Personalized Medication Review Throughout the Care Continuum

Abstract

Personalized medication review (PMR) is an evolving practice that holds significant promise in optimizing pharmacotherapy across the entire spectrum of patient care. This review synthesizes recent evidence and guidelines to elucidate the clinical and scientific rationale for integrating PMR at multiple care touchpoints, highlighting its impact on patient safety, therapeutic outcomes, and healthcare resource utilization. By exploring the epidemiology, pathophysiology, risk factors, clinical features, diagnostic considerations, and management strategies, this article provides a comprehensive reference for clinicians aiming to implement evidence-based, patient-centered medication management throughout the care continuum.

Introduction

Medication errors and adverse drug events (ADEs) remain a leading cause of morbidity and mortality in healthcare settings globally. The complex interplay of polypharmacy, multimorbidity, and care transitions underscores the necessity for systematic medication reviews tailored to individual patient profiles. Personalized medication review, distinct from conventional approaches, leverages patient-specific data, pharmacogenomics, and real-time clinical context to assess and optimize therapeutic regimens continuously. This article examines the clinical implications and scientific underpinnings of PMR, providing a framework for its integration at various care levels.

Epidemiology / Disease Burden

Polypharmacy affects up to 50% of elderly patients and is implicated in a significant proportion of hospital admissions due to ADEs. According to recent studies, medication-related problems account for approximately 6-10% of all hospitalizations in adults over 65 years. The burden is magnified in patients with chronic diseases, mental health disorders, and those transitioning between care settings. Globally, the economic impact of preventable drug-related morbidity and mortality exceeds hundreds of billions of dollars annually, emphasizing the urgent need for robust medication safety strategies such as PMR.

Pathophysiology

The pathophysiological basis for medication-related harm stems from drug-drug interactions, pharmacokinetic and pharmacodynamic variability, organ dysfunction, and genetic polymorphisms affecting drug metabolism. Inadequate medication selection or dosing can precipitate toxicity, therapeutic failure, or exacerbation of comorbidities. Personalized medication review addresses these mechanisms by integrating clinical data, laboratory values, and pharmacogenomic insights to anticipate and prevent adverse outcomes, especially in high-risk populations.

Risk Factors

Key risk factors for medication-related problems include advanced age, renal or hepatic impairment, multiple comorbidities, cognitive impairment, low health literacy, and frequent transitions between care settings. Polypharmacy commonly defined as the use of five or more medications significantly increases the risk of drug interactions and non-adherence. Specific pharmacogenetic variants, such as CYP2C19 and CYP2D6 polymorphisms, further alter drug metabolism and response, necessitating individualized review and adjustment of therapy.

Clinical Features

Clinical manifestations of medication-related problems are diverse, ranging from subtle cognitive changes or gastrointestinal disturbances to acute organ dysfunction, falls, and hospitalizations. In elderly or frail patients, non-specific symptoms such as confusion or functional decline may be the first indicators of inappropriate medication use. Routine clinical evaluation should include a detailed medication history, assessment of adherence, and vigilance for signs suggestive of ADEs or therapeutic failure.

Diagnosis

Diagnosing medication-related problems requires systematic review of current medications, recent clinical events, laboratory results, and pharmacogenomic data where available. Tools such as the Beers Criteria, STOPP/START, and Medication Appropriateness Index provide structured methodologies for identifying potentially inappropriate medications. In complex cases, multidisciplinary collaboration including input from clinical pharmacists, pharmacologists, and genetic counselors enhances diagnostic accuracy and facilitates individualized care planning.

Treatment & Management

Effective management hinges on regular, structured PMR performed at key transition points: hospital admission, discharge, outpatient visits, and during significant clinical changes. Core components include reconciliation of medication lists, assessment of indication, efficacy, safety, and adherence, and adjustment of regimens based on evolving clinical status. Patient education and shared decision-making are integral, particularly in deprescribing and tailoring therapy to patient preferences and goals of care. Integration of electronic health records and clinical decision support systems further streamlines the review process and reduces errors.

Recent Advances / Emerging Therapies

Recent advances in PMR include the incorporation of pharmacogenomic testing to guide drug selection and dosing, artificial intelligence-driven risk prediction models, and mobile health applications for real-time medication monitoring. Studies have demonstrated that pharmacogenetically informed prescribing reduces ADEs and improves therapeutic response, particularly in cardiovascular, psychiatric, and oncologic pharmacotherapy. The deployment of telemedicine and remote monitoring tools has expanded access to PMR services, especially for patients in rural and underserved areas.

Guideline Recommendations

Professional guidelines from organizations such as the American Geriatrics Society, National Institute for Health and Care Excellence (NICE), and the World Health Organization endorse regular medication review at least annually, and upon transitions of care for all patients at risk of polypharmacy or ADEs. Pharmacogenomic testing is recommended in select populations where evidence supports improved outcomes. Interdisciplinary collaboration and patient engagement are emphasized as critical elements of successful PMR implementation.

Conclusion

Personalized medication review represents a cornerstone of modern, patient-centered care, offering substantial benefits in reducing medication-related harm and optimizing therapeutic outcomes. By integrating clinical, pharmacological, and genetic data throughout the care continuum, PMR enables clinicians to deliver precision pharmacotherapy tailored to each patient's unique profile. Ongoing research, technological innovation, and guideline development will further enhance the impact of PMR on healthcare quality and patient safety in the years ahead.