Introduction
Medication review is a structured critical examination of a patient's medicines to optimise therapy, reduce harm, and improve adherence. With approximately 15% of hospital admissions in the UK directly attributable to adverse drug reactions or medication errors, structured review is one of the highest-impact clinical skills. In OSCE stations you may be asked to review a drug chart, counsel a patient about polypharmacy, identify inappropriate prescribing, or apply STOPP/START criteria.
Why Medication Review Matters
- Polypharmacy (≥5 regular medicines) affects over 50% of adults over 65 in the UK
- Each additional medicine increases the risk of drug–drug interactions, adverse effects, and adherence problems
- Problematic polypharmacy — medicines prescribed without clear indication, or where harms outweigh benefits — is common and often unrecognised
- Structured deprescribing reduces falls, cognitive impairment, and hospitalisation in older adults
💎 Clinical Pearl
The term polypharmacy is neutral — taking multiple medicines for multiple conditions can be entirely appropriate. The goal of medication review is not to reduce the number of medicines per se, but to ensure every medicine has a clear indication, a monitoring plan, and that benefits outweigh harms for that specific patient.
The Structured Medication Review Framework
🧠 Mnemonic
MEDICINES — Structured Review Framework
M — Match: does each medicine have a current, documented indication?
E — Efficacy: is the medicine achieving its therapeutic goal?
D — Dose: appropriate for renal/hepatic function, age, and weight?
I — Interactions: check drug–drug and drug–disease interactions
C — Contraindications: any medicines contraindicated by current diagnoses?
I — Information: does the patient understand what each medicine is for?
N — Non-adherence: assess adherence, identify barriers, review formulations
E — Evidence: apply STOPP/START criteria and deprescribing guidelines
S — Safety monitoring: is appropriate blood monitoring in place?
STOPP/START Criteria (Version 2)
The STOPP (Screening Tool of Older Persons' Prescriptions) and START (Screening Tool to Alert to Right Treatment) criteria are validated tools for identifying inappropriate prescribing in adults aged ≥65.
Key STOPP Criteria — Medicines to Consider Stopping
| Drug / Drug Class | Situation to STOP | Reason |
|---|---|---|
| NSAIDs | eGFR <50 mL/min/1.73m² | Nephrotoxicity, fluid retention |
| NSAIDs | Concurrent anticoagulation without PPI | Serious GI bleeding risk |
| Opioids | Chronic constipation without laxative | Bowel obstruction risk |
| Benzodiazepines | Falls risk patient | Sedation, falls, fractures, cognitive impairment |
| Antipsychotics | Behavioural symptoms of dementia | Increased mortality, stroke, sedation |
| Sulphonylureas | eGFR <30 mL/min/1.73m² | Prolonged hypoglycaemia risk |
| PPIs | No clear indication beyond 8 weeks | Hypomagnesaemia, C. diff, fractures |
| Alpha-blockers | Recurrent orthostatic hypotension | Falls risk |
| TCAs | Glaucoma, urinary retention, delirium history | Anticholinergic burden |
| Digoxin >125 mcg/day | eGFR <30 mL/min/1.73m² | Toxicity risk |
Key START Criteria — Medicines to Consider Starting
| Condition | Medicine to START | Reason |
|---|---|---|
| Systolic dysfunction heart failure | ACE inhibitor + beta-blocker | Mortality reduction |
| AF with CHA₂DS₂-VASc ≥2 | Anticoagulation (DOAC preferred) | Stroke prevention |
| Osteoporosis on steroids >3 months | Bisphosphonate + calcium/vitamin D | Fracture prevention |
| COPD FEV₁ <50% | LABA + ICS | Exacerbation prevention |
| Type 2 diabetes + CV disease | Empagliflozin or dapagliflozin | Cardiovascular and renal protection |
| CKD + proteinuria (diabetic) | ACE inhibitor or ARB | Nephroprotection |
⚠️ Red Flag
STOPP/START criteria are tools, not rules. Each recommendation must be assessed in the context of the individual patient's life expectancy, goals of care, comorbidities, and preferences. A patient with a 6-month prognosis from terminal cancer may appropriately receive opioids without a laxative if bowel symptoms are otherwise managed. Clinical judgement always supersedes the algorithm.
Anticholinergic Burden
Many commonly prescribed medicines carry significant anticholinergic activity. Cumulative anticholinergic burden is associated with cognitive impairment, delirium, constipation, urinary retention, falls, and increased mortality in older adults.
| Anticholinergic Burden (ACB) Score | Examples |
|---|---|
| High burden (ACB 3) | Amitriptyline, oxybutynin, tolterodine, chlorphenamine, promethazine, dicycloverine |
| Moderate burden (ACB 2) | Haloperidol, trazodone |
| Low burden (ACB 1) | Furosemide, prednisolone, nifedipine, codeine, metoprolol |
Total ACB score ≥3 is associated with increased cognitive impairment and mortality.
💎 Clinical Pearl
When reviewing an older patient with new confusion, urinary retention, or falls, always review the drug chart for anticholinergic medicines before attributing symptoms to dementia or medical illness. Common culprits: amitriptyline prescribed years ago for pain, oxybutynin for bladder symptoms, or chlorphenamine for allergy or sleep.
