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Morikawa N, Naito T, Morita M, Sekikawa M, Doshita K, Yabe M, Kodama H, Miura K, Iida Y, Mamesaya N, Kobayashi H, Ko R, Wakuda K, Ono A, Kenmotsu H, Murakami H, Takahashi T. Effect of polypharmacy on the outcomes of older patients with advanced non-small-cell lung cancer treated with PD-1/PD-L1 inhibitors: A retrospective cohort study. J Geriatr Oncol 2024; 15:101832. [PMID: 38997933 DOI: 10.1016/j.jgo.2024.101832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/31/2024] [Accepted: 06/28/2024] [Indexed: 07/14/2024]
Abstract
INTRODUCTION The effect of polypharmacy on older patients with cancer is unclear. This study aimed to explore the effect of polypharmacy on the outcomes of treatment in older patients with advanced non-small cell lung cancer (NSCLC) treated with PD-1/PD-L1 inhibitors. MATERIALS AND METHODS We retrospectively reviewed the records of older patients (aged ≥65 years) with advanced NSCLC who received PD-1/PD-L1 inhibitors with or without platinum-based chemotherapy as first-line treatment from March 2016 to December 2020. Patients with driver oncogenes or Eastern Cooperative Oncology Group performance status (PS) ≥2 were excluded. Polypharmacy was defined as receiving five or more oral or inhaled medications at baseline. We compared the progression-free survival (PFS), overall survival (OS), and mean cumulative length of hospital stays between the polypharmacy and non-polypharmacy groups. RESULTS A total of 122 patients, with a median age of 72 years (range, 65-89 years), were included in the analysis. Of the patients, 34 (27.8%) had a PS of 0 and 68 (55.7%) had a PD-L1 tumor proportion score (TPS) of ≥50%. The median number of oral or inhaled medications was 4 (range, 0-12), and 60 (49.1%) patients were taking ≥5 medications (polypharmacy). Age and Charlson Comorbidity Index score were significantly higher in the polypharmacy group (P = 0.01 and P < 0.001, respectively). Compared with the non-polypharmacy group, the polypharmacy group had a similar median PFS (6.7 vs. 8.5 months, P = 0.94) and a shorter median OS (17.3 vs. 26.0 months, P = 0.04). In the polypharmacy group, the adjusted hazard ratio for OS (adjusted for age, PS, and PD-L1 TPS) was 1.65 (95% confidence interval, 1.04-2.86, P = 0.03). Patients in the polypharmacy group had longer hospital stays (46.3 ± 7.5 vs. 27.7 ± 4.1 days/person, P < 0.05) and more emergency hospitalizations (1.6 ± 0.3 vs. 0.8 ± 0.1 times/person, P < 0.05) during the first year. DISCUSSION Polypharmacy was associated with shorter survival time and longer hospitalization in older patients with advanced NSCLC receiving first-line immunotherapy with or without chemotherapy.
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Affiliation(s)
- Noboru Morikawa
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Tateaki Naito
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan.
| | - Meiko Morita
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Motoki Sekikawa
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kosei Doshita
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Michitoshi Yabe
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hiroaki Kodama
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Keita Miura
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yuko Iida
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Nobuaki Mamesaya
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Haruki Kobayashi
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Ryo Ko
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kazushige Wakuda
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Akira Ono
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Haruyasu Murakami
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
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Oliveira RF, Oliveira AI, Cruz AS, Ribeiro O, Afreixo V, Pimentel F. Polypharmacy and drug interactions in older patients with cancer receiving chemotherapy: associated factors. BMC Geriatr 2024; 24:557. [PMID: 38918696 PMCID: PMC11201315 DOI: 10.1186/s12877-024-05135-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 06/10/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Polypharmacy in older adults with cancer receiving chemotherapy leads to increased risks of drug interactions, translating in potential hazardous health outcomes. This study aims to assess the prevalence of polypharmacy, drug-drug interactions (DDIs), and severe-drug interactions (SDIs) in older patients with cancer. Antineoplastic agents (ANAs) involvement and possible risk contexts (comorbidities with cardiac risk, and high-risk medications) were also analysed. METHODS Observational study with older adults (≥ 65 years) diagnosed with cancer, who were treated with antineoplastic agents (ANAs); it was conducted in three hospitals from the north of Portugal. Data collection was obtained using self-reports and medical records. DDIs were identified and classified using Micromedex® software. Descriptive and association analyze statistics were performed. Statistical hypothesis tests with p value less than 0.05 were considered significant. All statistical procedures and analysis were performed with R version 4.1.3. RESULTS We enrolled 552 patients. Polypharmacy prevalence was 88.40%; 76.45% and 56.16% of the patients presented with DDIs and SDIs, respectively. SDIs with ANAs were found in 21.20% of the patients. High-risk medications were associated with a higher risk of polypharmacy, DDIs, and SDIs. Polypharmacy and DDIs were higher in patients with hypertension or diabetes. SDIs were higher in patients with diabetes. CONCLUSION Polypharmacy, potential DDIs and SDIs were highly prevalent in older adults with cancer. A careful review of the medication administered is necessary to decrease it. These findings warrant further research to optimize medication in this population and decrease problems related to medication, which may lead to emergency room visits and hospitalisations, compromising patient safety and/or ongoing treatments.
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Affiliation(s)
- Rita F Oliveira
- University of Aveiro, Aveiro, Portugal.
- ESS, Polytechnic of Porto, Porto, Portugal.
- Center for Health Technology and Services Researchat the Associate Laboratory RISE - Health Research Network (CINTESIS@RISE), Department of Education and Psychology, University of Aveiro (UA), Aveiro, Portugal.
| | - Ana I Oliveira
- REQUIMTE/LAQV, ESS, Polytechnic of Porto, Porto, Portugal
| | | | - Oscar Ribeiro
- Center for Health Technology and Services Researchat the Associate Laboratory RISE - Health Research Network (CINTESIS@RISE), Department of Education and Psychology, University of Aveiro (UA), Aveiro, Portugal
| | - Vera Afreixo
- Center for Research and Development in Mathematics and Applications (CIDMA), Department of Mathematics, University of Aveiro (UA), Aveiro, Portugal
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Ramsdale E, Mohamed M, Holmes HM, Zubkoff L, Bauer J, Norton SA, Mohile S. Decreasing polypharmacy in older adults with cancer: A pilot cluster-randomized trial protocol. J Geriatr Oncol 2024; 15:101687. [PMID: 38302299 PMCID: PMC10923001 DOI: 10.1016/j.jgo.2023.101687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/02/2023] [Accepted: 12/07/2023] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Polypharmacy is prevalent in older adults with cancer and associated with multiple adverse outcomes. A single-site, cluster-randomized clinical trial will enroll older adults with cancer and polypharmacy starting chemotherapy and will assess the effectiveness and feasibility of deprescribing interventions by comparing two arms: a pharmacist-led deprescribing intervention and a patient educational brochure. MATERIALS AND METHODS The study will be conducted in two phases. In phase I, focus groups and semi-structured individual interviews will guide adaptation of deprescribing interventions for the oncology clinic (phase Ia), and eight patients will undergo the pharmacist-led deprescribing intervention with iterative adaptations (phase Ib). In phase II, a pilot cluster-randomized trial (n = 72) will compare a pharmacist-led deprescribing intervention with a patient education brochure, with treating oncologists as the cluster. Both efficacy (relative dose intensity of planned chemotherapy, potentially inappropriate medications successfully deprescribed, chemotherapy toxicity, functional status, hospitalizations, falls, and symptoms) and implementation outcomes (barriers and facilitators) will be assessed. DISCUSSION This study is anticipated to provide pilot data to inform a nationwide randomized clinical trial of deprescribing in older adults starting cancer treatment. The cluster randomization is intended to provide an initial estimate for the intervention effect as well as oncologists' intra-class correlation coefficient. Deprescribing interventions may improve outcomes in older adults starting cancer treatment, but these interventions are understudied in this population, and it is unknown how best to implement them into oncology practice. The results of this trial will inform the design of large, randomized phase III trials of deprescribing. CLINICALTRIALS gov Identifier:NCT05046171. Date of registration: September 16, 2021.
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Affiliation(s)
- Erika Ramsdale
- James P. Wilmot Cancer Center, University of Rochester Medical Center, NY, USA.
| | - Mostafa Mohamed
- James P. Wilmot Cancer Center, University of Rochester Medical Center, NY, USA
| | - Holly M Holmes
- Division of Geriatric and Palliative Medicine, McGovern Medical School, TX, USA
| | - Lisa Zubkoff
- Department of Medicine, University of Alabama at Birmingham, AL, USA
| | - Jessica Bauer
- James P. Wilmot Cancer Center, University of Rochester Medical Center, NY, USA
| | - Sally A Norton
- School of Nursing, University of Rochester Medical Center, NY, USA
| | - Supriya Mohile
- James P. Wilmot Cancer Center, University of Rochester Medical Center, NY, USA
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van Merendonk LN, Peters BJM, Möhlmann JE, Hunting CB, Kastelijn EA, van den Broek MPH. The potential for deprescribing in a palliative oncology patient population: a cross-sectional study. Eur J Hosp Pharm 2023; 31:10-15. [PMID: 35197277 PMCID: PMC10800274 DOI: 10.1136/ejhpharm-2021-003143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 02/08/2022] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES The use of preventive medication in palliative oncology patients may be inappropriate due to limited life expectancy. Deprescribing tools are available but time-consuming and not always tailored to this specific population. Our primary goal was to identify potentially inappropriate medications (PIMs) in palliative oncology patients with a life expectancy of up to 2 years using an adapted deprescribing tool. Our secondary aim was to identify patient characteristics associated with the presence of PIMs. METHODS Oncology patients with a life expectancy of up to 2 years were included cross-sectionally. An adapted deprescribing tool was developed to identify PIMs. Logistic regression was used to identify factors associated with having PIMs. RESULTS A total of 218 patients were included in this study of which 56% had at least one PIM with a population mean of 1.1 PIM per patient. Most frequently defined PIMs were antihypertensive drugs and gastric acid inhibitors. Identification of PIMs by review took an estimated 5-10 min per patient. Polypharmacy, age >65 years and inpatient/outpatient status were found to be associated with having at least one PIM. CONCLUSIONS Deprescribing is possible in more than half of palliative oncology patients with a life expectancy of up to 2 years. The adapted deprescribing tool used is non-time consuming and suitable for palliative oncology patients, regardless of age.
