Polypharmacy and prescription medication use in a population-based sample of adolescent and young adult cancer survivors

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.

Managing older people with atrial fibrillation and preventing stroke: a review of anticoagulation approaches

INTRODUCTION

Oral anticoagulants (OACs) are the cornerstone of stroke prevention in atrial fibrillation (AF), but prescribing decisions in older people are complicated. Clinicians must assess the net clinical benefit of OAC in the context of multiple chronic conditions, polypharmacy, frailty and life expectancy. The under-representation of high-risk, older adult sub-populations in clinical trials presents the challenge of choosing the right OAC, where a 'one-size-fits-all' approach cannot be taken.

AREAS COVERED

This review discusses OAC approaches for stroke prevention in older people with AF and presents a prescribing aid to support clinicians' decision-making. High-risk older adults with multiple chronic conditions, specifically chronic kidney disease, dementia/cognitive impairment, previous stroke/transient ischemic attack or intracranial hemorrhage, polypharmacy, frailty, low body weight, high falls risk, and those aged ≥75 years are considered.

EXPERT OPINION

Non-vitamin K antagonist OACs are the preferred first-line OAC in older adults with AF, including high-risk subpopulations, after individual assessment of stroke and bleeding risk, except those with mechanical heart valves and moderate-to-severe mitral stenosis. Head-to-head comparisons of NOACs are not available, therefore the choice of drug (and dose) should be based on an individual's risk (stroke and bleeding) and incorporate their treatment preferences. Treatment decisions must be person-centered and principles of shared decision-making applied.

Caregiver involvement in managing medications among older adults with multiple chronic conditions

OBJECTIVE

We sought to characterize caregiver medication assistance for older adults with multiple chronic conditions.

DESIGN

Semi-structured qualitative interviews.

SETTING

Community and academic-affiliated primary care practices.

PARTICIPANTS

A total of 25 caregivers to older adults participating in an ongoing cohort study with ≥3 chronic conditions.

MEASUREMENTS

A semi-structured interview guide, informed by the Medication Self-Management model, aimed to understand health-related and medication-specific assistance caregivers provided.

RESULTS

Three typologies of caregiver assistance with medications emerged: Actively Involved, Peripherally Involved, and Not Involved. A total of 10 caregivers were Actively Involved, which was defined as when the caregiver perceived a need for and offered assistance, and the patient accepted the assistance. Peripherally Involved (n = 6) was defined as when the caregiver perceived a need and offered assistance; however, the patient rejected this assistance, yet relied on the caregiver as a backup in managing his or her medications. To combat resistance from the patient, caregivers in this typology disguised assistance and deployed workaround strategies to monitor medication-taking behaviors to ensure safety. Lastly, nine caregivers were classified as Not Involved, defined as when the caregiver did not perceive a need to offer assistance with medications, and the patient managed his or her medicines independently. A strong preference toward autonomy in medication management was shared across all three typologies.

CONCLUSION

These findings suggest that caregivers value independent medication management by their care recipient, up until safety is seriously questioned. Clinicians should not assume caregivers are actively and consistently involved in older adults' medication management; instead, they should initiate conversations with patients and caregivers to better understand and facilitate co-management responsibilities, especially among those whose assistance is rejected by older adults.

Overview of High Yield Geriatrics Assessment for Clinic and Hospital

Geriatric assessment is a comprehensive, multifaceted, and interdisciplinary evaluation of medical, socioeconomic, environmental, and functional concerns unique to older adults; it can be focused or broadened according to the needs of the patient and the concerns of clinical providers. Herein, the authors present a high-yield framework that can be used to assess older adult patients across a variety of settings.

Thoughtful Prescribing and Deprescribing

Polypharmacy, the use of five or more medications, is common in older adults. It can lead to the use of potentially inappropriate medications and severe adverse outcomes. Deprescribing is an essential step of the thoughtful prescribing process and it can decrease the use of potentially inappropriate medications. Studies have demonstrated that deprescribing is feasible in the clinical setting, especially when it incorporates patient preferences, shared decision making, and an interdisciplinary team. Medication-specific algorithms can facilitate deprescribing in the clinical setting.

