Agreeing specific objectives with the patient about what matters in terms of therapeutic objectives and current life priorities (step 1) sets the context within which all further decisions are made. This includes which medicines are essential (step 2) or unnecessary (step 3), whether therapeutic objectives that matter to the patient are achieved (step 4), which medicines are too risky or cause unacceptable adverse effects (step 5), which medicines are not cost effective (step 6), and whether the patient is willing and able to manage their medicines in a way that avoids harm and maximises benefit (step 7). 

The guidance also includes a medication effectiveness section, which allows clinicians and patients to gain a better understanding of the likely impact of a medication, including safety and the need for the medication. This is provided by a section containing numbers needed to treat (NNT) for a range of commonly prescribed medications, together with details of the key clinical trials. 

Working through the seven steps may result in reducing or stopping medication that is no longer needed – sometimes referred to as deprescribing. Although the NNTs provided allow a numerical comparison between treatments, it is important that they are not taken in isolation from other issues. For instance: 

What is the outcome being avoided? 

Death is more significant than a vertebral fracture, but different outcomes will be more or less significant to the individual patient

Over what period does the benefit accrue? 

Two drugs may have the same NNT to avoid one death, but the drug that achieves that over six months is more effective than the drug that takes 10 years 

What is the likelihood and severity of harm caused by the drug? 

If a medicine saves the life of one patient in 25, but causes debilitating side effects for the rest then its costs may outweigh its benefits.