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Affiliation(s)
| | - Bas J M Peters
- Clinical Pharmacy, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Julia E Möhlmann
- Clinical Pharmacy, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Cornelis B Hunting
- Department of Internal Medicine, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Elisabeth A Kastelijn
- Department of Pulmonary Diseases, Sint Antonius Hospital, Nieuwegein, The Netherlands
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Orzetti S, Baldo P. Toxicity Derived from Interaction between Natural Compounds and Cancer Therapeutic Drugs Metabolized by CYP3A4: Lessons Learned from Two Clinical Case Reports. Int J Mol Sci 2023; 24:15976. [PMID: 37958959 PMCID: PMC10648905 DOI: 10.3390/ijms242115976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 11/15/2023] Open
Abstract
The use of natural compounds and, in general, the use of Complementary and Alternative Medicine (CAM), is growing steadily worldwide, both due to commercial pressure and the increasing use of self-medication and the desire to manage one's own personal health and well-being. Patients facing a cancer diagnosis are also strongly pressured to use these compounds, which are often added to standard therapeutic regimens, that should instead be based solely on diagnostic and therapeutic care pathways (DTCP) or evidence-based medicine (EBM). This study presents two clinical cases of cancer patients who presented to the pharmaceutical consultation service (PCD-Pharmacy Clinical Desk) established at the CRO Institute in Aviano, Italy. Both patients were using natural products along with prescribed chemotherapy. In the first case, a 55-year-old woman diagnosed with bilateral breast cancer with bone metastases, who was using natural compounds based on diosmin, escin (or aescin) and resveratrol in combination with ribociclib anticancer therapy, a severe ADR (neutropenia) was identified as a consequence of the drug-natural product interaction. In the second case, following a detailed medication review by the PCD, we avoided taking a therapeutic treatment (with natural compounds) that in itself could potentially render chemotherapy ineffective in a 57-year-old woman with multiple infiltrating ductal carcinoma of the left breast; the patient was planning to take a natural product containing St. John's Wort tincture and lemon balm tincture, in combination with paclitaxel and trastuzumab. In addition, we describe the corrective actions taken, thus outlining the main objectives of the activity of the PCD's pharmacy counseling service: first, to identify, report, and manage adverse drug reactions (ADRs), and second, to identify therapeutic combinations that present potential risks of toxicity or ineffectiveness of the drug therapy itself.
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Affiliation(s)
- Sabrina Orzetti
- PCD Pharmacy Clinical Desk, Hospital Pharmacy Unit of the “Centro di Riferimento Oncologico (CRO) di Aviano IRCCS”, Via F. Gallini, 33081 Aviano, Italy;
| | - Paolo Baldo
- Hospital Pharmacy Unit of the “Centro di Riferimento Oncologico (CRO) di Aviano IRCCS”, Via F. Gallini, 33081 Aviano, Italy
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Li Y, Wu Y, Jiang T, Xing H, Xu J, Li C, Ni R, Zhang N, Xiang G, Li L, Li Z, Gan L, Liu Y. Opportunities and challenges of pharmacovigilance in special populations: a narrative review of the literature. Ther Adv Drug Saf 2023; 14:20420986231200746. [PMID: 37780667 PMCID: PMC10540608 DOI: 10.1177/20420986231200746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 08/22/2023] [Indexed: 10/03/2023] Open
Abstract
The relatively new discipline of pharmacovigilance (PV) aims to monitor the safety of drugs throughout their evolution and is essential to discovering new drug risks. Due to their specific and complex physiology, children, pregnant women, and elderly adults are more prone to adverse drug reactions (ADRs). Additionally, the lack of clinical trial data exacerbates the challenges faced with pharmacotherapy in these populations. Elderly patients tend to have multiple comorbidities often requiring more extensive medication, which adds additional challenges for healthcare professionals (HCPs) in delivering safe and effective pharmacotherapy. Clinical trials often have inherent limitations, including insufficient sample size and limited duration of research; as some ADRs are attributed to long-term use of a drug, these may go undetected during the course of the trial. Therefore, the implementation of PV is key to insuring the safe and effective use of drugs in special populations. We conducted a thorough review of the scientific literature on PV systems across the European Union, the United States, and China. Our review focused on basic physiological characteristics, drug use, and PV for specific populations (children, pregnant women, and the elderly). This article aims to provide a reference for the development of follow-up policies and improvement of existing policies as well as provide insight into drug safety with respect to patients of special populations.
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Affiliation(s)
- Yanping Li
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Yuanlin Wu
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Tingting Jiang
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Haiyan Xing
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Jing Xu
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Chen Li
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Rui Ni
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Ni Zhang
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Guiyuan Xiang
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Li Li
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Ziwei Li
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Lanlan Gan
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Yao Liu
- Department of Pharmacy, Daping Hospital, Army Medical University, No. 10 Changjiang Branch Road, Yuzhong District, Chongqing 400042, China
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Betts AC, Murphy CC, Shay LA, Balasubramanian BA, Markham C, Allicock M. Polypharmacy and prescription medication use in a population-based sample of adolescent and young adult cancer survivors. J Cancer Surviv 2023; 17:1149-1160. [PMID: 34997910 PMCID: PMC10614319 DOI: 10.1007/s11764-021-01161-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/22/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE We examined prescription medication use and identified correlates of polypharmacy-taking multiple medications-in adolescent and young adult cancer survivors (AYAs), who experience early-onset chronic conditions. METHODS Our cross-sectional study pooled data (2008-2017) from the national Medical Expenditure Panel Survey. We estimated prevalence of polypharmacy (≥ 5 unique prescription medications over an approximate 1-year period) in AYAs (age 18-39 years with a history of cancer) and age- and sex-matched controls, overall and by sociodemographics, clinical factors, and health indicators. We compared survivors' and controls' medication use across therapeutic classes. To identify correlates of polypharmacy among AYAs, we included factors with p < 0.20 in bivariable analysis in a multivariable logistic regression model. RESULTS AYAs (n = 601) had a higher prevalence of polypharmacy than controls (n = 2,402), overall (31.5% vs. 15.9%, p < .01) and by all sociodemographics, clinical factors, and health indicators. A majority of AYAs with multiple chronic conditions (58.8%, 95% CI 47.3-70.4) or disability (61.3%, 95% CI 52.6-70.0) had polypharmacy. Patterns of AYAs' medication use across therapeutic classes were consistent with their chronic conditions. Nearly one-third used opioid/narcotic analgesics (32.2% vs. 13.7% of controls, p < 0.01). Among AYAs, multiple chronic conditions (aOR 4.68, 95% CI 2.23-9.83) and disability (aOR 3.70, 95% CI 2.23-6.14) were correlated with polypharmacy. CONCLUSIONS Chronic conditions and disabilities, including aftereffects of cancer treatment, may drive polypharmacy in AYAs. Future research should examine adverse outcomes of polypharmacy and opioid/narcotic use in AYAs. IMPLICATIONS FOR CANCER SURVIVORS AYAs with chronic conditions or disabilities should be monitored for polypharmacy.
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Affiliation(s)
- Andrea C Betts
- Department of Health Promotion and Behavioral Sciences, School of Public Health, University of Texas Health Science Center at Houston (UTHealth), 2777 N. Stemmons Fwy., Ste. 8400, Dallas, TX, 75207, USA.
| | - Caitlin C Murphy
- Department of Health Promotion and Behavioral Sciences, UTHealth School of Public Health, Houston, TX, USA
- Center for Health Promotion and Prevention Research, UTHealth School of Public Health, Houston, TX, USA
| | - L Aubree Shay
- Department of Health Promotion and Behavioral Sciences, UTHealth School of Public Health, San Antonio, TX, USA
- Center for Health Promotion and Prevention Research, UTHealth School of Public Health, Houston, TX, USA
| | - Bijal A Balasubramanian
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Dallas, TX, USA
- Center for Health Promotion and Prevention Research, UTHealth School of Public Health, Dallas, TX, USA
| | - Christine Markham
- Department of Health Promotion and Behavioral Sciences, UTHealth School of Public Health, Houston, TX, USA
- Center for Health Promotion and Prevention Research, UTHealth School of Public Health, Houston, TX, USA
| | - Marlyn Allicock
- Department of Health Promotion and Behavioral Sciences, School of Public Health, University of Texas Health Science Center at Houston (UTHealth), 2777 N. Stemmons Fwy., Ste. 8400, Dallas, TX, 75207, USA
- Center for Health Promotion and Prevention Research, UTHealth School of Public Health, Dallas, TX, USA
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Clarkson L, Hart L, Lam AK, Khoo TK. Reducing inappropriate polypharmacy for older patients at specialist outpatient clinics: a systematic review. Curr Med Res Opin 2023; 39:545-554. [PMID: 36847597 DOI: 10.1080/03007995.2023.2185390] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
OBJECTIVE Polypharmacy is associated with negative clinical consequences. The efficacy of deprescribing interventions within medical specialist outpatient clinics remains unclear. Here, we reviewed the research on the effectiveness of deprescribing interventions implemented within specialist outpatient clinics for patients ≥ 60 years. METHODS Systematic searches of key databases were undertaken for studies published between January 1990 and October 2021. The diverse nature of the study designs made it unsuitable for pooling for meta-analysis, thus, a narrative review was conducted and presented in both text and tabular formats. The primary outcome for review was that intervention resulted in a change in medication load (either total number of medications or appropriateness of medication). Secondary outcomes were the maintenance of deprescription and clinical benefits. Methodological quality of the publications was assessed using the revised Cochrane risk-of-bias tools. RESULTS Nineteen studies with a total of 10,914 participants were included for review. These included geriatric outpatient clinics, oncology/hematology clinics, hemodialysis clinics, and designated polypharmacy/multimorbidity clinics. Four randomized controlled trials (RCTs) reported statistically significant reductions in medication load with intervention; however, all studies had a high risk of bias. The inclusion of a pharmacist in outpatient clinics aims to increase deprescribing, however, the current evidence is mainly restricted to prospective and pilot studies. The data on secondary outcomes were very limited and highly variable. CONCLUSIONS Specialist outpatient clinics may provide valuable settings for implementing deprescribing interventions. The addition of a multidisciplinary team including a pharmacist and the use of validated medication assessment tools appear to be enablers. Further research is warranted.
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Affiliation(s)
- Louise Clarkson
- School of Medicine & Dentistry, Menzies Health Institute Queensland, Griffith University, Queensland, Australia
- Northern New South Wales Local Health District, NSW Health, Australia
| | - Laura Hart
- Lancet Neurology, London, London, United Kingdom
| | - Alfred K Lam
- School of Medicine & Dentistry, Menzies Health Institute Queensland, Griffith University, Queensland, Australia
| | - Tien K Khoo
- School of Medicine & Dentistry, Menzies Health Institute Queensland, Griffith University, Queensland, Australia
- Northern New South Wales Local Health District, NSW Health, Australia
- Graduate School of Medicine, University of Wollongong, New South Wales, Australia
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Darcis E, Germeys J, Stragier M, Cortoos P. The impact of medication reconciliation and review in patients using oral chemotherapy. J Oncol Pharm Pract 2023; 29:270-275. [PMID: 36729465 DOI: 10.1177/10781552211066959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Verifying and reviewing a patients medication list can detect and reduce drug related problems (DRPs). However little is known about its effects in patients using oral chemotherapy. The aim of this study was to evaluate the impact of these interventions and the adapted Medication Appropriateness Index (aMAI) as a tool to carry out a medication review. METHODS A case-control study was carried out. The hospital pharmacist performed a medication reconciliation and medication review, using the aMAI tool, in 54 patients starting oral chemotherapy. Discrepancies, DRP's and associated pharmaceutical interventions were reported via the electronic patient record (EPR). After one month, the acceptance rate was measured and the aMAI score recalculated. Kappa statistics were used to test intra- and interrater reliability. RESULTS The medication list in the EPR was incomplete in 74,1% of patients with an average of 2.4 errors per patient. After medication review, the aMAI score decreased significantly from 7.2 to 5.4 (SD = 4,7; p <0.001), indicating an improvement in the appropriateness of the drugs patients were taking. Acceptance rates were 41,4% and 53,2% for advices resulting from medication reconciliation and medication review respectively. Kappa values of 0.90 and 0.70 respectively indicate good intra- and interrater reliability. DISCUSSION AND CONCLUSION The study shows that medication reconciliation can identify and address discrepancies. Furthermore, medication review seems to ensure that drug treatment better meets patient needs. The aMAI was a reliable tool. Future research will have to determine the clinical relevance of these interventions.
