10 minute consultation: Using the NO TEARS tool for medication review

What issues you should cover

At least a third of patients in Britain aged more than 75 years are taking four or more drugs. Adverse drug reactions are implicated in 5% to 17% of hospital admissions. Hence the dictum “first, do no harm” becomes prescient. Doctors need to be able to critically assess a patient's treatments. Waste is substantial: £19 000 worth of drugs were returned to pharmacies over an eight week period in Gwent.

Need - Does he know why he takes each drug? Does he still need them? Was long term treatment intended? Is the dose appropriate? Has the diagnosis been refuted? Would nonpharmacological treatments be better?

Open questions - Give him the opportunity to express his views by asking questions: “I realise a lot of people don't take all their tablets. Do you have any problems?” “Can I check that we both agree what you're taking regularly?” or “Do you think your tablets work?” Compare his replies with the number of prescription requests.

Tests and monitoring - Assess disease control. Are any of his conditions undertreated? Get advice on appropriate monitoring from prescribing guidelines such as the British National Formulary or the US Physicians' Desk Reference and other primary care documents.

Evidence and guidelines - Has the evidence base changed since his prescription was initiated? Do the prescribing guidelines indicate that any of his drugs are now less suitable for prescribing? Is the dose appropriate? (For example, dose optimisation of angiotensin converting enzyme inhibitors in cardiac failure.) Are other investigations now advised, such as echocardiograpy or testing for Helicobacter pylori?

Adverse events - Does he have any side effects? Is he taking complementary or over the counter preparations? Check for interactions, duplications, or contraindications. Remember the “prescribing cascade” (misinterpreting an adverse reaction as a new medical condition).

Risk reduction or prevention - If time allows, update opportunistic screening. What are his risks, such as of falls? Are the drugs optimised to reduce these risks?

Switches and simplification - Can treatment be simplified? Does he know which treatments are important? It may be better to replace low doses of several agents by one full dose. Explain any switches that increase the cost effectiveness of treatment.

What you should do

• Read code and document the discussion. It will make the next review easier and may be important medicolegally.

• Overlap of the parts of the NO TEARS tool means you can adapt it to your consultation style, increasing the chance of identifying a problem. For example, consideration of bone protection in patients taking steroids may be an adverse effect for one doctor, but another may deal with it at the guidelines or prevention stage.

• Identify important or controversial issues that may need to be covered at a subsequent consultation (adjust the number of authorised repeats accordingly).

• Agree a recall system with your colleagues. This should include a facility for amending the repeat prescription after home visits, discharge from hospital, and outpatient clinic attendances.

• In the United Kingdom the Task Force on Medicines Partnership has described various levels of medication review (see Useful reading). Although a pharmacist may do some types of review, it is important to remember that signing a script makes you ultimately responsible. A structured approach to repeat prescribing should improve confidence of doctor and patient.