Quality prescribing for antidepressants: guide for improvement 2024 to 2027

4. The 7-Steps medication review

The 7-Steps person-centred medication review process can be used at both initiation of new medications and when reviewing existing treatments, including non-pharmacological approaches. This process ensures a shared decision-making approach to prescribing, with discussion of risks and benefits of treatments and enable safe, sustainable and effective person-centred care.

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

Person specific issues to address

Ask person to complete PROMs (questions to prepare for my review) before their review

• Ensure person-centred approach
• Consider non-pharmacological options where appropriate
• Before initiation of treatment discuss the risk of dependency/ withdrawal reaction with use

Step: 2. Need

Identify essential drug therapy

Process

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

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

Person specific issues to address

• Although not classed as an essential medicine, prescribers should be aware of the potential for dependence and withdrawal reaction with these medicines

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

• consider non-pharmacological approaches where appropriate, either alone or as an adjunct to medicines (e.g. CBT)
• if first episode of depression treated for six months and course complete, consider managed reduction and stop
• Ensure optimum dose of therapy e.g. 20’s plenty (fluoxetine, citalopram) or 50’s enough (sertraline) for depression

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

• With SSRIs there is limited additional benefit and increased risk of adverse effects with increasing doses (see dose response curve). Review and decrease dose where appropriate
• If no response to optimal dose within two to four weeks consider change to alternative medication, rather than increase dose further
• Consider non-pharmacological approaches

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

Person specific issues to address

• Consider combinations of high-risk medications e.g. NSAIDs and SSRIs
• Some antidepressants can have a high anticholinergic burden that can be additive
• Consider the increased potential for harm in combination with other CNS depressants
• Co-prescribing of benzodiazepine or z-drugs for antidepressant induced insomnia is no longer recommended
• Co-prescribing of two antidepressant agents for depression should be for specialist initiation only

Step: 6. Sustainability

Is drug therapy cost-effective and environmentally sustainable?

Process

Identify unnecessarily costly drug therapy by

• considering more cost-effective or environmentally sensitive alternatives, but balance against safety, convenience and individual preferences

Consider the environmental impact of

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

Person specific issues to address

• Are all medicines formulary choices?
• Advise to dispose of medicines through community pharmacy to ensure safe disposal
• Medicines should not be disposed of in household waste, pouring down sink or flushing down toilet
• Advise to only order what is needed, do not stockpile 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

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?
• what assistance is needed?
• 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

• Consider review period for management of depression
• If there is dosage reduction, agree a reduction plan and agree with individual to prevent withdrawal
• Signpost appropriate non-pharmacological support and resources (e.g. NHS Inform)

Key concepts in this case

• Take a holistic person-centred approach with regular reviews of treatment
• Consider the use of non-pharmacological options where appropriate
• For a polypharmacy review, if reviewing existing treatment prior to initiation of antidepressant medicines, use read code 8B31B Polypharmacy medication review.