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Affiliation(s)
| | - Jana Germeys
- Pharmacy, 82214Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | - Pieterjan Cortoos
- 60201Academisch Ziekenhuis van de Vrije Universiteit Brussel, Brussel, Belgium
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Whitman A, Fitch E, Nightingale G. The role of oncology pharmacists and comprehensive medication reconciliation in informing treatment plans for older adults with cancer and downstream outcomes. Curr Opin Support Palliat Care 2023; 17:3-7. [PMID: 36695863 DOI: 10.1097/spc.0000000000000634] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE OF REVIEW Proper medication management is an essential part of older adult cancer care. An aging population, an increase in anticancer treatment options, and high rates of comorbid conditions make navigating general medication reconciliation complicated. This review will highlight the recent literature describing the roles of the oncology pharmacist in caring for older adults with cancer. RECENT FINDINGS The body of literature highlighting oncology pharmacist roles in this population is mainly focused on polypharmacy and potentially inappropriate medication assessments, deprescribing nonessential therapies, drug-drug interaction reviews, and immunization optimization. Outcomes associated with oncology pharmacist interventions are still lacking as well as the development of benchmarks for appropriate pharmacy-based care in the older adult oncology population. SUMMARY Oncology pharmacist interventions in older adults with cancer have the potential to improve patient care. Future randomized studies in this area of practice are warranted in order to clearly define the optimal impact of oncology pharmacists.
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Affiliation(s)
- Andrew Whitman
- Department of Pharmacy Services, University of Virginia Health, Charlottesville, Virginia
| | - Emily Fitch
- Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Ginah Nightingale
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Malta JS, Drummond PLDM, Silveira LP, Costa NL, Santos RMMD, Machado CJ, Reis AMM, de Pádua CAM. Effect of therapeutic regimens and polypharmacy on health-related quality of life of people with multiple myeloma: a cross-sectional study in Belo Horizonte, Brazil. Curr Med Res Opin 2022; 38:1275-1283. [PMID: 35083943 DOI: 10.1080/03007995.2022.2034387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Multiple myeloma (MM) is an incurable hematological cancer and its treatment is geared to promote better Health-Related Quality of Life (HRQoL). We aimed to assess HRQoL and compare scores between variables on therapeutic regimens and polypharmacy in MM patients. METHODS This cross-sectional study was performed from April/2019 to February/2020 in Belo Horizonte, Brazil. HRQoL scores were obtained by the QLQ-C30 and QLQ-MY20 instruments. Data were retrieved from interviews and medical records. Therapeutic regimens were grouped into thalidomide-containing regimens; bortezomib-containing regimens; bortezomib and thalidomide-containing regimens; other therapeutic regimens, and remission group. We performed univariate analyses by the Mann-Whitney method and adopted the Kruskal-Wallis test for multiple comparisons. Robust multiple linear regression was used to determine the association between independent variables and the HRQoL scores. RESULTS The sample included 225 participants and most patients (65.3%) were on active treatment and had worse scores concerning future perspective. Polypharmacy was associated with worse scores on all scales in the univariate analyses. We observed a difference in the global health and body image (p < .05) scales in the multiple comparisons with therapeutic regimens. The global health scale difference was found between groups with other regimens and the remission group (p < .05). The difference between the bortezomib and thalidomide-containing regimens and remission group was not statistically significant (p = .077) in the body image scale. The multiple linear regression maintained the association of polypharmacy with worse HRQoL scores. CONCLUSION We identified an independent association between HRQoL and polypharmacy in MM patients. However, there was no difference between the evaluated regimens, suggesting they are equivalent in Brazil about HRQoL.
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Affiliation(s)
- Jéssica Soares Malta
- Departamento de Farmácia Social, Universidade Federal de Minas Gerais - UFMG, Belo Horizonte, Brasil
| | - Paula Lana de Miranda Drummond
- Departamento de Farmácia Social, Universidade Federal de Minas Gerais - UFMG, Belo Horizonte, Brasil
- Fundação Ezequiel Dias - Funed, Belo Horizonte, Brasil
| | - Lívia Pena Silveira
- Departamento de Farmácia Social, Universidade Federal de Minas Gerais - UFMG, Belo Horizonte, Brasil
- Hospital das Clínicas da UFMG, Belo Horizonte, Brasil
| | - Naiane Lima Costa
- Departamento de Farmácia Social, Universidade Federal de Minas Gerais - UFMG, Belo Horizonte, Brasil
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12
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Novak J, Goldberg A, Dharmarajan K, Amini A, Maggiore RJ, Presley CJ, Nightingale G. Polypharmacy in older adults with cancer undergoing radiotherapy: A review. J Geriatr Oncol 2022; 13:778-783. [PMID: 35227626 PMCID: PMC9283217 DOI: 10.1016/j.jgo.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 12/09/2021] [Accepted: 02/10/2022] [Indexed: 01/09/2023]
Abstract
Polypharmacy is characterized by the simultaneous use of multiple medications, including prescription drugs, over-the-counter drugs, and nutritional supplements. Polypharmacy is known to increase the risk of adverse drugs reactions, drug-drug interactions, and medication errors, and to negatively impact quality of life. The prevalence of polypharmacy varies by population, but has been reported to exceed 90% among older adults with cancer. Polypharmacy may be exacerbated among older adults with cancer receiving radiation therapy due to the resulting acute or chronic side effects that need to be managed with additional medications. The medications prescribed to manage radiation-related side effects increase the risk of adverse drug events, as do changes in nutritional status related to the secondary side effects of radiation treatment. Side effects from treatment may result in the need for breaks in cancer therapy or treatment delays, which ultimately can lead to worse oncologic outcomes. Few studies have examined polypharmacy in the context of older adults undergoing radiation therapy. We sought to review the literature pertaining to polypharmacy among older adults with cancer and discuss implications specifically for those individuals undergoing radiation therapy. This paper presents a narrative review of studies published in the past decade that provided detailed information on polypharmacy in older adults undergoing radiation therapy for cancer. The review elucidated good practices to avoid adverse drug events from polypharmacy, but more studies are warranted to develop standard guidelines.
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Affiliation(s)
- Jennifer Novak
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Annette Goldberg
- Department of Nutrition Services, Dana Farber Cancer Institute, Boston, MA, USA
| | - Kavita Dharmarajan
- Department of Geriatrics and Palliative Medicine, Mount Sinai Health System, New York, NY, USA; Department of Radiation Oncology, Mount Sinai Health System, New York, NY, USA
| | - Arya Amini
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Ronald J Maggiore
- Department of Medical Oncology, University of Rochester, Rochester, NY, USA
| | - Carolyn J Presley
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Ginah Nightingale
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA.
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13
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O'Mahony D, Rochon PA. Prescribing cascades: we see only what we look for, we look for only what we know. Age Ageing 2022; 51:6625698. [PMID: 35776668 DOI: 10.1093/ageing/afac138] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Indexed: 11/13/2022] Open
Abstract
Prescribing cascades are increasingly recognized since they were described in the mid-1990s. Cascades are more likely in older people with multimorbidity and associated polypharmacy where multiple medications can induce a variety of side effects that manifest with various non-specific symptoms that may be misidentified as new geriatric syndromes such as falls, dizziness and new-onset incontinence. Geriatricians encounter medication side effects frequently and will usually consider if an older patient presenting with new symptoms could be experiencing an adverse drug reaction or event. However, most medications prescribed to multimorbid older patients are initiated and continued by prescribers without specialist geriatric training who may not detect medication-induced morbidity. Therefore, novel approaches to the detection and management of prescribing cascades in older people are needed. Currently, the knowledge base surrounding prescribing cascades in older people is evolving towards better methods for cascade detection and secondary prevention. However, the large number of cascades described in the literature, the wide-ranging symptomatology of cascades and the rapidly increasing number of multimorbid older people at risk of cascades represent major challenges for prescribers. Furthermore, prospective prevalence studies of prescribing cascades in older people are lacking. To detect and correct prescribing cascades during routine medication review in multimorbid older people, awareness of cascades is essential. Prescribing cascade awareness in turn requires novel explicit ways of defining cascades to facilitate their rapid detection and correction during medication review. Given that prescribing cascades represent another aspect of inappropriate prescribing (IP), explicit cascades criteria should be integrated with other explicit IP criteria.
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Affiliation(s)
- Denis O'Mahony
- Department of Medicine (Geriatrics), University College Cork & Cork University Hospital, T12DC4A Cork, Ireland
| | - Paula A Rochon
- Women's Age Lab and Women's College Research Institute, Women's College Hospital, Toronto, ON M5S 1B2, Canada.,Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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Kantilal K, Kantilal K, Nightingale G, Ramsdale E. How-to guide for medication reviews in older adults with cancer: A Young International Society of Geriatric Oncology and Nursing & Allied Health Interest Group initiative. J Geriatr Oncol 2022; 13:1283-1286. [PMID: 35690585 DOI: 10.1016/j.jgo.2022.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/27/2022] [Accepted: 05/27/2022] [Indexed: 10/18/2022]
Abstract
For patients with polypharmacy or potentially inappropriate medication (PIM) use identified on geriatric assessment, a medication review is recommended. The medication review aims to ensure that the potential benefits of medication outweigh any potential harms and ensures the patient is receiving medication to effectively treat their medical conditions while minimizing risk of toxicity. The medication review encompasses: (1) collecting information to identify medication indications, efficacy and side effects, (2) evaluating adherence, (3) identifying PIMs, (4) identifying drug interactions, and (5) deprescribing. This paper provides the "how-to" guide to conduct a high-quality medication review by the cancer care multidisciplinary team.
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Affiliation(s)
- Kumud Kantilal
- College of Life Sciences, University of Leicester, Leicester, LE1 7RH, UK.
| | - Kavita Kantilal
- Pharmacy Department, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK.
| | - Ginah Nightingale
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Erika Ramsdale
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA.
