Medication Regimen Review and Therapy Optimization

Medication regimen review is the systematic, structured examination of all the medicines a patient takes in order to identify drug therapy problems and to refine the regimen so that each medicine is appropriately indicated, effective, safe, and able to be taken as intended. It is the analytic core of medication optimization and underpins services such as MTM, transitions-of-care review, and consultant-pharmacist review in long-term care.

Definition

Medication regimen review is a structured evaluation of a patient's complete medication regimen that seeks to detect, resolve, and prevent drug therapy problems and to align therapy with the goals of being indicated, effective, safe, and convenient for the patient.

Scope

The topic describes the logic and categories of regimen review: how a complete medication list is assembled, how drug therapy problems are classified, and how findings translate into a plan to optimize therapy. It is a reference account of the review process and its conceptual structure, not clinical guidance for changing any individual regimen.

Key concepts

• Best possible medication history
• Medication reconciliation
• Drug therapy problem categories
• Indication, effectiveness, safety, adherence assessment
• Explicit and implicit review criteria
• Care plan and follow-up

Key theories

Drug therapy problem framework

Cipolle, Strand and Morley organize regimen review around a small set of drug therapy problem categories — needing additional therapy, unnecessary therapy, ineffective drug, dosage too low, dosage too high, adverse drug reaction, and non-adherence — providing a systematic way to assess every medication for indication, effectiveness, safety, and adherence.

Mechanisms

A regimen review begins with assembling an accurate and complete medication list (the best possible medication history) and reconciling it against what the patient actually takes. Each medication is then assessed in turn for whether it has a valid indication, whether it is effective for the intended goal, whether it is safe given the patient's other drugs and conditions, and whether the patient can and does take it as prescribed. Problems are classified into standard drug therapy problem categories, prioritized, and translated into a documented plan. Reviews may use explicit criteria (predefined lists of potentially inappropriate medicines, such as STOPP/START) or implicit, judgement-based appraisal of the whole regimen.

Clinical relevance

Structured regimen review is the mechanism by which many medication-related problems are surfaced and addressed; it informs interventions in MTM, hospital admission and discharge, and long-term-care settings. This entry describes the review process and is not a basis for individual prescribing, dosing, or discontinuation decisions.

Epidemiology

The yield of regimen review rises with regimen complexity and the number of medicines, so the activity is most consequential among older adults and patients with multimorbidity, where drug therapy problems are common and the potential for harm from interactions and adverse effects is greatest.

Evidence & guidelines

Regimen review draws on the drug-therapy-problem framework from the pharmaceutical care literature and on explicit prescribing-appropriateness criteria such as STOPP/START; outcome evidence comes mainly from observational evaluations of pharmacist-led review, with heterogeneous designs and endpoints.

History

Systematic regimen review grew out of the pharmaceutical care movement, which reframed medication assessment as a structured, documentable professional process rather than an ad hoc check. The development of explicit appropriateness criteria, including STOPP/START in Europe, gave reviewers standardized tools to complement implicit clinical judgement.

Debates

Explicit criteria versus implicit judgement

Explicit, list-based criteria such as STOPP/START offer reproducibility and are easy to apply, but may miss patient-specific context; implicit, judgement-based review captures context but is less reproducible, and how best to combine the two remains debated.

Key figures

• Robert Cipolle
• Linda Strand
• Denis O'Mahony

Seminal works

• hepler-strand-1990
• cipolle-2012
• omahony-2014

Frequently asked questions

What does a medication regimen review actually assess?

It assesses each medicine for whether it is indicated, effective, safe in the context of the patient's other drugs and conditions, and able to be taken as intended (adherence), classifying any shortfalls as drug therapy problems.

What is the difference between explicit and implicit review criteria?

Explicit criteria are predefined lists (for example STOPP/START) that flag specific potentially inappropriate medicines; implicit criteria rely on the reviewer's structured clinical judgement about the whole regimen. Many reviews combine both.