Medication Review Worksheet

M Mecca, MD, K Niehoff, PharmD, M Grammas, MD

Age:Gender:Liver disease? Y/NSerum Cr:

How many pharmacies and providers?Calculated CrCl (Calculatora):

Is refill history up to date/pt taking meds? Y/NVit D:B12:

Strategies for med management (pill box?):A1C:TSH:

Height:Weight:Other pertinent labs (INR if on warfarin, etc.):

BP ranges:Pulse ranges: Allergies/Adverse drug reactions:

Complete table by including full list of current problems and medications (VA, non-VA, OTC), matching line by line each problem with a medication. Place an * next to medications that do not have an active problem.

Problem/PMH: / Medications:
1. / 1.
2. / 2.
3. / 3.
4. / 4.
5. / 5.
6. / 6.
7. / 7.
8. / 8.
9. / 9.
10. / 10.
11. / 11.
12. / 12.
13. / 13.
14. / 14.
15. / 15.
16. / 16.
17. / 17.
18. / 18.
19. / 19.
20. / 20.
  1. Does every medication match an active medical problem or condition?
  2. Are there medications for which there is not an active condition or a clear indication?
  3. Are there medications with similar mechanisms of action or within similar drug categories?
  4. Are there active conditions for which a medication is indicated but not prescribed (START criteriab)?
  1. Are the dosages appropriate for the patient’s age (e.g., JNC 8c, ACC/AHAd), liver, and renal function?
  1. Are there medications that could be eliminated due to disease remission or resolution? (e.g., PPIs, supplements)
  1. Which of the patient’s current symptoms could be medication related?
  1. Are there medications with high risk for adverse drug events?
  2. Anticoagulants – weigh stroke risk (CHA2DS2‐VASce) vs. bleeding risk (HAS-BLEDf)
  3. Insulin/oral hypoglycemics–intensity of glycemic control depends on patient’s health status(ADAg, AGSh)
  4. Digoxin – narrow therapeutic window in older patients, consider safer alternative, do not exceed more than 125 mcg/d
  1. Are there potentially inappropriate medications that could be tapered/stopped? (STOPP criteriab, Beersi)
  1. Are there other medication-related concerns that need to be addressed? (e.g., practicality/complexity of regimen, ability to administer safely, adherence, cost)

Plan for improving patient’s medication regimen:

Useful Resources:

  1. Creatinine Clearance Calculator: Multiple creatinine clearance methods.Global RPh. Available
  1. 2014 STOPP/START Criteria

O'Mahony D, O'Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age and Ageing, 0:1-6,2014.

Supplementary Data

  1. Hypertension: JNC 8

James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eight Joint National Committee (JNC 8). JAMA, 311(5): 507-20, 2014.

  1. Statins: ACC/AHA Guidelines

Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association task force on practice guidelines.J Am CollCardiol, 63(25 Pt B): 2889-934, 2014.

ACC/AHA CV Risk Calculator

  1. CHA2DS2‐VASc Score for Atrial Fibrillation Stroke Risk

Hwang C. CHA2DS2-VASc score for atrial fibrillation stroke risk.MD+Calc. Available

  1. HAS‐BLED-Bleeding Risk

Andrade, J.HAS-BLED Score.QxMD. Available

  1. American Diabetes Association Diabetes Guidelines 2014:See pg S23 for A1c Goals

American Diabetes Association.Standards of medical care in diabetes-2014. Diabetes Care, 37(S1):14-80,2014.

  1. American Geriatrics Society Diabetes Guidelines 2013: See pg 2021 for A1c Goals

American Geriatrics Society Expert Panel on the Care of Older Adults with Diabetes Mellitus. Guidelines abstracted from the American Geriatrics Society guidelines for improving the care of older adults with diabetes mellitus: 2013 update. J Am GeriatrSoc, 61:2020-26, 2013.

  1. 2015 Beers Criteria

American Geriatrics Society 2015 Beers Criteria Update Expert Panel.American Geriatrics Society 2015 Updated Beers criteria for potentially inappropriate medication use in older adults.J Am GeriatrSoc,Epub ahead of print,2015.

Steinman MA, Beizer JL, DuBeau CE, et al.How to use the American Geriatrics Society 2015 Beers criteria-a guide for patients, clinicians, health systems, and payors.J Am GeriatrSoc, Epub ahead of print, 2015.

Hanlon JT, Semla TP, Schmader KE. Alternative medications for medications in the use of high-risk medications in the elderly and potentially harmful drug-disease interactions in the elderly quality measures.J Am GeriatrSoc, Epub ahead of print, 2015.