Optimising medication management for polymedicated home-dwelling older adults with multiple chronic conditions: a mixed-methods study protocol

INTRODUCTION

Optimal medication management is one of the basic conditions necessary for home-dwelling older adults living with multiple chronic conditions (OAMCC) to be able to remain at home and preserve their quality of life. Currently, the reasons for such high numbers of emergency department visits and the very significant rate of hospitalisations for OAMCC, due to medication-related problems (MRPs), is poorly explored. This study aims to reveal the current state of the medication management practices of polymedicated, home-dwelling OAMCC and to make proposals for improving clinical and medication pathways through an innovative and integrated model for supporting medication management and preventing adverse health outcomes.

METHODS AND ANALYSIS

A mixed-methods study will address the medication management of polymedicated, home-dwelling OAMCC. Its explanatory sequential design will involve two major phases conducted sequentially over time. The quantitative phase will consist of retrospectively exploiting the last 5 years of electronic patient records from a local hospital (N ≈ 50 000) in order to identify the different profiles-made up of patient-related, medication-related and environment-related factors-of the polymedicated, home-dwelling OAMCC at risk of hospitalisation, emergency department visits, hospital readmission (notably for MRPs), institutionalisation or early death. The qualitative study will involve: (a) obtaining and understanding the medication management practices and experiences of the identified profiles extracted from the hospital data of OAMCC who will be interviewed at home (N ≈ 30); (b) collecting and analysing the perspectives of the formal and informal caregivers involved in medication management at home in order to cross-reference perspectives about this important dimension of care at home. Finally, the mixed-methods findings will enable the development of an innovative, integrated model of medication management based on the Agency for Clinical Innovation framework and Bodenheimer and Sinsky's quadruple aim.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Human Research Ethics Committee of the Canton Vaud (2018-02196). Findings will be disseminated in peer-reviewed journals, professional conferences and other knowledge transfer activities with primary healthcare providers, hospital care units, informal caregivers' and patients' associations.

Prescribing patterns of polypharmacy in Korean pediatric patients

Background

Several studies have examined the risk and health outcomes related to polypharmacy among the elderly. However, information regarding polypharmacy among pediatric patients is lacking.

Objective

The aim of this study was to investigate the prevalence of polypharmacy and its related factors among the pediatric population of South Korea.

Methods

We used national claim data from the Health Insurance Review and Assessment Service—Pediatric Patients Sample (HIRA-PPS) in Korea originating from 2012 through 2016. Polypharmacy was defined as a daily average of two or more drugs used yearly. Complex chronic conditions (CCCs) were examined to evaluate concomitant chronic diseases in pediatric patients. Age-specific contraindications and potential drug-drug interactions were assessed according to criteria established by the Korea Institute of Drug Safety & Risk Management (KIDS). Descriptive statistics and logistic regression were conducted to analyze the status of polypharmacy and its associated risk factors in pediatric patients.

Results

The 5-year prevalence of pediatric polypharmacy in pediatric patients was 3.7%. The prevalence of polypharmacy was much higher in younger pediatric patients: 9.5% for patients between the ages of 1–7 years, 0.9% for ages 6–11 years, and 1.1% for ages 12–19 years. Pediatric patients with CCCs, Medical Aid benefits, or a hospital admission history had a significantly higher prevalence of polypharmacy when compared to their counterparts without those conditions. The most commonly prescribed drugs were respiratory agents (29%) followed by anti-allergic drugs (18.7%), central nervous system agents (15.9%), antibiotics (10.1%), and gastrointestinal drugs (7.7%). There was a positive correlation between the daily average number of inappropriate prescriptions and the degree of polypharmacy, especially in pediatric patients between the ages of 1–7 years. Contraindications and potential drug-drug interactions occurred in 11.0% and 10.1% of patients exposed to polypharmacy, respectively.

