Synopsis
Recognise when multiple medicines create disproportionate burden, reconcile what is actually taken, and complete a person-centred structured review that protects essential treatment while improving safety, function and adherence.
- Polypharmacy describes medicine count, whereas problematic polypharmacy means the combined regimen no longer delivers acceptable benefit, safety or practical fit.
- First-line review begins with reconciliation: prescribed, dispensed and actually taken medicines, including non-prescription products, doses, timing, indication and last use.
- Prioritise people with frailty, multimorbidity, recent admission, falls, delirium, renal decline, high-risk medicines, adherence difficulty or major treatment change.
- A structured medication review is a shared, holistic clinical review, not an automated deletion exercise or a check confined to interaction software.
- For every medicine ask: current indication, evidence of benefit, time to benefit, ongoing need, safety, monitoring, formulation, adherence and the person's goal.
- Review high-risk combinations explicitly: anticoagulants and antiplatelets, opioids and sedatives, anticholinergics, insulin or sulfonylureas, diuretics and renally cleared medicines.
- Estimate renal function using the method required for the medicine; eGFR and Cockcroft–Gault creatinine clearance are not interchangeable for every drug.
- Change one or a small number of medicines at a time where feasible, document the reason, and provide withdrawal, relapse and monitoring plans.
- Use capacity support, accessible information, interpreter or advocate, monitored dosage systems and carer involvement only when these solve an identified barrier.
- Communicate the final list, stopped medicines, pending tests and named owners across GP, pharmacy, care setting and specialist teams.
Key red flags
Reduced consciousness, slow breathing or pinpoint pupils in an opioid-exposed person requires immediate airway support and naloxone consideration.
Melaena, haematemesis, intracranial symptoms or falling haemoglobin during antithrombotic treatment requires urgent bleeding and reversal assessment.
Collapse, bradycardia, prolonged QT, broad-complex rhythm or severe electrolyte disturbance after a medicine change needs monitored acute care.
New delirium, falls, urinary retention or constipation after adding an anticholinergic or sedative should trigger prompt toxicity review.
Vomiting, dehydration or sepsis while taking renally cleared medicines can cause rapid accumulation and requires sick-day and renal assessment.
Conflicting supplies, duplicate brands, missed monitored medicines or inability to self-administer safely creates an urgent medicines and support risk.
New sedation, bleeding or toxicity follows renal, hepatic, weight or hydration decline.
An indicated medicine such as insulin, steroid replacement or antiseizure therapy is absent or unintentionally stopped.
Investigation priorities
Establish actual exposure before making decisions.
Management branches
Polypharmacy, frailty or a transition creates potential medicine-related harm.
- Establish the person's priorities, stable baseline, prognosis, functional goals and actual medicine exposure from reliable sources.
- Review each item for indication, benefit, safety, monitoring, interaction, adherence, formulation and time to benefit.
- Agree a ranked plan with implementation, withdrawal and relapse safeguards, named owners and a specific review date.