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Thibaud V, Billy C, Prud’homm J, Garin J, Hue B, Cattenoz C, Somme D, Corvol A. Inside the Black Box: A Narrative Review on Comprehensive Geriatric Assessment-Driven Interventions in Older Adults with Cancer. Cancers (Basel) 2022; 14:cancers14071642. [PMID: 35406414 PMCID: PMC8996864 DOI: 10.3390/cancers14071642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/17/2022] [Accepted: 03/21/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary Comprehensive geriatric assessment is defined as a multi-dimensional, multi-disciplinary diagnostic and therapeutic process that is conducted to determine the medical, mental, and functional problems that older people with frailty have so that a coordinated and integrated plan for treatment and follow-up can be developed. Progress has been made in the definition of the best way to detect problems, but the benefits are mostly based on prognosis stratification and on the adaptation of cancer treatment. The present review aims to evaluate the level of evidence regarding geriatric interventions proposed following the detection of a problem in cancer patients. This review highlights the scarcity of published studies on this topic. Comprehensive geriatric assessment-based interventions have not yet demonstrated their specific impact. Multi-domain interventions seem promising, especially when they are based on global assessments. However, standardization seems difficult considering the lack of evidence for each domain. Abstract There is a consensus that the use of comprehensive geriatric assessment (CGA) is good clinical practice for older patients with solid tumors or hematological malignancies. To be complete, a CGA must include a geriatric assessment and an intervention plan. According to the SIOG consensus, a CGA should assess several domains: functional status, comorbidity, cognition, mental health status, fatigue, social status and support, nutrition, and the presence of geriatric syndromes. Progress has been made in the definition of the best way to detect problems, but the benefits are mostly based on prognosis stratification and on the adaptation of cancer treatment. The present review aims to evaluate the level of evidence regarding geriatric interventions proposed following the detection of a problem in cancer patients in each domain mentioned in the SIOG consensus. An online search of the PubMed database was performed using predefined search algorithms specific for each domain of the CGA. Eligible articles had to have well-defined interventions targeting specific domains of the CGA. We screened 1864 articles, but only a few trials on single-domain interventions were found, and often, these studies involved small groups of patients. This review highlights the scarcity of published studies on this topic. The specific impacts of CGA-based interventions have not yet been demonstrated. Multi-domain interventions seem promising, especially when they are based on global assessments. However, standardization seems difficult considering the lack of evidence for each domain. New studies are necessary in multiple care contexts, and innovative designs must be used to balance internal and external validity. An accurate description of the intervention and what “usual care” means will improve the external validity of such studies.
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Affiliation(s)
- Vincent Thibaud
- Department of Geriatrics, CHU Rennes, Université Rennes 1, 35000 Rennes, France; (C.B.); (J.G.); (C.C.)
- Department of Hematology, CHU Rennes, Université Rennes 1, 35000 Rennes, France
- Department of Hematology, Hôpital Saint-Vincent, Université Catholique de Lille, 59000 Lille, France
- Correspondence:
| | - Claire Billy
- Department of Geriatrics, CHU Rennes, Université Rennes 1, 35000 Rennes, France; (C.B.); (J.G.); (C.C.)
| | - Joaquim Prud’homm
- Laboratoire Traitement du Signal et de l’Image (INSERM LTSI—UMR 1099), CHU Rennes, Université Rennes 1, 35000 Rennes, France;
| | - Jeanne Garin
- Department of Geriatrics, CHU Rennes, Université Rennes 1, 35000 Rennes, France; (C.B.); (J.G.); (C.C.)
| | - Benoit Hue
- Department of Pharmacy, CHU Rennes, Université Rennes 1, 35000 Rennes, France;
| | - Catherine Cattenoz
- Department of Geriatrics, CHU Rennes, Université Rennes 1, 35000 Rennes, France; (C.B.); (J.G.); (C.C.)
- Centre Eugène Marquis, Department of Medical Oncology, Université Rennes 1, 35000 Rennes, France
| | - Dominique Somme
- Laboratoire Arènes(CNRS UMR 6051), CHU Rennes, Université Rennes 1, 35000 Rennes, France; (D.S.); (A.C.)
| | - Aline Corvol
- Laboratoire Arènes(CNRS UMR 6051), CHU Rennes, Université Rennes 1, 35000 Rennes, France; (D.S.); (A.C.)
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Prescribing practices, patterns, and potential harms in patients receiving palliative care: A systematic scoping review. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2021; 3:100050. [PMID: 35480601 PMCID: PMC9031741 DOI: 10.1016/j.rcsop.2021.100050] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 07/12/2021] [Accepted: 07/20/2021] [Indexed: 01/25/2023] Open
Abstract
Background Patients receiving palliative care often have existing comorbidities necessitating the prescribing of multiple medications. To maximize quality of life in this patient cohort, it is important to tailor prescribing of medication for preventing and treating existing illnesses and those for controlling symptoms, such as pain, according to individual specific needs. Objective(s) To provide an overview of peer-reviewed observational research on prescribing practices, patterns, and potential harms in patients receiving palliative care. Methods A systematic scoping review was conducted using four electronic databases (PubMed, EMBASE, CINAHL, Web of Science). Each database was searched from inception to May 2020. Search terms included ‘palliative care,’ ‘end of life,’ and ‘prescribing.’ Eligible studies had to examine prescribing for adults (≥18 years) receiving palliative care in any setting as a study aim or outcome. Studies focusing on single medication types (e.g., opioids), medication classes (e.g., chemotherapy), or clinical indications (e.g., pain) were excluded. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews, and the findings were described using narrative synthesis. Results Following deduplication, 16,565 unique citations were reviewed, and 56 studies met inclusion criteria. The average number of prescribed medications per patient ranged from 3 to 23. Typically, prescribing changes involved decreases in preventative medications and increases in symptom-specific medications closer to the time of death. Twenty-one studies assessed the appropriateness of prescribing using various tools. The prevalence of patients with ≥1 potentially inappropriate prescription ranged from 15 to 92%. Three studies reported on adverse drug events. Conclusions This scoping review provides a broad overview of existing research and shows that many patients receiving palliative care receive multiple medications closer to the time of death. Future research should focus in greater detail on prescribing appropriateness using tools specifically developed to guide prescribing in palliative care and the potential for harm.
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Ham L, Geijteman ECT, Aarts MJ, Kuiper JG, Kunst PWA, Raijmakers NJH, Visser LE, van Zuylen L, Brokaar EJ, Fransen HP. Use of potentially inappropriate medication in older patients with lung cancer at the end of life. J Geriatr Oncol 2021; 13:53-59. [PMID: 34366274 DOI: 10.1016/j.jgo.2021.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 06/10/2021] [Accepted: 07/29/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Medications at the end of life should be used for symptom control. Medications which potential adverse effects outweigh their expected benefits are called 'potentially inappropriate medications' (PIMs). PIMs are related with adverse drug events and reduced quality of life. In this study, we investigated to what extent PIMs are dispensed to older patients with lung cancer in the last month of life. METHODS We selected patients with lung cancer, aged 65+, diagnosed between 2009 and 2014, and who died before April 1st 2015 from the population-based Netherlands Cancer Registry (NCR). The NCR is linked to the PHARMO Database Network, that includes medications dispensed by community pharmacies in the Netherlands. The eight PIM groups were based on the OncPal Deprescribing Guideline: aspirin, dyslipidaemia medications, antihypertensives, osteoporosis medications, peptic ulcer prophylaxis, oral hypoglycaemics, vitamins and minerals. RESULTS Data of 7864 patients with lung cancer were analyzed. Median age was 74 year (IQR = 70-79) and 67% was male. 45% of all patients received at least one PIM in their last month of life. Taking into account all dispensed medications, patients receiving PIMs received more different medications compared to those receiving no PIMs, respectively 10 (SD = 5) vs. 3 (SD = 4) different medications (P < 0.001). CONCLUSION Almost half of the older patients with lung cancer in the Netherlands received PIMs in their last month of life. Since PIM use is associated with reduced quality of life, it is important that health care professionals continue to critically assess which medication can be discontinued at the end of life.
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Affiliation(s)
- Laurien Ham
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands; Netherlands Association for Palliative Care (PZNL), PO box 19079, Utrecht 3501 DB, the Netherlands.
| | - Eric C T Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, PO box 2040, Rotterdam 3000 CA, the Netherlands
| | - Mieke J Aarts
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands
| | - Josephina G Kuiper
- PHARMO Institute for Drug Outcomes Research, Van Deventerlaan 30-40, Utrecht 3528 AE, the Netherlands
| | - Peter W A Kunst
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands; Onze Lieve Vrouwe Gasthuis, PO box 9243, Amsterdam 1006 AE, the Netherlands
| | - Natasja J H Raijmakers
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands; Netherlands Association for Palliative Care (PZNL), PO box 19079, Utrecht 3501 DB, the Netherlands
| | - Loes E Visser
- Department of Hospital Pharmacy, Haga Teaching Hospital, PO box 40551, The Hague 2504 LN, the Netherlands; Department of Epidemiology, Erasmus Medical Centre, PO box 2040, Rotterdam 3000 CA, the Netherlands; Department of Hospital Pharmacy, Erasmus Medical Centre, PO box 2040, Rotterdam 3000 CA, the Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Amsterdam University Medical Centre, De Boelelaan 1117, Amsterdam 1081 HV, the Netherlands
| | - Edwin J Brokaar
- Department of Hospital Pharmacy, Haga Teaching Hospital, PO box 40551, The Hague 2504 LN, the Netherlands
| | - Heidi P Fransen
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands; Netherlands Association for Palliative Care (PZNL), PO box 19079, Utrecht 3501 DB, the Netherlands
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Correa E, Lindsay T, Dotan E. Management of Metastatic Colorectal Carcinoma in Older Adults: Balancing Risks and Benefits of Novel Therapies. Drugs Aging 2021; 38:639-654. [PMID: 34143421 PMCID: PMC9951235 DOI: 10.1007/s40266-021-00869-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2021] [Indexed: 11/25/2022]
Abstract
The prevalence of older patients with metastatic colorectal cancer (mCRC) will continue to increase with our aging population. Treatment of mCRC has changed significantly in the last few decades as we have learned how to personalize the treatment of mCRC to the biology of the tumor, utilizing new treatment approaches. With an ever-changing treatment paradigm, managing the population of older adults becomes paramount. This review highlights the pivotal clinical trials that defined the use of systemic therapy, immunotherapy and targeted therapies for mCRC, and how those are applied to the older patient population. In addition, we outline the tools for an in-depth assessment of an older adult in regards to treatment planning and management of therapy-related toxicities. A comprehensive geriatric assessment can assist in the selection of treatment for an older adult with mCRC. While frail older patients can frequently only tolerate single agents or modified regimens, fit older adults remain candidates for a wider range of treatment options. However, since all of these treatments are associated with possible toxicities, each patient's treatment must be personalized to the patient's goals and wishes through a shared decision-making process.
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Affiliation(s)
- Erika Correa
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Timothy Lindsay
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Efrat Dotan
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
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Nightingale G, Mohamed MR, Holmes HM, Sharma M, Ramsdale E, Lu-Yao G, Chapman A. Research priorities to address polypharmacy in older adults with cancer. J Geriatr Oncol 2021; 12:964-970. [PMID: 33589379 PMCID: PMC9320625 DOI: 10.1016/j.jgo.2021.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 01/31/2021] [Accepted: 01/31/2021] [Indexed: 11/25/2022]
Abstract
Polypharmacy poses a significant public health problem that disproportionately affects older adults (≥65 years) since this population represents the largest consumers of medications. Clinicians caring for older adults with cancer must rely on evidence to understand polypharmacy and its implications, not only to communicate with patients and other healthcare providers, but also because of the significant interplay between polypharmacy, cancer, cancer-related treatment, and clinical outcomes. Interest in polypharmacy is rising because of its prevalence, the origins and facilitating factors behind it, and the direct and indirect clinical outcomes associated with it. The growing body of publications focused on polypharmacy in older adults with cancer demonstrates that this is a significant area of research; however, limited evidence exists to guide medication use (e.g., prescribing, administration) in this population. Currently, research priorities aimed at polypharmacy in the field of geriatric oncology lack clarity. We identified current gaps in the literature in order to establish research priorities for polypharmacy in older adults with cancer. The five research priorities-Polypharmacy Methodology and Definitions, Suboptimal Medication Use, Comorbidities and Geriatric Syndromes, Underrepresented Groups, and Polypharmacy Interventions-highlight critical areas for future research to improve outcomes for older adults with cancer.