Conclusions

One in ten pediatric patients under the age of 7 years was prescribed two or more concurrent drugs on average per day. Furthermore, pediatric patients exposed to polypharmacy showed an increased risk of inappropriate drug use. The implementation of a medication review system that considers pediatric patient polypharmacy exposure would reduce inappropriate drug use and prevent unwanted adverse outcomes.

Polypharmacy: Evaluating Risks and Deprescribing

Polypharmacy, defined as regular use of at least five medications, is common in older adults and younger at-risk populations and increases the risk of adverse medical outcomes. There are several risk factors that can lead to polypharmacy. Patient-related factors include having multiple medical conditions managed by multiple subspecialist physicians, having chronic mental health conditions, and residing in a long-term care facility. Systems-level factors include poorly updated medical records, automated refill services, and prescribing to meet disease-specific quality metrics. Tools that help identify potentially inappropriate medication use include the Beers, STOPP (screening tool of older people's prescriptions), and START (screening tool to alert to right treatment) criteria, and the Medication Appropriateness Index. No one tool or strategy has been shown to be superior in improving patient-related outcomes and decreasing polypharmacy risks. Monitoring patients' active medication lists and deprescribing any unnecessary medications are recommended to reduce pill burden, the risks of adverse drug events, and financial hardship. Physicians should view deprescribing as a therapeutic intervention similar to initiating clinically appropriate therapy. When deprescribing, physicians should consider patient/ caregiver perspectives on goals of therapy, including views on medications and chronic conditions and preferences and priorities regarding prescribing to slow disease progression, prevent health decline, and address symptoms. Point-of-care tools can aid physicians in deprescribing and help patients understand the need to decrease medication burden to reduce the risks of polypharmacy.

Medication patterns in older adults with multimorbidity: a cluster analysis of primary care patients

BACKGROUND

Older adults suffer from various chronic conditions which make them particularly vulnerable. The proper management of multiple drug use is therefore crucial. The aim of our study was to describe drug prescription and medication patterns in this population.

METHODS

A cross-sectional study in Barcelona (Spain) using electronic health records from 50 primary healthcare centres. Participants were aged 65 to 94 years, presenting multimorbidity (≥2 chronic diseases), and had been prescribed at least 1 drug for 6 months or longer during 2009. We calculated the prevalence of prescribed drugs and identified medication patterns using multiple correspondence analysis and k-means clustering. Analyses were stratified by sex and age (65-79, 80-94 years).

RESULTS

We studied 164,513 patients (66.8% women) prescribed a median of 4 drugs (interquartile range [IQR] = 3-7) in the 65-79 age-group and 6 drugs (IQR = 4-8) in the 80-94 age-group. A minimum of 45.9% of patients aged 65-79 years, and 61.8% of those aged 80-94 years, were prescribed 5 or more drugs. We identified 6 medication patterns, a non-specific one and 5 encompassing 8 anatomical groups (alimentary tract and metabolism, blood, cardiovascular, dermatological, musculo-skeletal, neurological, respiratory, and sensory organ).

CONCLUSIONS

Drug prescription is widespread among the elderly. Six medication patterns were identified, 5 of which were related to one or more anatomical group, with associations among drugs from different systems. Overall, guidelines do not accurately reflect the situation of the elderly multimorbid, new strategies for managing multiple drug uses are needed to optimize prescribing in these patients.

Associations Between Polypharmacy, Symptom Burden, and Quality of Life in Patients with Advanced, Life-Limiting Illness

BACKGROUND

Polypharmacy may be particularly burdensome near the end of life, as patients "accumulate" medications to treat and prevent multiple diseases.

OBJECTIVE

To evaluate associations between polypharmacy, symptom burden, and quality of life (QOL) in patients with advanced, life-limiting illness (clinician-estimated, 1 month-1 year).