Deprescribing
Deprescribing is the planned, supervised reduction or stopping of a medicine that may be causing harm or no longer providing benefit.
| Deprescribing Step | What to Do |
|---|---|
| 1. Identify candidates | Apply STOPP criteria, assess current indication, consider patient's goals |
| 2. Prioritise | Tackle highest-risk medicines first (falls risk, renal toxins, anticholinergics) |
| 3. Discuss with patient | Explore concerns; many patients welcome reducing medicines if explained clearly |
| 4. Taper or stop | Some medicines require gradual withdrawal (see below) |
| 5. Monitor | Follow up within 2–4 weeks to review symptoms and reassess |
| 6. Document | Record the reason for stopping and the plan in the notes |
⚠️ Red Flag
Never stop the following medicines abruptly without a taper plan: benzodiazepines (withdrawal seizures), SSRIs/SNRIs (discontinuation syndrome), corticosteroids (adrenal insufficiency if >3 weeks of systemic therapy), beta-blockers (rebound tachycardia, angina, hypertension), and opioids (withdrawal syndrome). Always wean gradually with monitoring.
The Beers Criteria
The American Geriatrics Society Beers Criteria is a US-based list of potentially inappropriate medicines in older adults (≥65 years), widely taught alongside STOPP/START in UK medical schools.
| Category | Examples |
|---|---|
| High anticholinergic burden | First-generation antihistamines, TCAs, bladder antimuscarinics |
| Falls risk | Benzodiazepines, Z-drugs (zopiclone, zolpidem), antipsychotics |
| Renal risk | NSAIDs, nitrofurantoin in eGFR <30 |
| Cardiovascular | Digoxin >0.125 mg/day long-term, amiodarone as first-line AF |
Common Drug Interactions to Know for OSCEs
| Drug Combination | Interaction | Risk |
|---|---|---|
| Warfarin + NSAIDs | Additive anticoagulation + GI mucosal damage | Major GI bleed |
| ACE inhibitor + potassium-sparing diuretic | Hyperkalaemia | Arrhythmia, cardiac arrest |
| Metformin + IV contrast | Lactic acidosis | Acute kidney injury |
| SSRIs + tramadol | Serotonin syndrome | Life-threatening |
| Digoxin + amiodarone | Raised digoxin levels | Digoxin toxicity |
| Statins + clarithromycin/erythromycin | Raised statin levels (CYP3A4 inhibition) | Myopathy, rhabdomyolysis |
| Lithium + NSAIDs/thiazides | Raised lithium levels | Lithium toxicity |
Conducting a Medication Review Consultation
In an OSCE, a medication review station will typically require you to:
- 1Introduce yourself and confirm the patient's identity and reason for attendance
- 2Obtain a full drug history: prescribed medicines, OTC medicines, herbal remedies, supplements, recreational drugs
- 3Review each medicine: indication, duration, dose, last review, monitoring, adherence
- 4Assess the patient's perspective using ICE: *"Is there anything about your medicines that concerns you? Are there any you find difficult to take?"*
- 5Apply clinical knowledge: identify STOPP/START opportunities, anticholinergic burden, drug interactions
- 6Negotiate shared decisions: never unilaterally stop a medicine without discussing with the patient and documenting
- 7Safety-net: confirm follow-up and monitoring plan
💡 Tip
In OSCE medication review stations, marks are often awarded specifically for acknowledging the patient's concerns about their medicines. Many patients are afraid that stopping a medicine means their condition will worsen. Explain the rationale in simple terms: *"This medicine is actually less effective for you now and may be contributing to your dizziness — stopping it carefully is likely to help, not harm."*
FAQs
"How should I approach a patient who refuses to stop a medicine I think is inappropriate?"
Acknowledge their autonomy and explore their concerns — patients are often attached to a medicine because they associate it with past benefit or fear recurrence. Provide clear, jargon-free information about the specific risk. If the patient still declines after informed discussion, document the conversation and your recommendation, and review again at the next appointment.
"What is the difference between STOPP and Beers criteria?"
Both are evidence-based screening tools for potentially inappropriate prescribing in older adults. STOPP/START are validated in European populations and are the standard in UK clinical practice. Beers criteria are US-based and include some medicines not commonly used in the UK. STOPP also has a complementary START component for identifying undertreated conditions. In UK OSCEs, STOPP/START is the expected tool.
"What monitoring is required for common medicines in an older patient?"
ACE inhibitors/ARBs: renal function and potassium at baseline, 1–2 weeks after initiation, then annually. Metformin: eGFR annually (stop if <30). Digoxin: digoxin levels, renal function, ECG. Lithium: levels and TFTs every 6 months. Amiodarone: TFTs, LFTs, CXR annually. Warfarin: INR as per clinical status.
"What is anticholinergic burden and why does it matter clinically?"
Anticholinergic burden refers to the cumulative anticholinergic effect of all medicines a patient is taking. High total burden (ACB score ≥3) is independently associated with cognitive impairment, delirium, falls, urinary retention, constipation, and increased mortality in older adults. It matters because individual low-burden medicines combine to create significant cumulative harm that may be attributed to ageing rather than recognised as iatrogenic.
"How do I distinguish appropriate polypharmacy from problematic polypharmacy?"
Appropriate polypharmacy: multiple medicines each with a clear indication, documented review, monitoring in place, and patient-informed consent — for example, an 80-year-old with heart failure taking a diuretic, ACE inhibitor, beta-blocker, and aldosterone antagonist. Problematic polypharmacy: medicines prescribed without current indication, for symptoms caused by another medicine, never reviewed after initiation, or with accumulated harms outweighing benefits.
Related Posts
- Drug History OSCE — systematic drug history taking including OTC, herbal, adherence, and adverse effects
- Prescribing Safety OSCE — safe prescribing principles, drug chart completion, and avoiding common errors
- Blood Results Interpretation OSCE — renal function, electrolytes, and drug levels relevant to medication monitoring