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Affiliation(s)
- Ginah Nightingale
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Mostafa R Mohamed
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA; Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Holly M Holmes
- McGovern Medical School, University of Texas Health Science Center of Houston, Houston, TX, USA
| | - Manvi Sharma
- Pharmacy Administration, School of Pharmacy, University of Mississippi, University, MS, USA
| | - Erika Ramsdale
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Grace Lu-Yao
- College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA; Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA, USA; Sidney Kimmel Cancer Center, Jefferson Health, Philadelphia, PA, USA
| | - Andrew Chapman
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA, USA; Sidney Kimmel Cancer Center, Jefferson Health, Philadelphia, PA, USA
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20
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Cadogan CA, Murphy M, McLean S, Bennett K, Hughes CM. Development of criteria for identifying potentially inappropriate prescribing in older adults with cancer receiving palliative care (PIP-CPC). J Geriatr Oncol 2021; 12:1193-1199. [PMID: 34144924 DOI: 10.1016/j.jgo.2021.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 05/03/2021] [Accepted: 06/10/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To develop criteria for identifying potentially inappropriate prescribing of medications for symptomatic relief in older adults (≥65 years) with cancer who are receiving palliative care and have an estimated life expectancy of <1 year. MATERIALS AND METHODS A two-round Delphi exercise was conducted using web-based questionnaires. A panel of 18 expert stakeholders with expertise in palliative care, oncology and/or geriatric medicine across Ireland and the United Kingdom rated their level of agreement with each statement using a 5-point Likert scale and had the option of adding free-text comments throughout the questionnaire. A priori decision rules were used to accept or reject criteria. RESULTS Twenty-eight criteria were presented in Round 1. Group consensus was achieved for 15 criteria which were included in the final set of criteria. Following a review of the panel's ratings and additional comments for the remaining 13 criteria, four criteria were removed from Round 2. Group consensus was achieved for all nine criteria included in Round 2. The final set comprised 24 criteria relating to: anorexia-cachexia (n = 1); anxiety (n = 2); constipation (n = 5); delirium (n = 1); depression (n = 3); diarrhoea (n = 1); dyspnoea/breathlessness (n = 1); fatigue (n = 2); insomnia (n = 2); nausea and vomiting (n = 2); pain (n = 3); duplicate drug classes (n = 1). CONCLUSION A consensus-agreed set of prescribing criteria has been developed for identifying potentially inappropriate prescribing of medications for symptomatic relief in older adults with cancer who are receiving palliative care and have an estimated life expectancy of less than one year. Future studies should examine the application and validity of these criteria.
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Affiliation(s)
- Cathal A Cadogan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland.
| | - Melanie Murphy
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, 123 St. Stephens Green, Dublin, Ireland
| | - Sarah McLean
- St Vincent's Private Hospital, Merrion Road, Dublin, Ireland
| | - Kathleen Bennett
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, 123 St. Stephens Green, Dublin, Ireland
| | - Carmel M Hughes
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast, United Kingdom
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Whitman A, Erdeljac P, Jones C, Pillarella N, Nightingale G. Managing Polypharmacy in Older Adults with Cancer Across Different Healthcare Settings. DRUG HEALTHCARE AND PATIENT SAFETY 2021; 13:101-116. [PMID: 33953612 PMCID: PMC8092848 DOI: 10.2147/dhps.s255893] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 03/25/2021] [Indexed: 11/23/2022]
Abstract
The care of older patients with cancer is becoming increasingly complex. Common challenges for this population include management of comorbidities, safe transitions of care, and appropriate medication use. In particular, polypharmacy-generally defined as the regular use of five or more medications-and inappropriate medication use can lead to adverse effects and poor outcomes in older adults with cancer, including falls, hospital readmissions, cognitive impairment, poor adherence to essential medications, chemotherapy toxicity, and increased mortality. Managing polypharmacy across different cancer care settings is often challenging. Providers face barriers to safe and successful medication management that may include lack of time, absence of reimbursement, underappreciation of the scale of polypharmacy-related harm, lack of ownership of deprescribing efforts, and poor communication across care settings. Existing literature on managing inappropriate medication use and polypharmacy in older adults with cancer has often focused on ideal state settings in which resources are plentiful and time is purposefully allocated for medication interventions. This paper presents a narrative, rather than a systematic review, of studies published in the past decade that provided detailed information on medication management and polypharmacy across cancer care settings. This review aims to also summarize different healthcare provider roles in taking action against inappropriate medication use and polypharmacy in older adults with cancer.
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Affiliation(s)
- Andrew Whitman
- Department of Pharmacy, University of Virginia Health, Charlottesville, VA, USA
| | - Paige Erdeljac
- Department of Pharmacy, James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Caroline Jones
- Department of Pharmacy, University of Virginia Health, Charlottesville, VA, USA
| | - Nicole Pillarella
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ginah Nightingale
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA
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22
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Guven DC, Kavgaci G, Aktepe OH, Yildirim HC, Sahin TK, Aksoy S, Erman M, Kilickap S, Yalcin S. The burden of polypharmacy and drug-drug interactions in older cancer patients treated with immunotherapy. J Oncol Pharm Pract 2021; 28:785-793. [PMID: 33878976 DOI: 10.1177/10781552211012038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Polypharmacy is a common problem in older cancer patients, although the data about polypharmacy and potentially inappropriate prescription practices is limited in patients treated with immune checkpoint inhibitors (ICIs). Therefore, we aimed to evaluate the polypharmacy frequency and drug-drug interactions in older cancer patients (≥65 years) treated with ICIs. METHODS A total of 70 geriatric patients with advanced cancer were included. The polypharmacy was defined as regular use of 5 or more drugs. The START/STOPP Criteria Version 2 was used for the potentially inappropriate medications (PIM) and potential prescription omissions (PPO). The Medscape Drug Interaction Checker was used for potential drug-drug interactions. RESULTS The patients had a median of 6 regular drugs, and polypharmacy was present in 77.1%. The polypharmacy risk was significantly increased in patients over 75 years of age (p = 0.028) and with opioid use (p = 0.048). The 50% of patients had category D or X interactions. Patients with higher Charlson Comorbidity Index had significantly increased risk for drug interactions (CCI ≤10 vs. >10, p = 0.017). The PIMs were present in 44.3% and the PPOs in 68.6% of the patients. While the overall survival and immune related adverse events were similar according to polypharmacy, in patients using seven or more drugs, the acute kidney injury risk was increased (HR: 4.667, p = 0.038). CONCLUSION In this study, we observed a high rate of polypharmacy and inappropriate prescription practices in ICI-treated patients. These issues pointed out the need for improved general medical care and attention for better comedication management in ICI-treated patients.
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Affiliation(s)
- Deniz C Guven
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Gozde Kavgaci
- Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Oktay H Aktepe
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Hasan C Yildirim
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Taha K Sahin
- Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Sercan Aksoy
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Mustafa Erman
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Saadettin Kilickap
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Suayib Yalcin
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
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23
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Murphy M, Bennett K, Ryan S, Hughes CM, Lavan AH, Cadogan CA. A systematic scoping review of interventions to optimise medication prescribing and adherence in older adults with cancer. Res Social Adm Pharm 2021; 18:2392-2402. [PMID: 33903064 DOI: 10.1016/j.sapharm.2021.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Older adults with cancer often require multiple medications (polypharmacy) comprising cancer-specific treatments, supportive care medications (e.g. analgesics), and medications for pre-existing health conditions. Increasing numbers of medications may increase risks of potentially inappropriate prescribing and non-adherence. OBJECTIVE To provide an overview of evaluations of interventions aimed at optimising medication prescribing and/or adherence in older adults with cancer. METHODS A systematic scoping review was undertaken. Four databases (PubMed, EMBASE, CINAHL, PsycINFO) were searched using relevant search terms (e.g. cancer, older adults). Eligible studies evaluated interventions seeking to improve medication prescribing and/or adherence in older adults (≥65 years) with cancer using a comparative evaluation. All outcomes for studies that met inclusion criteria were included in the review. Extracted data were collated using tables and accompanying narrative descriptive summaries. The review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. RESULTS Nine studies met inclusion criteria comprising five randomised controlled trials (RCTs) and four before-and-after study designs. Studies were primarily conducted in oncology clinics, ranging from single study sites to 109 oncology clinics. Sample sizes ranged between 33 and 4844 patients. Interventions most commonly involved patient education (n = 6) delivered by pharmacists or nurses. Three studies reported on prescribing-related outcomes and seven studies reported on adherence-related outcomes, using different terminology and assessment methods. Prescribing-related outcomes focused on medication appropriateness (using Beers criteria) and drug-related problems including drug interactions. Adherence-related outcomes included assessments of self-reported medication adherence and calculation of patients' medication possession ratio. CONCLUSIONS This scoping review highlights a lack of robust evaluations of interventions aimed at optimising medication prescribing and adherence in older adults with cancer. Future research should improve rigour during intervention development, evaluation and reporting in order to generate findings that could inform future practice.
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Affiliation(s)
- Melanie Murphy
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Kathleen Bennett
- Population Health Sciences Division, Royal College of Surgeons in Ireland, Dublin, Ireland; Data Science Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Sinéad Ryan
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Carmel M Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, United Kingdom
| | - Amanda H Lavan
- Department of Medicine for the Elderly, St James's Hospital, Dublin, Ireland
| | - Cathal A Cadogan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland.
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24
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Barlow A, Prusak ES, Barlow B, Nightingale G. Interventions to reduce polypharmacy and optimize medication use in older adults with cancer. J Geriatr Oncol 2021; 12:863-871. [PMID: 33353854 DOI: 10.1016/j.jgo.2020.12.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/22/2020] [Accepted: 12/10/2020] [Indexed: 02/07/2023]
Abstract
The use of polypharmacy and potentially inappropriate medications (PIMs) is an increasingly common, concerning public health issue in older adults, and a concurrent cancer diagnosis only further escalates the prevalence and complexity. Polypharmacy and PIM use has been associated with negative patient outcomes, including falls, chemotherapy toxicities and other adverse events, postoperative complications, frailty, functional impairment, and shortened survival. Despite the recognition of the harms, the prevalence of polypharmacy and PIM use continues to rise due to a lack of standardized identification and intervention methods. Efforts to reduce the prevalence have included use of explicit PIM screening tools (e.g., Beers criteria), comprehensive medication reviews, and deprescribing algorithms. However, these efforts are not widespread and the research on the effectiveness of such interventions is limited. To better understand what is known, this paper summarized available studies evaluating the effect of interventions on reducing the burden of polypharmacy/PIMs and provided recommendations to guide further practice models to reduce the negative consequences associated with polypharmacy and PIM use. Furthermore, we aim to establish a framework for clinical practice and to highlight areas for future intervention-based research to improve outcomes for older adults with cancer.
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Affiliation(s)
- Ashley Barlow
- Department of Pharmacy, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Brooke Barlow
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| | - Ginah Nightingale
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA.