DESIGN

Secondary analysis of baseline data from a trial of statin discontinuation.

PARTICIPANTS

Adults with advanced, life-limiting illness.

MAIN MEASURES

Polypharmacy was assessed by summing the number of non-statin medications taken regularly or as needed. Symptom burden was assessed using the Edmonton Symptom Assessment Scale (range 0-90; higher scores indicating greater symptom burden) and QOL was assessed using the McGill QOL Questionnaire (range 0-10; higher scores indicating better QOL). Linear regression models assessed associations between polypharmacy, symptom burden, and QOL.

KEY RESULTS

Among 372 participants, 47% were age 75 or older and 35% were enrolled in hospice. The mean symptom score was 27.0 (standard deviation (SD) 16.1) and the mean QOL score was 7.0 (SD 1.3). The average number of non-statin medications was 11.6 (SD 5.0); one-third of participants took ≥ 14 medications. In adjusted models, higher polypharmacy was associated with higher symptom burden (coefficient 0.81; p < .001) and lower QOL (coefficient - .06; p = .001). Adjusting for symptom burden weakened the association between polypharmacy and QOL (coefficient - .03; p = .045) without a significant interaction, suggesting that worse quality of life associated with polypharmacy may be related to medication-associated symptoms.

CONCLUSIONS

Among adults with advanced illness, taking more medications is associated with higher symptom burden and lower QOL. Attention to medication-related symptoms and shared decision-making regarding deprescribing are warranted in this setting.

NIH TRIAL REGISTRY NUMBER

ClinicalTrials.gov Identifier for Parent Study - NCT01415934.

Polypharmacy in older patients with chronic diseases: a cross-sectional analysis of factors associated with excessive polypharmacy

BACKGROUND

Polypharmacy is common in older people and associated with potential harms. The aim of this study was to analyse the characteristics of an older multimorbid population with polypharmacy and to identify factors contributing to excessive polypharmacy in these patients.

METHODS

This cross-sectional analysis is based on the PRIMA-eDS trial, a large randomised controlled multicentre study of polypharmacy in primary care. Patients' baseline data were used for analysis. A number of socioeconomic and medical data as well as SF-12-scores were entered into a generalized linear mixed model to identify variables associated with excessive polypharmacy (taking ≥10 substances daily).

RESULTS

Three thousand nine hundred four participants were recruited. Risk factors significantly associated with excessive polypharmacy were frailty (OR 1.45; 95% CI 1.22-1.71), > 8 diagnoses (OR 2.64; 95% CI 2.24-3.11), BMI ≥30 (OR 1.18; 95% CI 1.02-1.38), a lower SF-12 physical health composite score (OR 1.47; 95% CI 1.26-1.72), and a lower SF-12 mental health composite score (OR 1.33; 95% CI 1.17-1.59) than the median of the study population (≤36.6 and ≤ 48.7, respectively). Age ≥ 85 years (OR 0.83; 95% CI 0.70-0.99) led to a significantly lower risk for excessive polypharmacy. No association with excessive polypharmacy could be found for female sex, low educational level, and smoking. Regarding the study centres, being recruited in the UK led to a significantly higher risk for excessive polypharmacy compared to being recruited in Germany 1/Rostock (OR 1.71; 95% CI 1.27-2.30). Being recruited in Germany 2/Witten led to a slightly significant lower risk for excessive polypharmacy compared to Germany 1/Rostock (OR 0.74; 95% CI 0.56-0.97).

CONCLUSIONS

Frailty, multimorbidity, obesity, and decreased physical as well as mental health status are risk factors for excessive polypharmacy. Sex, educational level, and smoking apparently do not seem to be related to excessive polypharmacy. Physicians should especially pay attention to their frail, obese patients who have multiple diagnoses and a decreased health-related quality of life, to check carefully whether all the drugs prescribed are evidence-based, safe, and do not interact in an unfavourable way.

