Although many tools have been used to identify potentially inappropriate prescribing (e.g. Beers criteria, Laroche criteria and START STOPP criteria), they do not provide a structure to review patients and their medicines holistically. 

The SIMPATHY project and '7-Steps' approach

The SIMPATHY project evaluated all available EU guidance documents relating to the management of polypharmacy and found that only those from Scotland, the Netherlands and Germany scored the maximum quality rating.

The third edition of Scotland’s polypharmacy guidance, Realistic Prescribing, published in 2018, aims to provide advice on preventing inappropriate polypharmacy at every stage of the patient journey. It contains a clear structure for both the initiation of new treatments and the review of existing medications. The 2018 version was updated to place greater emphasis on “what matters to the patient?”. A ‘7-Steps’ approach to medication review was developed with patient groups and doctors, and pharmacists in primary and secondary care (see diagram).

Agreeing specific objectives with the patient in terms of both therapeutic outcomes and current life priorities (step 1) sets the context within which all further decisions are made, namely 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). 

Core elements that aim to inform and support this review process are:

• Establishing those issues that are common reasons for under-treatment
• Establishing areas that are common reasons for medication-related harm
  (for instance, drug-drug or drug-disease interactions) 
• Examining medication effectiveness and allowing clinicians and patients to gain a better understanding of the likely impact of treatment, including safety and the need for it in the first place. This is provided by a section in the guidance containing numbers needed to treat (NNT) for a range of commonly prescribed medications, together with details of key clinical trials