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25
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Domínguez-Alonso JA, Conde-Estévez D, Bosch D, Pi-Figueras M, Tusquets I. Breast cancer, placing drug interactions in the spotlight: is polypharmacy the cause of everything? Clin Transl Oncol 2021; 23:65-73. [PMID: 32449126 DOI: 10.1007/s12094-020-02386-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/10/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Breast cancer is the most prevalent and lethal cancer among women. Forty-one percent of cases occur in people ≥ 70 years, hindering their treatment given its comorbidities and polypharmacy (PP). Potential drug-drug interactions (PDDI) were analyzed in elderly breast cancer patients between daily and oncospecific treatments and their associations with Age, BMI, Mini Nutritional Assessment (MNA), Frailty categorization, PP, and adverse effects. PATIENTS/METHODS A cohort of 77 patients ≥ 70 years with breast cancer who underwent a Comprehensive Geriatric Assessment (CGA) were included. Clinical characteristics were collected using medical records. PDDI between treatments were analyzed using two databases. Data were assessed using linear regression, Chi-square, Mann-Whitney U, and Kruskal-Wallis tests. Finally, a multivariate logistic regression model was built and tested to predict adverse effects. RESULTS From 719 PDDI, 530 (74%) were moderate (r2 = 0.72) and the median number of drugs during oncospecific treatment (r2 = 0.73) was 9 (range 3-26). Overall, 59 patients (77%) had adverse effects associated with Frailty categorization and MNA (p < 0.05). The distribution of major, moderate, minor, and total PDDI was associated with PP at CGA and during oncospecific treatment (p < 0.05). Moreover, it was verified that Frailty categorization protects from adverse effects given the intervention made at CGA. CONCLUSIONS CGA should be applied in oncologic elderly patients to assess clinical outcomes and categorize them according to their frailty but also to analyze PDDI. Furthermore, we encourage the use of the model in clinical practice for predicting the occurrence of adverse effects, improving therapeutic conciliation.
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Affiliation(s)
| | | | - David Bosch
- Departament de Dinàmica de la Terra i de l'Oceà, Facultat de Ciències de la Terra, Universitat de Barcelona, Barcelona, Spain
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26
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Murphy M, Bennett K, Hughes CM, Lavan A, Cadogan CA. Interventions to optimise medication prescribing and adherence in older people with cancer: A systematic scoping review. Res Social Adm Pharm 2020; 16:1627-1631. [DOI: 10.1016/j.sapharm.2020.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/02/2020] [Accepted: 02/28/2020] [Indexed: 11/26/2022]
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27
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Bhargava D, Arora M, DeFor TE, Brunstein CG, Thyagarajan B, El Jurdi N, Holtan SG, Rashidi A, Warlick E, Ramesh V, Rogosheske J, Bhatia S, Weisdorf DJ. Use of Potentially Inappropriate Medications in Older Allogeneic Hematopoietic Cell Transplantation Recipients. Biol Blood Marrow Transplant 2020; 26:2329-2334. [PMID: 32919078 PMCID: PMC7683366 DOI: 10.1016/j.bbmt.2020.08.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/26/2020] [Accepted: 08/29/2020] [Indexed: 01/10/2023]
Abstract
The use of potentially inappropriate medications (PIMs) using Beers criteria and its impact on older allogeneic hematopoietic cell transplantation (HCT) recipients is not known. Here the use of any PIMs and their therapeutic classes in reduced-intensity conditioning allogeneic HCT recipients were compared between older (≥65 years; n = 114) and younger (40 to 64 years; n = 240) patients during their initial HCT admission, defined as the number of days that a patient received 1 or more PIMs between day -14 and day +28. Poisson regression was used to determine rate ratios (RRs) in the 2 groups. In the ≥65 years group, we evaluated the impact of PIMs on Common Terminology Criteria for Adverse Events (CTCAE) grade 3-4 toxicities within 100 days and on overall mortality within 1 year post-HCT. The rate of any PIM use was similar in the older and younger groups (RR, .98; 95% confidence interval [CI], .90 to 1.06; P = .65). In terms of PIM classes, the older group had a 48% higher rate of gastrointestinal (GI) medication use (RR, 1.48; 95% CI, 1.32 to 1.65; P < .01) and a 25% higher rate of genitourinary (GU) medication use (RR, 1.25; 95% CI, 1.02 to 1.53; P = .03). Compared with males, females had a 19% higher rate of central nervous system (CNS) medication use (RR, 1.19; 95% CI, 1.03 to 1.37; P = .02) and a 30% higher rate of benzodiazepine use (RR, 1.30; 95% CI. 1.09 to 1.54; P < .01). A high-risk HCT-CI was associated with a higher rate of use of any PIMs (RR, 1.13; 95% CI, 1.01 to 1.26; P = .02), CNS medications (RR, 1.26; 95% CI, 1.04 to 1.53; P = .02) and GU medications (RR, 1.46; 95% CI, 1.09 to 1.94; P = .01). Compared with matched sibling donor HCT recipients, umbilical cord blood transplantation recipients had higher rates of GI medication use (RR, 1.32; 95% CI, 1.14 to 1.53; P < .01) and anticholinergic medication use (RR, 1.30; 95% CI, 1.06 to 1.61; P = .01). In the ≥65 years group, increasing duration of narcotic use was associated with a 1.3-fold (95% CI, 1.0 to 1.7; P = .05) higher risk of overall mortality and a 1.6-fold (95% CI, 1.02 to 2.69) greater odds of CTCAE grade 3-4 toxicities (P = .04). Our data show that older recipients (≥65 years) were as likely as their younger counterparts to receive PIMs. Among older recipients, the use of PIMs, particularly narcotics, was associated with higher mortality and higher incidence of grade 3-4 toxicities. Identifying and reducing the use of PIMs in older HCT recipients may help decrease the burden of adverse events and associated health care costs.
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Affiliation(s)
- Divya Bhargava
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota.
| | - Todd E DeFor
- Biostatistics, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota
| | - Claudio G Brunstein
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Bharat Thyagarajan
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota; Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Najla El Jurdi
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Shernan G Holtan
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Armin Rashidi
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Erica Warlick
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Vidhyalakshmi Ramesh
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota; Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - John Rogosheske
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
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Turner J, Kantilal K, Kantilal K, Holmes H, Koczwara B. Optimising Medications for Patients With Cancer and Multimorbidity: The Case for Deprescribing. Clin Oncol (R Coll Radiol) 2020; 32:609-617. [DOI: 10.1016/j.clon.2020.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 04/24/2020] [Accepted: 05/19/2020] [Indexed: 12/18/2022]
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29
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Miller MG, Kneuss TG, Patel JN, Parala-Metz AG, Haggstrom DE. Identifying potentially inappropriate medication (PIM) use in geriatric oncology. J Geriatr Oncol 2020; 12:34-40. [PMID: 32571665 DOI: 10.1016/j.jgo.2020.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 06/05/2020] [Accepted: 06/06/2020] [Indexed: 10/24/2022]
Abstract
The median number of medications taken by adults aged 65 and older is four, but may be higher in older adults with cancer. A high number of prescribed medications increases risk for adverse drug reactions (ADRs), drug-drug interactions, drug-disease interactions, and overall healthcare utilization, emphasizing the need for frequent review of medications. There are many tools available to help the health care team assess medication appropriateness; however, none of the currently available tools have been validated in the geriatric oncology population. Older adults with cancer are at increased risk for ADRs and potentially inappropriate medications (PIMs) given the common need for multiple medications to manage cancer and cancer-related symptoms. Frequently used PIM identification tools, such as the American Geriatrics Society's (AGS) Beers criteria, often identify medications as "potentially inappropriate", although many of these medications are considered necessary to provide adequate supportive care in older patients with cancer. There are currently no specific guidelines to help direct application of available tools. This review summarizes literature available on the use of PIM identification tools in geriatric oncology and highlights a theoretical case and proposed medication management strategy, which combines the use of objective review with Beer's criteria and clinical judgement with the Medication Appropriateness Index (MAI). This two-pronged approach can serve to identify PIMs while recognizing factors unique to the geriatric oncology population.
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Affiliation(s)
- Mary Gwen Miller
- Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Dr, Charlotte, NC 28204, USA.
| | - Tiffany G Kneuss
- Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Dr, Charlotte, NC 28204, USA.
| | - Jai N Patel
- Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Dr, Charlotte, NC 28204, USA.
| | - Armida G Parala-Metz
- Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Dr, Charlotte, NC 28204, USA.
| | - Daniel E Haggstrom
- Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Dr, Charlotte, NC 28204, USA.
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30
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Mohamed MR, Ramsdale E, Loh KP, Arastu A, Xu H, Obrecht S, Castillo D, Sharma M, Holmes HM, Nightingale G, Juba KM, Mohile SG. Associations of Polypharmacy and Inappropriate Medications with Adverse Outcomes in Older Adults with Cancer: A Systematic Review and Meta-Analysis. Oncologist 2020; 25:e94-e108. [PMID: 31570516 PMCID: PMC6964156 DOI: 10.1634/theoncologist.2019-0406] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/11/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Polypharmacy (PP) and potentially inappropriate medications (PIM) are highly prevalent in older adults with cancer. This study systematically reviews the associations of PP and/or PIM with outcomes and, through a meta-analysis, obtains estimates of postoperative outcomes associated with PP in this population. MATERIALS AND METHODS We searched PubMed, Embase, Web of Science, and Cochrane Register of Clinical Trials using standardized terms for concepts of PP, PIM, and cancer. Eligible studies included cohort studies, cross-sectional studies, meta-analyses, and clinical trials which examined outcomes associated with PP and/or PIM and included older adults with cancer. A random effects model included studies in which definitions of PP were consistent to examine the association of PP with postoperative complications. RESULTS Forty-seven articles met the inclusion criteria. PP was defined as five or more medications in 57% of the studies. Commonly examined outcomes included chemotherapy toxicities, postoperative complications, functional decline, hospitalization, and overall survival. PP was associated with chemotherapy toxicities (4/9 studies), falls (3/3 studies), functional decline (3/3 studies), and overall survival (2/11 studies). A meta-analysis of four studies indicated an association between PP (≥5 medications) and postoperative complications (overall odds ratio, 1.3; 95% confidence interval [1.3-2.8]). PIM was associated with adverse outcomes in 3 of 11 studies. CONCLUSION PP is associated with postoperative complications, chemotherapy toxicities, and physical and functional decline. Only three studies showed an association between PIM and outcomes. However, because of inconsistent definitions, heterogeneous populations, and variable study designs, these associations should be further investigated in prospective studies. IMPLICATIONS FOR PRACTICE Polypharmacy and potentially inappropriate medications (PIM) are prevalent in older adults with cancer. This systematic review summarizes the associations of polypharmacy and PIM with health outcomes in older patients with cancer. Polypharmacy and PIM have been associated with postoperative complications, frailty, falls, medication nonadherence, chemotherapy toxicity, and mortality. These findings emphasize the prognostic importance of careful medication review and identification of PIM by oncology teams. They also underscore the need to develop and test interventions to address polypharmacy and PIM in older patients with cancer, with the goal of improving outcomes in these patients.