TRIAL REGISTRATION

This trial has been registered with Current Controlled Trials Ltd. on 31 July 2014 (ISRCTN10137559).

Potential Medication-Related Problems in Older Breast, Colon, and Lung Cancer Patients in the United States

Background: Older adults are often exposed to multiple medications, some of which could be inappropriate or have the potential to interact with each other. Older cancer patients may be at increased risk for medication-related problems due to exposure to cancer-directed treatment.Methods: We described patterns of potentially inappropriate medication (PIM) use and potential drug-chemotherapy interactions among adults age 66+ years diagnosed with stage I-III breast, stage II-III colon, and stage I to II lung cancer. Within the Surveillance, Epidemiology, and End Results-Medicare database, patients had to have Medicare Part D coverage with 1+ prescription in the diagnosis month and Medicare Parts A/B coverage in the prior 12 months. We estimated monthly prevalence of any and cancer-related PIM from 6 months pre- to 23 months postcancer diagnosis and 12-month period prevalence of potential drug-chemotherapy interactions.Results: Overall, 19,318 breast, 7,283 colon, and 7,237 lung cancer patients were evaluated. Monthly PIM prevalence was stable prediagnosis (37%-40%), but increased in the year following a colon or lung cancer diagnosis, and decreased following a breast cancer diagnosis. Changes in PIM prevalence were driven primarily by cancer-related PIM in patients on chemotherapy. Potential drug-chemotherapy interactions were observed in all cohorts, with prevalent interactions involving hydrochlorothiazide, warfarin, and proton-pump inhibitors.Conclusions: There was a high burden of potential medication-related problems among older cancer patients; future research to evaluate outcomes of these exposures is warranted.Impact: Older adults diagnosed with cancer have unique medication management needs. Thus, pharmacy specialists should be integrated into multidisciplinary teams caring for these patients. Cancer Epidemiol Biomarkers Prev; 27(1); 41-49. ©2017 AACR.

Use of polypharmacy and herbal medication on quality of life in elderly patients at Okmeydani hospital's polyclinics in Istanbul, Turkey

OBJECTIVE

To determine what should be done as a preventive medicine physician by analysing the effect of polypharmacy and herbal treatment.

METHODS

This survey-based, cross-sectional study was carried out at Istanbul Okmeydani Training and Research Hospital, Istanbul, Turkey, from February to May 2015, and comprised patients using two or more medicines at full strength for at least 240 days. The patients were classified into two groups. Group A comprised those who were using less than 4 medications (at least 2), while group B comprised patients using more than 4 medications. The short version of World Health Organisation's quality-of-life questionnaire was applied. SPSS 22 was used for data analysis.

RESULTS

Of the 350 participants, 106(30.3%) were receiving herbal treatment while 244(69.7%) had no such treatment. Group B patients had meaningfully lower scores for body, spiritual, social and external environment (p=0.001). Moreover, the patients having no herbal or supportive treatment scored significantly higher in the physical, spiritual, social relations and external environment (p=0.001). In group A, patients receiving no herbal treatment scored meaningfully higher in all fields, including physical (p=0.009), social relations (p=0.043) and external environment (p=0.001).

CONCLUSIONS

Old age, living alone, level of education, having a regular monthly income, the number of drugs used, chronic diseases and herbal treatments affected the life quality.

Chronic Pain: How Challenging Are DDIs in the Analgesic Treatment of Inpatients with Multiple Chronic Conditions?

Background

Chronic pain is common in multimorbid patients. However, little is known about the implications of chronic pain and analgesic treatment on multimorbid patients. This study aimed to assess chronic pain therapy with regard to the interaction potential in a sample of inpatients with multiple chronic conditions.

