doses associated with increased risk of falls
• Hypertensive while sitting. Previous stroke
• Unclear indication for fludrocortisone. Consider stopping if no indication as increases blood pressure
• Osteoporosis – forgets to take alendronate. Advised to take at 11am on Fridays (two hours before and after meals)
• Senna not required – stop

Step: 4. Effectiveness

Are therapeutic objectives being achieved?

Process

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

• to achieve symptom control
• to achieve biochemical/clinical targets
• to prevent disease progression/ exacerbation
• is there a more appropriate medication to achieve goals?

Person specific issues to address

• Depression resolved – trial stopping sertraline – taper gradually
• As required co-codamol, using both strengths depending on pain intensity, finds effective – not causing drowsiness, constipation
• Stroke prevention medicines: simvastatin, aspirin, hypertension control
• Osteoporosis treatment: alendronic acid and colecalciferol
• Forgetting to take alendronic acid - discuss strategies to help, such as calendar reminder or phone alarm

Step: 5. Safety

Does the individual have or is at risk of ADR/ Side effects?

Does the person know what to do if they’re ill?

Process

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• drug-disease interactions
• drug-drug interactions (see ADR table)
• monitoring mechanisms for high-risk drugs
• risk of accidental overdosing

Identify adverse drug effects by checking for

• specific symptoms/laboratory markers (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Ensure discussion and clear information on which medicines to withhold at times of dehydrating illness

Person specific issues to address

• Two strengths of co-codamol for knee and back pain. Paracetamol only is ineffective. Takes 8/500 during day and 30/500 at night. Knows not to take both at same time. Uses sparingly
• Fludrocortisone increasing risk of high blood pressure – stop
• GI protection – aspirin and sertraline, GI bleed risk
• Omeprazole to continue as needed for GI protection

Step: 6. Sustainability

Is drug therapy cost-effective and environmentally sustainable?

Process

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, safety, convenience

Consider the environmental impact of

• inhaler use
• single use plastics
• medicines waste
• water pollution

Person specific issues to address

• Formulary preferred list medicines options being prescribed.
• Advise to take unused or expired medicines back to community pharmacy for safe disposal
• Unnecessary/ineffective medicines stopped

Step: 7. Person-centredness

Is the person willing and able to take drug therapy as intended?

Process

Does the person understand the outcomes of the review?

• Consider Teach back
• Involve the adult where possible. If deemed to lack capacity, discuss with relevant others, e.g. welfare guardian, power of attorney, nearest relative if one exists. Even if adult lacks capacity, adults with Incapacity Act still requires that the adult’s views are sought. Ensure “Adults with Incapacity Documentation” in place

Ensure drug therapy changes are tailored to individual’s preferences. Consider

• is the medication in a form they can take?
• is the dosing schedule convenient?
• are they able to take medicines as intended?

Agree and communicate plan

• discuss and agree with the individual/ carer/welfare proxy therapeutic objectives and treatment priorities
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Ask person to complete the post-review PROMs questions after their review

Person specific issues to address

Agreed plan

• Trial reduction of sertraline, reducing every four weeks: 100mg to 50mg to 25mg then stop
• Osteoporosis – forgets to take alendronate. Advised to take at 11am Fridays (two hours before and after meals)
• Plantar fasciitis – refer for podiatry review
• Understands and agrees to changes to medicines
• Poor sleep since retired – uses sleep hygiene techniques: low caffeine intake, reads when has insomnia/night-time wakening
• Has capacity and is independent and capable of looking after her own medicines

Key concepts in this case

• Importance of regular review of long-term antidepressant therapy
• Higher dose SSRIs associated with increased risk of falls^[43]
• eGFR overestimating renal function. Although eGFR is routinely reported with U&Es it does not routinely reflect older adults’ renal function therefore it may be prudent to calculate individual’s creatinine clearance – see BNF Prescribing in Renal Failure section
• Minimise the number of unnecessary medicines
• Fludrocortisone – increases blood pressure, and borderline hypertensive with a previous history of stroke. Fludrocortisone may have increased the risk of future strokes
• Podiatry assessment not included in routine falls team review therefore referral was needed

Case study 4: Long-term antidepressant use

Background (age, sex, occupation, baseline function)

• 60-year-old female
• Works part-time

History of presentation/ reason for review

• Identified from ‘long-term antidepressant use” search using STU within the GP practice and invited for review. Receiving paroxetine 20mg daily for over two years
• At review tells you her mood is good and asks if she can stop her antidepressant

Current medical history and relevant comorbidities

• Mixed anxiety and depression following death of son four years ago

Current medication and drug allergies (include over the counter (OTC) preparation and herbal remedies)

• Paroxetine 20mg tablets – one tablet daily (approximately 2.5 years)
• Temazepam 10mg tablets – one tablet at night (approximately 3 years - does not over order)
• Drug allergies: Nitrofurantoin – rash

Lifestyle and current function (include frailty score for >65yrs), alcohol, smoking, diet, physical activity

• Lives alone
• No alcohol
• Good concentration, appetite and weight stable, sleeping well
• Helps to look after grandson to support her daughter-in-law
• Looking forward to the future and seeing her grandson growing up
• No thoughts of suicide/deliberate self-harm

“What matters to me” (ideas, concerns and expectations of treatment)

• Would like to stop antidepressant as has been taking a long time
• Ask person to complete questions to prepare for the review (PROMs)

Results e.g. biochemistry, other relevant investigations or monitoring

Note: local lab reference ranges may vary

• Blood tests at diagnosis (including TFT’s) all within normal range

Most recent relevant consultations

• Urinary tract infection six months previously

Step: 1. Aims

What matters to the individual about their condition(s)?