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Affiliation(s)
- Mostafa R. Mohamed
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
| | - Erika Ramsdale
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
| | - Kah Poh Loh
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
| | - Asad Arastu
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
| | - Huiwen Xu
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
- Department of Public Health, University of Rochester School of Medicine and DentistryRochesterNew YorkUSA
| | - Spencer Obrecht
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
| | - Daniel Castillo
- MLIS‐Miner Library, University of Rochester School of Medicine and DentistryRochesterNew YorkUSA
| | - Manvi Sharma
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, UniversityMississippiUSA
| | - Holly M. Holmes
- The University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Ginah Nightingale
- Department of Pharmacy Practice, Thomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Katherine M. Juba
- Department of Pharmacy, University of Rochester Medical CenterRochesterNew YorkUSA
- Department of Pharmacy Practice, Wegmans School of PharmacyRochesterNew YorkUSA
| | - Supriya G. Mohile
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
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31
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Feng X, Higa GM, Safarudin F, Sambamoorthi U, Chang J. Prevalence and factors associated with potentially inappropriate medication use in older medicare beneficiaries with cancer. Res Social Adm Pharm 2019; 16:1459-1471. [PMID: 31926877 DOI: 10.1016/j.sapharm.2019.12.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 10/29/2019] [Accepted: 12/20/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the factors related to potentially inappropriate medication (PIM) use in elderly patients with cancer, as well as to compare the PIM prevalence in older adults with and without cancer. METHODS Data from the Surveillance, Epidemiology, and End Results-Medicare-linked base (2009-2011) were accessed to conduct a retrospective study comparing patients with cancers of the breast, colon/rectum, and prostate against a matched population of subjects without cancer. PIM use was defined based on the 2015 Beers Criteria and was quantified using prescription claims. Multivariable logistic regression models were used to assess the associations between the patients' characteristics, clinical factors, and PIM use in patients with cancer based on Beers criteria. Propensity score matching was applied to compare use of PIM in patients with versus without cancer. RESULTS PIM usage rates in patients with colorectal and breast cancers were significantly higher than non-cancer-bearing adults; the difference in PIM usage rate was not significantly different in the prostate cancer-matched cohort. The prevalence of inappropriate medication use in the three types of cancers evaluated was directly correlated with number of medications prescribed, treatment with chemotherapy, and co-morbid medical problems. CONCLUSION Patients diagnosed with cancer were more likely to use PIM compared with their non-cancer counterparts. The updated Beers criteria has the potential to serve as an important tool in geriatric oncology practice but it may still need to take into consideration different cancer types and their respective treatments.
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Affiliation(s)
- Xue Feng
- Department of Pharmaceutical Systems and Policy, West Virginia University, School of Pharmacy, WV, USA
| | - Gerald M Higa
- Department of Clinical Pharmacy, West Virginia University, School of Pharmacy, WV, USA.
| | - Fnu Safarudin
- Department of Pharmaceutical Systems and Policy, West Virginia University, School of Pharmacy, WV, USA; Department of Pharmacy, School of Mathematics and Natural Sciences, Tadulako University-Palu, Central Sulawesi, Indonesia
| | - Usha Sambamoorthi
- Department of Pharmaceutical Systems and Policy, West Virginia University, School of Pharmacy, WV, USA
| | - Jongwha Chang
- Department of Pharmacy Practice, The University of Texas, School of Pharmacy, El Paso, TX, USA
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32
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Hong S, Lee JH, Chun EK, Kim KI, Kim JW, Kim SH, Lee YG, Hwang IG, Kim JY, Koh SJ, Ko YH, Shin SH, Woo IS, Kim TY, Baek JY, Kim HJ, Kim HJ, Lee MA, Kwon JH, Hong YS, Ryoo HM, Kim JH. Polypharmacy, Inappropriate Medication Use, and Drug Interactions in Older Korean Patients with Cancer Receiving First-Line Palliative Chemotherapy. Oncologist 2019; 25:e502-e511. [PMID: 32162799 DOI: 10.1634/theoncologist.2019-0085] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 10/14/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Polypharmacy is an important issue in the care of older patients with cancer, as it increases the risk of unfavorable outcomes. We estimated the prevalence of polypharmacy, potentially inappropriate medication (PIM) use, and drug-drug interactions (DDIs) in older patients with cancer in Korea and their associations with clinical outcomes. SUBJECTS, MATERIALS, AND METHODS This was a secondary analysis of a prospective observational study of geriatric patients with cancer undergoing first-line palliative chemotherapy. Eligible patients were older adults (≥70 years) with histologically diagnosed solid cancer who were candidates for first-line palliative chemotherapy. All patients enrolled in this study received a geriatric assessment (GA) at baseline. We reviewed the daily medications taken by patients at the time of GA before starting chemotherapy. PIMs were assessed according to the 2015 Beers criteria, and DDIs were assessed by a clinical pharmacist using Lexi-comp Drug Interactions. We evaluated the association between polypharmacy and clinical outcomes including treatment-related toxicity, and hospitalization using logistic regression and Cox regression analyses. RESULTS In total, 301 patients (median age 75 years; range, 70-93) were enrolled; the most common cancer types were colorectal cancer (28.9%) and lung cancer (24.6%). Mean number of daily medications was 4.7 (±3.1; range, 0-14). The prevalence of polypharmacy (≥5 medications) was 45.2% and that of excessive polypharmacy (≥10 medications) was 8.6%. PIM use was detected in 137 (45.5%) patients. Clinically significant DDIs were detected in 92 (30.6%) patients. Polypharmacy was significantly associated with hospitalization or emergency room (ER) visits (odds ratio: 1.73 [1.18-2.55], p < .01). Neither polypharmacy nor PIM use showed association with treatment-related toxicity. CONCLUSION Polypharmacy, PIM use, and potential major DDIs were prevalent in Korean geriatric patients with cancer. Polypharmacy was associated with a higher risk of hospitalization or ER visits during the chemotherapy period. IMPLICATIONS FOR PRACTICE This study, which included 301 older Korean patients with cancer, highlights the increased prevalence of polypharmacy in this population planning to receive palliative chemotherapy. The prevalence of polypharmacy and excessive polypharmacy was 45.2% and 8.6%, respectively. The prescription of potentially inappropriate medications (PIMs) was detected in 45.5% and clinically significant drug-drug interaction in 30.6% of patients. Given the association of polypharmacy with increased hospitalization or emergency room visits, this study points to the need for increased awareness and intervention to minimize polypharmacy in the geriatric cancer population undergoing chemotherapy. Moreover, specific criteria for establishing PIMs should be adopted for the treatment of older adults with cancer.
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Affiliation(s)
- Soojung Hong
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Ju Hyun Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Eun Kyeong Chun
- Department of Pharmacy, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Kwang-Il Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Jin Won Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Se Hyun Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Yun-Gyoo Lee
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - In Gyu Hwang
- Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Jin Young Kim
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, College of Medicine, Keimyung University, Daegu, Republic of Korea
| | - Su-Jin Koh
- Department of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Yoon Ho Ko
- Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Republic of Korea
| | - Seong Hoon Shin
- Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Pusan, Republic of Korea
| | - In Sook Woo
- Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Tae-Yong Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Yeon Baek
- Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Hyun Jung Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Hyo Jung Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Myung Ah Lee
- Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jung Hye Kwon
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Yong Sang Hong
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hun-Mo Ryoo
- Department of Internal Medicine, Daegu Catholic University Hospital, Daegu Catholic University College of Medicine, Daegu, Republic of Korea
| | - Jee Hyun Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
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Vrijkorte E, de Vries J, Schaafsma R, Wymenga M, Oude Munnink T. Optimising pharmacotherapy in older cancer patients with polypharmacy. Eur J Cancer Care (Engl) 2019; 29:e13185. [PMID: 31692151 PMCID: PMC7063689 DOI: 10.1111/ecc.13185] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 08/06/2019] [Accepted: 10/14/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Polypharmacy is frequent among older cancer patients and increases the risk of potential drug-related problems (DRPs). DRPs are associated with adverse drug events, drug-drug interactions and hospitalisations. Since no standardised polypharmacy assessment methods for oncology patients exist, we aimed to develop one that can be integrated into routine care. METHODS Based on the Systematic Tool to Reduce Inappropriate Prescribing (STRIP), we developed OncoSTRIP, which includes a polypharmacy anamnesis, a concise geriatric assessment, a polypharmacy analysis taking life expectancy into account and an optimised treatment plan. Patients ≥65 years with ≥5 chronic drugs visiting our outpatient oncology clinic were eligible for the polypharmacy assessment. RESULTS OncoSTRIP was integrated into routine care of our older cancer patients. In 47 of 60 patients (78%), potential DRPs (n = 101) were found. In total, 85 optimisations were recommended, with an acceptance rate of 41%. It was possible to reduce the number of potential DRPs by 41% and the number of patients with at least one potential DRP by 30%. Mean time spent per patient was 71 min. CONCLUSIONS Polypharmacy assessment of older cancer patients identifies many pharmacotherapeutic optimisations. With OncoSTRIP, polypharmacy assessments can be integrated into routine care.
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Affiliation(s)
- Elze Vrijkorte
- Department of Clinical Pharmacy, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Jennifer de Vries
- Department of Internal Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Ron Schaafsma
- Department of Internal Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Machteld Wymenga
- Department of Internal Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Thijs Oude Munnink
- Department of Clinical Pharmacy, Medisch Spectrum Twente, Enschede, The Netherlands.,Department of Clinical Pharmacy & Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Simões PA, Santiago LM, Maurício K, Simões JA. Prevalence Of Potentially Inappropriate Medication In The Older Adult Population Within Primary Care In Portugal: A Nationwide Cross-Sectional Study. Patient Prefer Adherence 2019; 13:1569-1576. [PMID: 31571839 PMCID: PMC6756837 DOI: 10.2147/ppa.s219346] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 08/21/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In potentially inappropriate medications harm potentially outweighs benefits. Even appropriately prescribed medications may become inappropriate. They can lead to a high risk of adverse drug reactions, morbidity and mortality. The aim of this study was to determine the prevalence of potentially inappropriate medication in the older adult population attending primary care in Portugal and to identify associated sociodemographic and clinical factors. METHODS We conducted a cross-sectional, analytical study in primary care centres from the five Portuguese healthcare administrative regions and the two autonomous regions. We used a random sample of 757 older patients provided by the information department of the ministry of health (SPMS) and family doctors from the autonomous regions. Data collection occurred March 2018 and we studied sociodemographic characteristics, clinical profile and medication. We used 2015 Beers Criteria to assess potentially inappropriate medications. Logistic regression analyses were performed to determine associations between potentially inappropriate medications' prescriptions and other variables. RESULTS Potentially inappropriate medication was present in 68.6% and 46.1% of the sample had two or more. The likelihood of having potentially inappropriate medication increased significantly with being female (OR=1.56 [1.05 to 2.31]), number of chronic health problems (OR=1.06 [1.01 to 1.13]), number of pharmacological subclasses (OR=1.40 [1.30 to 1.51]) and number of prescribers (OR=1.34 [1.09 to 1.65]). Proton-pump inhibitors, nonsteroidal anti-inflammatory drugs and benzodiazepines were the most commonly found ones. CONCLUSION Potentially inappropriate medication in older adults was found to be a common occurrence in Portugal. It is important that doctors are aware of this problem, namely in the primary care setting due to the longitudinal care.
