Medicines optimisation, polypharmacy and deprescribing

Reconciliation, structured review, burden, adherence, deprescribing and shared decisions.

Pre-prescribing foundation: this module develops knowledge and judgement for formal prescribing education; it does not authorise prescribing.

• Explain medicines reconciliation and why discrepancies need resolution.
• Conduct foundation-level benefit-harm and treatment-burden reasoning.
• Recognise polypharmacy as a clinical context rather than a simple medicine count.
• Explain deprescribing as an active therapeutic process.
• Integrate patient goals, adherence and follow-up into medication review.

Medication review is a structured critical examination of medicines with the person, aiming to optimise benefit, minimise problems and reduce burden/waste.

Reconciliation is not simply copying a list; discrepancies must be identified, explained and resolved.

Polypharmacy can be appropriate or problematic; medicine count alone does not define quality.

Deprescribing requires a plan for withdrawal, monitoring, communication and re-escalation when needed.

1. Define the clinical problem and whether prescribing is indicated.
2. Gather the patient-specific assessment and diagnostic information needed.
3. Check competence, professional authority and employer/service scope.
4. Compare reasonable options using current authoritative sources.
5. Agree the plan with the patient, including uncertainty and alternatives.
6. Prescribe accurately only when the decision is justified.
7. Document, monitor, review and safety-net.

Module emphasis: Reconcile the medicine list, define each indication and goal, weigh benefit against harm and burden, and agree any change with monitoring and follow-up.

Scenario 1. A patient takes 14 medicines but values some strongly and questions others.

Reasoning prompt: Reconcile the medicine list, define each indication and goal, weigh benefit against harm and burden, and agree any change with monitoring and follow-up.

Scenario 2. A hospital discharge list omits a long-term medicine without explanation.

Reasoning prompt: Reconcile the medicine list, define each indication and goal, weigh benefit against harm and burden, and agree any change with monitoring and follow-up.

Scenario 3. A medicine is stopped abruptly despite withdrawal risk.

Reasoning prompt: Reconcile the medicine list, define each indication and goal, weigh benefit against harm and burden, and agree any change with monitoring and follow-up.

• Polypharmacy is always bad.
• Deprescribing is simply stopping medicines.
• Reconciliation is complete once two lists match.

• What clinical problem am I trying to solve, and is prescribing indicated?
• What information is missing before a safe decision can be made?
• Is this within my current competence, professional authority and employer/service scope?
• Which current authoritative medicine or guideline source should I check?
• What patient-specific factors change benefit, harm, dose, route or monitoring?
• What will I document, monitor, review and safety-net?
• When should I seek supervision, pharmacy advice, specialist input or urgent escalation?

Optional reflection: Without entering identifiable patient or employer information, identify one capability you would need to strengthen before prescribing independently in this area.

• Medication review is a structured critical examination of medicines with the person, aiming to optimise benefit, minimise problems and reduce burden/waste.
• Reconciliation is not simply copying a list; discrepancies must be identified, explained and resolved.
• Polypharmacy can be appropriate or problematic; medicine count alone does not define quality.
• Deprescribing requires a plan for withdrawal, monitoring, communication and re-escalation when needed.

Check current versions for time-sensitive decisions.

• NICE-01 - NICE: NG5 Medicines optimisationOpen official source
• RPS-01 - Royal Pharmaceutical Society: A Competency Framework for All Prescribers (2021)Open official source
• HEIW-01 - Health Education and Improvement Wales: Standards for Competency Assurance of Independent and Supplementary Prescribers in WalesOpen official source