Synopsis
Choose an integrated medicines-management plan that fits the patient’s priorities, balances immediate and future outcomes, and includes implementation and reassessment.
- Begin with the problem and the desired outcome, then choose among starting, continuing, changing, reducing or stopping treatment. A management plan is broader than naming another medicine.
- Identify immediate instability before routine optimisation. Hypotension with poor perfusion, dangerous electrolytes or a suspected serious adverse reaction needs acute assessment.
- Reconstruct the reason for every medicine and ask whether it remains current. Short-term symptom treatment can persist long after the symptom has resolved.
Reasoning priorities
Build the factual basis for an integrated management plan.
Combine the patient’s account with available prescribing and specialist records. Document uncertainty when a medicine’s purpose cannot yet be established. Do not substitute assumptions about common uses for the actual indication, particularly with drugs that can treat several unrelated conditions.
Worked reasoning
A 78-year-old with two recent non-injurious falls reports new daytime drowsiness. Hydroxyzine 25 mg orally nightly began 3 weeks ago for itch that has resolved. Other medicines are unchanged. Seated pressure is 132/74 mmHg, standing pressure 128/72, pulse 72 regular, and there are no syncope, focal neurological or acute illness features.
- Assess the falls and supplied observations, checking injury, gait and other causes rather than assuming medicine causation. The stable standing pressure does not support reflex reduction of every antihypertensive, while the new sedating medicine has a clear temporal relationship to drowsiness.
- Reconstruct the hydroxyzine indication: the itch has resolved, so ongoing benefit is uncertain. Its sedating and anticholinergic burden is relevant in this older adult, and MHRA advises avoiding use in older people where possible because susceptibility to adverse effects is greater.
- Agree the final medicine action to stop the unnecessary hydroxyzine, with appropriate non-drug skin care and reassessment if itch returns, while preserving other treatment pending its own review. Explain the expected improvement in alertness and the need to report another fall or new warning symptoms.
- Arrange contact within several days and a fuller review within 1–2 weeks for this illustrative plan. Independently verify that the repeat list and supplied tablets no longer direct nightly use, ask the patient to repeat the change, and compare alertness, falls and itch with the baseline at follow-up.