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Affiliation(s)
- Pedro Augusto Simões
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
- ARS Centro, USF Pulsar, Coimbra, Portugal
- Correspondence: Pedro Augusto Simões ARS Centro, USF Pulsar, Rua Teófilo Braga, nº 25 5º Dto, Coimbra3030-076, PortugalTel +351 239 968384396 Email
| | - Luiz Miguel Santiago
- University of Coimbra, Faculty of Medicine, Coimbra, Portugal
- University of Coimbra, General Practice/Family Medicine University Clinic of the Faculty of Medicine, Coimbra, Portugal
- University of Coimbra, CEISUC – Center for Health Studies and Research, Coimbra, Portugal
| | - Katia Maurício
- University of Coimbra, Faculty of Medicine, Coimbra, Portugal
| | - José Augusto Simões
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
- ARS Centro, USF Caminhos Do Cértoma, Mealhada, Portugal
- University of Porto, CINTESIS – Centre for Research in Health Technologies and Service, Oporto, Portugal
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Freedman SF, Johnston C, Faragon JJ, Siegler EL, Del Carmen T. Older HIV-infected adults. Complex patients (III): Polypharmacy. Eur Geriatr Med 2018; 10:199-211. [PMID: 31983932 DOI: 10.1007/s41999-018-0139-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Polypharmacy is a well-described problem in the geriatric population. It is a relatively new problem for people living with HIV (PLWH), as this group now has a life expectancy approaching that of the general population. Defining polypharmacy for PLWH is difficult, since the most common traditional definition of at least five medications would encompass a large percentage of PLWH who are on antiretrovirals (ARVs) and medications for other medical comorbidities. Even when excluding ARVs, the prevalence of polypharmacy in PLWH is higher than the general population, and not just in resource-rich countries. Using a more nuanced approach with "appropriate" or "safer" polypharmacy allows for a better framework for discussing how to mitigate the associated risks. Some of the consequences of polypharmacy include adverse effects of medications including the risk of geriatric syndromes, drug-drug interactions, decreased adherence, and over- and undertreatment of medical comorbidities. Interventions to combat polypharmacy include decreasing pill burden-specifically with fixed-dose combination (FDC) tablets- and medication reconciliation/deprescription using established criteria. The goal of these interventions is to decrease drug interactions and improve quality of life and outcomes. Some special populations of interest within the community of PLWH include those with chronic pain, substance abuse, or requiring end of life care. A final look into the future of antiretroviral therapy (ART) shows the promise of possible two-drug regimens, which can help reduce the above risks of polypharmacy.
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Affiliation(s)
- Samuel F Freedman
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Carrie Johnston
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA
| | | | - Eugenia L Siegler
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Tessa Del Carmen
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York, USA
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Whitman A, DeGregory K, Morris A, Mohile S, Ramsdale E. Pharmacist-led medication assessment and deprescribing intervention for older adults with cancer and polypharmacy: a pilot study. Support Care Cancer 2018; 26:4105-4113. [PMID: 29869294 PMCID: PMC6204077 DOI: 10.1007/s00520-018-4281-3] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 05/17/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE The aims of this study were to compare the application of three geriatric medication screening tools to the Beers Criteria alone for potentially inappropriate medication quantification and to determine feasibility of a pharmacist-led polypharmacy assessment in a geriatric oncology clinic. METHODS Adult patients with cancer aged 65 and older underwent a comprehensive geriatric assessment. A polypharmacy assessment was completed by a pharmacist and included a review of all drug therapies. Potentially inappropriate medications were screened using the Beers Criteria, Screening Tool to Alert doctors to Right Treatment/Screening Tool of Older Persons' Prescriptions, and the Medication Appropriateness Index. Deprescribing occurred after discussion with the pharmacist, geriatric oncologist, patient, and caregiver. RESULTS Data were collected for 26 patients. The mean number of medications was 12. The Beers Criteria alone identified 38 potentially inappropriate medications compared to 119 potentially inappropriate medications with the three-tool assessment; a mean of 5 potentially inappropriate medications were identified per patient. After the application of the three-tool assessment, 73% of potentially inappropriate medications identified were deprescribed, resulting in a mean of 3 medications deprescribed per patient. Approximately two thirds of patients reported a reduction in symptoms after the deprescribing intervention. Healthcare expenditures of $4282.27 per patient were potentially avoided as a result of deprescribing. CONCLUSIONS Our three-tool assessment identified three times more potentially inappropriate medications than the Beers Criteria alone. Pharmacist-led deprescribing interventions are feasible and may lead to improved patient outcomes and cost savings. This three-tool assessment process should be incorporated into interdisciplinary assessments of older patients with cancer and validated in future studies.
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Affiliation(s)
- Andrew Whitman
- Department of Pharmacy, University of Virginia Health System, Charlottesville, VA, USA.
| | - Kathlene DeGregory
- Department of Pharmacy, University of Virginia Health System, Charlottesville, VA, USA
| | - Amy Morris
- Department of Pharmacy, University of Virginia Health System, Charlottesville, VA, USA
| | - Supriya Mohile
- Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | - Erika Ramsdale
- Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, NY, USA
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Simões PA, Santiago LM, Simões JA. Deprescribing in primary care in Portugal (DePil17-20): a three-phase observational and experimental study protocol. BMJ Open 2018; 8:e019542. [PMID: 30018092 PMCID: PMC6059343 DOI: 10.1136/bmjopen-2017-019542] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Polypharmacy is commonly defined as the simultaneous taking of five or more drugs. Deprescribing is the process of tapering or stopping medications with the aim of improving patient outcomes and optimising current therapy, and there are several tools aiming at identifying potentially inappropriate medications, especially in the elderly. The direct involvement of patients and their caregivers in the choice and administration of drugs has long been known to be very important, but it is not usually applied. The aim of this study is to assess the knowledge of older adults about deprescription, the effect on willingness to have regular medications deprescribed and its quality-of-life outcome. METHODS AND ANALYSIS This study protocol comprises three phases. The first two phases will be nationwide and aim to evaluate the prevalence and patterns of polypharmacy and assess the barriers and facilitators of deprescribing perceived by older adults, as well as their willingness to have regular medications deprescribed and to self-medicate. The third and last phase will be a non-pharmacological randomised clinical study to measure older patients' acceptance to have regular medications deprescribed and related quality of life. ETHICS AND DISSEMINATION The study will be conducted in accordance with the principles expressed in the Declaration of Helsinki. It has been approved by the Ethics Committee of the University of Beira Interior and Portuguese National Data Protection Commission. Study results will be published in peer-reviewed journals and presented at national and international conferences. In short, no action will be taken without written consent from patients and doctors. TRIAL REGISTRATION NUMBER > NCT03283735.
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Affiliation(s)
- Pedro Augusto Simões
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
- USF Pulsar, ARS Centro, Coimbra, Portugal
| | - Luiz Miguel Santiago
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- USF Topázio, ARS Centro, Coimbra, Portugal
| | - José Augusto Simões
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
- UCSP Mealhada, ARS Centro, Mealhada, Portugal
- CINTESIS - Centre for Research in Health Technologies and Service, Porto, Portugal
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Geriatric assessment-driven polypharmacy discussions between oncologists, older patients, and their caregivers. J Geriatr Oncol 2018. [PMID: 29530495 DOI: 10.1016/j.jgo.2018.02.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Polypharmacy (PP) and potentially inappropriate medications (PIM) are common in older adults with cancer, increasing the risk of adverse outcomes. Approaches to identifying and addressing PP/PIM are needed. MATERIALS AND METHODS Patients ≥70 years with advanced cancer were enrolled in this cluster-randomized study. All underwent geriatric assessment (GA), and oncologists randomized to the intervention arm received GA-driven recommendations; no information was provided to oncologists at usual care sites. For patients with PP (≥5 medications or ≥1 high-risk medication), clinic visits with treating oncologists were audiorecorded and transcribed, and discussions regarding PP/PIM identified. Quality of provider response was coded as dismissed, mentioned, acknowledged, or addressed. RESULTS Forty patient transcripts were analyzed (20 per arm). More discussions occurred in the intervention group (n = 81) versus the usual care group (n = 51). More concerns per patient were brought up in the intervention group (4.1 vs. 2.6, p = 0.07). Physician-initiated discussions were higher in the intervention group (73% vs. 49%, p = 0.006). More PP concerns were "addressed" in the intervention group (59% vs. 45%, p = 0.1). Oncology supportive care medication concerns were more often addressed in the usual care group (58% vs. 18%, p = 0.008), but medication management concerns were addressed more commonly in the intervention group (38% vs. 79%, p = 0.003). CONCLUSION In this secondary analysis, a GA-driven intervention increased PP discussions, particularly about total number of medications and medication management. PP/PIM concerns were more commonly addressed in the intervention group, except for the subset of conversations about supportive care medications.
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Leger DY, Moreau S, Signol N, Fargeas JB, Picat MA, Penot A, Abraham J, Laroche ML, Bordessoule D. Polypharmacy, potentially inappropriate medications and drug-drug interactions in geriatric patients with hematologic malignancy: Observational single-center study of 122 patients. J Geriatr Oncol 2018; 9:60-67. [DOI: 10.1016/j.jgo.2017.07.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 05/23/2017] [Accepted: 07/27/2017] [Indexed: 01/02/2023]
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Suhonen R, Stolt M, Berg A, Katajisto J, Lemonidou C, Patiraki E, Sjövall K, Charalambous A. Cancer patients' perceptions of quality-of-care attributes-Associations with age, perceived health status, gender and education. J Clin Nurs 2017; 27:306-316. [DOI: 10.1111/jocn.13902] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2017] [Indexed: 12/31/2022]
Affiliation(s)
- Riitta Suhonen
- Department of Nursing Science; University of Turku; Turku Finland
- University Hospital and City of Turku; Welfare Division; Turku Finland
| | - Minna Stolt
- Department of Nursing Science; University of Turku; Turku Finland
| | - Agneta Berg
- Department of Health Science; Kristianstad University; Kristianstad Sweden
| | - Jouko Katajisto
- Department of Mathematics and Statistics; University of Turku; Turku Finland
| | - Chryssoula Lemonidou
- Faculty of Nursing; National and Kapodistrian University of Athens; Athens Greece
| | - Elisabeth Patiraki
- Faculty of Nursing; National and Kapodistrian University of Athens; Athens Greece
| | - Katarina Sjövall
- Department of Health Sciences and Skåne University Hospital; Lund University; Lund Sweden
| | - Andreas Charalambous
- Department of Nursing Studies; Cyprus University of Technology; Limassol Cyprus
- University of Turku; Turku Finland
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Exploring the Impact of Human Papillomavirus Status, Comorbidity, Polypharmacy, and Treatment Intensity on Outcome of Elderly Oropharyngeal Cancer Patients Treated With Radiation Therapy With or Without Chemotherapy. Int J Radiat Oncol Biol Phys 2017; 98:858-867. [DOI: 10.1016/j.ijrobp.2016.11.044] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 11/14/2016] [Accepted: 11/21/2016] [Indexed: 11/23/2022]
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Reis CM, dos Santos AG, de Jesus Souza P, Reis AMM. Factors associated with the use of potentially inappropriate medications by older adults with cancer. J Geriatr Oncol 2017; 8:303-307. [DOI: 10.1016/j.jgo.2017.05.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/24/2017] [Accepted: 05/24/2017] [Indexed: 01/29/2023]
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