Methods and Findings

We conducted a retrospective study with all multimorbid inpatients aged ≥18 years admitted to the Department of Internal Medicine of University Hospital Zurich in 2011 (n = 1,039 patients). Data were extracted from the electronic health records and reviewed. We identified 433 hospitalizations of patients with chronic pain and analyzed their combinations of chronic conditions (multimorbidity). We then classified all analgesic prescriptions according to the World Health Organization (WHO) analgesic ladder. Furthermore, we used a Swiss drug-drug interactions knowledge base to identify potential interactions between opioids and other drug classes, in particular coanalgesics and other concomitant drugs. Chronic pain was present in 38% of patients with multimorbidity. On average, patients with chronic pain were aged 65.7 years and had a mean number of 6.6 diagnoses. Hypertension was the most common chronic condition. Chronic back pain was the most common painful condition. Almost 90% of patients were exposed to polypharmacotherapy. Of the chronic pain patients, 71.1% received opioids for moderate to severe pain, 43.4% received coanalgesics. We identified 3,186 potential drug-drug interactions, with 17% classified between analgesics (without coanalgesics).

Conclusions

Analgesic drugs-related DDIs, in particular opioids, in multimorbid patients are often complex and difficult to assess by using DDI knowledge bases alone. Drug-multimorbidity interactions are not sufficiently investigated and understood. Today, the scientific literature is scarce for chronic pain in combination with multiple coexisting medical conditions and medication regimens. Our work may provide useful information to enable further investigations in multimorbidity research within the scope of potential interactions and chronic pain.

Association among change in medical costs, level of comorbidity, and change in adherence behavior

OBJECTIVES

Interventions to improve medication adherence are effective, but resource intensive. Interventions must be targeted to those who will potentially benefit most. We examined what heterogeneity exists in the value of adherence based on levels of comorbidity, and the changes in spending on medical services that followed changes in adherence behavior.

STUDY DESIGN

Retrospective cohort study examining medical spending for 2 years (April 1, 2011, to March 31, 2013) in commercial insurance beneficiaries.

METHODS

Multivariable linear modeling was used to adjust for differences in patient characteristics. Analyses were performed at the patient/condition level in 2 cohorts: adherent at baseline and nonadherent at baseline.

RESULTS

We evaluated 857,041 patients, representing 1,264,797 patient therapies consisting of 40% high cholesterol, 48% hypertension, and 12% diabetes. Among those with 3 or more conditions, annual savings associated with becoming adherent were $5341, $4423, and $2081 for patients with at least diabetes, hypertension, and high cholesterol, respectively. The increased costs for patients in this group who became nonadherent were $4653, $7946, and $4008, respectively. Depending on the condition and the direction of behavior change, savings were 2 to 7 times greater than the value for individuals with fewer than 3 conditions. In most cases, the value of preventing nonadherence (ie, persistence) was greater than the value of moving people who are nonadherent to an adherent state.

CONCLUSIONS

There is important heterogeneity in the impact of medication adherence on medical spending. Clinicians and policy makers should consider this when promoting the change of adherence behavior.

[Polypharmacy viewed not only through the prism of multi-morbidity, but also as an independent geriatric syndrome]

Polypharmacy is common in the elderly, especially in the late age (over 75 years). Usually it is closely related to the geriatric multi-morbidity. The authors highlight the medication used in the anticipated positive and potential negative potential. While physicians often must make difficult trade-offs between the guidelines on one hand and complicated multi-morbidity, on the other hand, while trying to avoid polypharmacy ( 5 drugs), especially excessive polypharmacy ( 10 drugs). Multimorbid elderly patients who are treated in accordance with guidelines typically use large amounts of medicaments. This polypharmacy increases the risk of adverse drug reactions and drug interactions. The authors point out the pitfalls of performance of large clinical studies and EBM on one side and the daily clinical practice at the risk of their indiscriminate application, albeit with good intentions to improve the health of seniors.Key words: evidence based medicine - geriatrisation of medicine - multi-morbidity - old age - polypharmacy - prescription - randomized clinical trials.