Quality prescribing for Benzodiazepines and z-drugs: 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 medication and when reviewing existing treatments. This process ensures a shared decision-making approach to prescribing, with discussion of risks and benefits of treatments, to 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

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

Person specific issues to address:

• Ensure a person-centred approach
• Consider non-pharmacological options where appropriate
• Consider if vulnerable or at risk of dependency

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:

• Benzodiazepines and z-drugs used for anxiety or insomnia are not regarded as essential. They are only indicated for a maximum of two to four weeks
• If prescribed for long-term use consider potential of withdrawal reaction and provide support for reduction and stopping

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:

• Not indicated for long-term use
• Consider the potential for harm (low numbers for NNH)

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:

• Can treatment be supported with non-pharmacological or psychological therapies where appropriate (such as sleep hygiene, CBT/cCBT resources)?
• Are alternative medicines more suitable for longer term management?

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 risk of ADRs such as drowsiness, falls, memory impairment
• If treatment has been taken for long periods of time gradually taper to avoid withdrawal reactions. Abrupt cessation may produce confusion, toxic psychosis, convulsions or a condition resembling delirium tremors
• Consider if vulnerable or at risk of dependency

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:

• Check that all medicines are formulary choices
• Advise to only order what is needed, do not stockpile medicines
• Advise not to dispose of in household rubbish or in water waste. Promote safe disposal of medicines via community pharmacy

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 alternatives to prescribing where appropriate
• If the benzodiazepine or z-drug is to be stopped/ reduced then consider and agree reduction schedule with individual and set achievable goals
• Ensure awareness of potential for dependence or withdrawal effects, when to seek help and what actions to take
• Utilise available self help resources (e.g. NHS inform)

Key concepts in this case

• Consider the use of PROMs and individualised dosing/reduction schedules
• Ensure use of shared decision-making tools during person-centred reviews
• Awareness of potential for dependency or withdrawal effects with B-Z medicines
• Consider non-pharmacological approaches where appropriate (e.g. sleep hygiene, CBT)