Process

Review diagnoses and consider:

• Therapeutic objectives of drug therapy
• Management of existing health problems
• Prevention of future health issues, including lifestyle advice
• Ask person to complete PROMs to prepare for the review

Person specific issues to address

• Would like to stop her antidepressant, as has been taking for over two years

Step: 2. Need

Identify essential drug therapy

Process

Identify essential drugs (not to be stopped without specialist advice)

• Drugs that have essential replacement functions (e.g. levothyroxine)
• Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)

Person specific issues to address

• no essential medicines
• if reducing or stopping paroxetine or temazepam, consider gradual reduction to avoid withdrawal symptoms

Step: 3.

Does the individual take unnecessary drug therapy?

Process

Identify and review the continued need for drugs

• what is medication for?
• with temporary indications
• with higher than usual maintenance doses
• with limited benefit/ evidence for use
• with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address

• temazepam no longer needed
• temazepam loses efficacy after two to four weeks. Licensed for a maximum of four weeks
• paroxetine no longer needed

insomnia – related to bereavement, sleep now improved.

Completed six-month course of treatment. Mood improved

Step: 4. Effectiveness

Are therapeutic objectives being achieved?

Process

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

• to achieve symptom control
• to achieve biochemical/clinical targets
• to prevent disease progression/exacerbation
• is there a more appropriate medication to achieve goals?

Person specific issues to address

Ensure appropriate non-pharmacological options discussed to maintain wellbeing

Step: 5. Safety

Does the individual have or is at risk of ADR/ Side effects?

Does the person know what to do if they’re ill?

Process

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• drug-disease interactions
• drug-drug interactions (see ADR table)
• monitoring mechanisms for high-risk drugs
• risk of accidental overdosing

Identify adverse drug effects by checking for

• specific symptoms/ laboratory markers (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Ensure discussion and clear information on which medicines to withhold at times of dehydrating illness

Person specific issues to address

• Temazepam – increased risk of cognitive effects, falls, lower mood, etc. Plan to stop
• Paroxetine – GI bleed risk, emotional blunting, etc. Risk of withdrawal effects higher than with other antidepressants. Plan appropriate reduction schedule

Step: 6. Sustainability

Is drug therapy cost-effective and environmentally sustainable?

Process

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, safety, convenience

Consider the environmental impact of

• inhaler use
• single use plastics
• medicines waste
• water pollution

Person specific issues to address

• Temazepam dose reduction and stop - oral solution significantly more expensive than tablets. Consider switch to diazepam to aid reduction - longer half-life and a number of preparations available

Step: 7. Person-centredness

Is the person willing and able to take drug therapy as intended?

Process

Does the person understand the outcomes of the review?

• Consider Teach back
• Involve the adult where possible. If deemed to lack capacity, discuss with relevant others, e.g. welfare guardian, power of attorney, nearest relative if one exists. Even if adult lacks capacity, adults with Incapacity Act still requires that the adult’s views are sought. Ensure “Adults with Incapacity Documentation” in place

Ensure drug therapy changes are tailored to individual’s preferences. Consider

• is the medication in a form they can take?
• is the dosing schedule convenient?
• are they able to take medicines as intended?

Agree and communicate plan

• discuss and agree with the individual/ carer/welfare proxy therapeutic objectives and treatment priorities
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Ask person to complete the post-review PROMs questions after their review

Person specific issues to address

Agreed plan

• Continue non-pharmacological support to maintain recovery: physical activity, minimise social isolation, etc. Signpost to resources e.g. local groups or online support
• Temazepam to reduce and stop, due to lack of efficacy and risk of ADR:.
  • Switch to diazepam 10mg at night and reduce by 1mg every two to four weeks.
  • Alternative: Temazepam 10mg/5ml oral solution, reducing by 1mg (0.5ml) every two to four weeks. (oral solution higher acquisition cost)
• Paroxetine withdrawal schedule options (after stopping temazepam):
  • Reduce to 10mg daily for four weeks, then 5mg daily for four weeks, then stop.
  • If problematic withdrawal or apprehensive: switch to equivalent dose of fluoxetine (20mg/5ml) oral solution for seven days, then reduce by 4mg (1ml) every four weeks

Key concepts in this case

• Benzodiazepines are associated with an increased risk of depression and are only licensed for a maximum of four weeks use. Stopping temazepam is a priority due to increased risk of avoidable ADRs. Reducing temazepam may require gradual reduction to assist with stopping.
• Switching from a short acting SSRI to a longer half-life SSRI may enable reduction and stopping.
• Paroxetine is associated with withdrawal effects. Therefore, have a range of options and agree the most appropriate approach to reducing and stopping, to improve chances of a successful withdrawal