Table 5.

Pharmacotherapeutic recommendations

Recommended optimisation	No. (%)	Examples
Discontinue drug	40 (47)	Preventive medication in case of a reduced life expectancy (e.g. statins, antihypertensive drugs) Irrelevant indication (e.g. clopidogrel >1 year after placing of a stent) Ineffectiveness (tamsulosin, fexofenadine)
Replace drug for better alternative	16 (19)	Adverse drug reaction (e.g. dexamethasone and hiccups, simvastatin and reflux, metformin and diarrhoea) Contraindication, for example due to renal dysfunction (e.g. barnidipine) Newer guidelines (e.g. switch acetylsalicylic acid + dipyridamole to clopidogrel for the treatment of a TIA/CVA)
Adjust dose	15 (18)	Reducing dose due to renal dysfunction (e.g. pramipexole) or reduced body weight (e.g. LMWH) Unnecessary or inadequate high dose (e.g. high dose of proton pump inhibitor solely for the purpose of gastric prophylaxis) Interaction (e.g. increasing dose omeprazole due to use of enzalutamide)
Start drug	5 (6)	Use of laxative with concurrent use of opioids Basic dermal product for the treatment of a rash
Other	9 (10)	Monitoring of certain parameters (e.g. QTc interval, lipids) Reducing the number of different types of inhalators Switching from two separate preparations to one combination preparation Clarifying discrepancies between presumed use and actual use of drugs by patient
Total	85