Table 1.

Medication-Related Concerns and Interventions: Definitions and Examples

Categories	Definition or criteria	Examples
Medication-related concerns
Inappropriate or unnecessary therapy	Use of medication that is not indicated for age or symptoms New serum levels or lack of symptoms indicate medication may no longer be needed	Chronic use of herbal supplement to boost immune system with no clinical evidence supporting benefit Use of vitamin D supplementation in patient with 25-hydroxy vitamin D level at or above upper limit of normal
Suboptimal therapy	Inadequate dosing for patient weight Current medication is not optimal according to GDMT	Subtherapeutic acetaminophen dose (e.g., 5 mg/kg) Consensus guidelines now recommend use of combination corticosteroid/beta-agonist inhalers for rescue therapy in adolescents with asthma
Undertreated symptoms	Symptom complaints documented during office encounter Gaps in therapy for guideline-directed care	Ongoing constipation symptoms despite current treatment (e.g., under-dosed polyethylene glycol) Frequent ongoing asthma symptoms despite current controller inhaler use
Adverse drug event	Side effect causing uncomfortable or intolerable symptoms Side effect potentially contributing to unsafe laboratory values or other diagnostic results	Constipation related to iron supplementation QTc-prolongation in setting of contributing medication use (e.g., amitriptyline)
Drug-drug interaction	Interaction through which serum drug levels are impacted Potential for adverse event resulting from use of multiple drugs with overlapping side effects	CYP2D6 inhibitor effect on aripiprazole concentrations Use of multiple medication classes with serotonergic properties
Duplication of therapy	Overlapping therapeutic effect Similar mechanism of action	Concurrent use of PPI and H2RA classes for reflux management without evidence supporting therapeutic benefit Use of both clonidine and guanfacine for behavioral symptoms
Unclear prescription instructions	Medication label missing specified strength, route, dose, or frequency	Home medication documentation missing strength, dose, or frequency on instructions (e.g., cholecalciferol by mouth)
Interventions
Dose modification	Medication dose is inappropriate for patient’s age, weight, or condition	Correction of subtherapeutic famotidine dose to appropriate therapeutic dose for current weight (e.g., 0.5 mg/kg)
Drug discontinuation	Unnecessary therapy for current condition	Discontinuation of vitamin D supplementation when levels are therapeutic and stable
Dosage form modification	Medication for which easier-to-use dosage form is commercially available	Modification of pregabalin regimen from capsules to solution when administration via gastrostomy tube is required
Dosing frequency modification	Medication for which less frequent dosing may achieve similar therapeutic effect Medication for which ER formulation could reduce dose frequency	Transition from twice daily to once daily omeprazole dosing in child who has not previously failed once daily therapy Change from methylphenidate immediate release tablet given twice daily to an equivalent ER tablet once every morning
Initiation of new drug therapy	Provider documentation expressing ongoing symptoms with no current medication management	Addition of an age/weight appropriate laxative for a patient receiving still-necessary iron supplementation but experiencing documented symptoms of constipation
Patient/caregiver education	Compounded or non-enteral medication for which repeated education could help improve administration technique or reduce risk of error	Education on injection technique for epinephrine injectable device or midazolam nasal atomizer Education on calculation/measurement of appropriate volume to achieve desired dose of compounded clonidine liquid
Change to alternative medication	Optimization of GDMT recommended in new or updated consensus guidelines Alternative formulation with reduced risk of documented side effects available	Change from SABA to combination corticosteroid/beta-agonist inhaler for rescue in appropriate patients with asthma Transition from ferrous sulfate to polysaccharide iron complex for patient experiencing ongoing gastric discomfort
Laboratory monitoring for safety or efficacy	Medication for which benefit to obtaining follow-up labs is known (e.g., narrow therapeutic index, risk for adverse effect)	Recommendation to obtain appropriate metabolic labs for patient receiving olanzapine for several years with no documented assessment of baseline or routine monitoring

GDMT: guideline-directed medical therapy; PPI: Proton pump inhibitor; H2RA: histamine-2 receptor antagonist; ER: extended release; SABA: short-acting beta agonist