Le bilan de médication est une activité de pharmacie clinique innovante dans la démarche de sécurisation de la prise en charge médicamenteuse des patients, son optimisation et le renforcement du lien ville-hôpital. Il se rapproche du « medication review type 3 » européen et « medication therapy review » américain couvrant différentes thématiques. Il comprend un entretien avec le patient explorant l’adhésion médicamenteuse, la connaissance et la gestion du traitement, la prévention des effets indésirables, un dépistage des addictions et une conciliation médicamenteuse d’entrée. Il repose également sur une expertise pharmaceutique clinique comprenant une analyse approfondie de l’ordonnance, des préconisations de suivi pharmacobiologique et clinique ainsi que l’utilisation d’outils tels que RISQ-PATH, l’échelle CIA et STOPP START v.2. Cet article détaille l’expérimentation d’un bilan de médication pour les patients hospitalisés à temps plein dans un secteur de psychiatrie générale du Groupe Hospitalier Paul-Guiraud (94). La cohorte comprend 23 patients et s’étend sur trois périodes, de juillet 2021 à août 2022. Les patients ont été inclus sur la base de critères prédéfinis : âge, pathologie somatique chronique, médicament à risque, addiction. Parmi les bilans de médication réalisés, seuls neuf patients connaissaient de façon satisfaisante leurs traitements, onze seulement étaient autonomes dans leur gestion du traitement et présentaient une adhésion thérapeutique correcte. Six patients présentaient des effets indésirables au moment de l’entretien. La conciliation médicamenteuse d’entrée a permis de détecter et de corriger treize divergences non intentionnelles par rapport au traitement ambulatoire des patients hospitalisés. L’expertise pharmaceutique clinique a permis d’optimiser les traitements de dix patients sur les plans psychiatrique et somatique et a également permis de renforcer le suivi pharmaco-biologique, clinique ou paraclinique de 21 d’entre eux. Le bilan de médication, à travers ses différents items explorés, permet une synergie d’action aboutissant à une optimisation renforcée de la prise en charge médicamenteuse du patient.

The “bilan de médication” is a French practice that finds close similarities in the rest of Europe within the “medication review type 3”. In the USA, it would relate strongly to the “medication therapy review”. The “bilan de médication” is an innovative clinical pharmacy activity ensuring that patient medication management is not only safe but also optimized. It plays a key role in strengthening the link between the city and the hospital. The “bilan de médication” presented in this article covers a range of topics. It includes a patient interview that aims to explore their adherence to the treatment, have a better picture and knowledge of their treatment, and a closer understanding of their treatment management. This interview enables side effects prevention, allows a screening for addictions, and is a tool for the establishment of a medication reconciliation when the patient is admitted in the hospital. Following this interview, if and when the need arose (e.g. side effects, poor treatment management, drug misuse, addiction, etc.) sessions of patient education were proposed to the patients, conducted by a dedicated team. On top of the patient interview, the “bilan de médication” is also based on a clinical pharmaceutical expertise that is deployed by several means. An in-depth analysis of the inpatient prescription is performed; some recommendations regarding the pharmaco-biological and clinical monitoring are issued as needed. The use of tools is part of the process too, such as RISQ-PATH used to assess the QTc prolongation, the CIA scale that enables to quantify the anticholinergic load linked to the patient treatment and STOPP START v.2 allowing the drug prescription assessment for the elderly patients. This article details the implement of the “bilan de médication” for patients hospitalized in a general adult psychiatry sector of the Groupe Hospitalier Paul-Guiraud, a hospital specialized in adult mental healthcare and located in the city of Villejuif, within the Paris suburbs in France. The cohort is composed of 23 patients and was built over three periods of time from July 2021 to August 2022. Patients were included on the basis of predefined criteria: age, chronic somatic pathology, high-risk medication, addiction. Among all the “bilan de médication” carried out, only nine patients had a satisfactory knowledge of their treatments, and only eleven were autonomous in their treatment management and showed good adherence. Six patients declared suffering from side effects at the time of their interviews. Based on the data collected, the outpatient prescription is reconstituted. Once the outpatient prescription available, it is compared to the inpatient prescription in order to identify any discrepancies. A joint review of these discrepancies is performed by both physicians and pharmacists during a dedicated meeting. Said discrepancies are then classified as intentional or unintentional and corrected as needed. Within the cohort, thirteen unintentional discrepancies from the outpatient treatment were detected and corrected. Clinical pharmaceutical expertise has enabled the risk assessment associated with two issues prevalent in psychiatry: the risk of prolonged QTc interval and the risk of anticholinergic impregnation. Indeed, more than one-third of the patients were at a high risk of significant QTc prolongation at the time of the interview, and more than two-thirds of them were at risk of developing anticholinergic side effects according to the scales used. Peripheral anticholinergic side effects are well known, but central side effects, particularly in elderly patients such as confusion and hallucinations, are frequently overlooked and can contribute to their clinical destabilization. The use of the STOPP/START criteria has made it possible to issue therapeutic optimization recommendations for all the elderly patients of this cohort, a particularly fragile subpopulation in psychiatry. The “bilan de medication” enabled the issue of some recommendations regarding the pharmaco-biological and clinical monitoring for almost all the patients, 21 out of 23. Moreover, for almost half of the cohort, 10 patients out of 23, recommendations were issued regarding the optimization of their inpatient prescriptions. Clinical pharmaceutical expertise enabled us to optimize the psychiatric and somatic treatment of various patients, and also to strengthen their pharmaco-biological and clinical monitoring. The “bilan de médication”, through the various items covered and explored, provides a synergy of action leading to a greater optimization of the patient's medication management. However, this synergy faces many challenges (time, organization) that have led to the implementation of the “bilan de médication” in the group's external facilities.