The development and evaluation of an oncological palliative care deprescribing guideline: the 'OncPal deprescribing guideline'

Impact of the deprescribing timing on medicines optimisation in older cancer patients receiving hospice care at the end of life: a comparative cohort study

BACKGROUND

Deprescribing, the systematic discontinuation of potentially inappropriate medications, is essential for optimising end-of-life care in older cancer patients, particularly in hospice settings. While the benefits of deprescribing are recognised, the timing of these interventions and their impact on patient outcomes, such as survival, remain underexplored.

AIM

This study aimed to compare the effects of deprescribing timing on medication appropriateness and survival time in older hospice cancer patients.

METHODS

A retrospective, observational cohort study that reviewed the medical records of all decedents aged 65 years and older who received palliative care consults in hospice settings was conducted between January 1 and December 31, 2022. Data collected included Palliative Performance Scale (PPS) scores and prescribed medications. Patients were categorised into early deprescribing (interventions initiated more than 30 days, but less than 180 days before death) and late deprescribing (within 30 days of death) groups. Unexpected deaths were excluded. Medication appropriateness was assessed using the OncPal deprescribing guideline.

RESULTS

Among 155 decedents, early deprescribing was associated with longer median survival time (81 versus 17 days; P < 0.001). Both early and late interventions significantly reduced preventive medications (4.6-1.6, 4.8-1.5, respectively; P < 0.001) and increased symptom control medications (3.6-6.0 and 3.7-5.5, respectively; P < 0.001). Late deprescribing was more common in patients with lower PPS scores (≤ 30%) and haematologic cancers.

CONCLUSION

Early deprescribing in hospice care was associated with longer survival and improved symptom management, though this may reflect underlying patient characteristics rather than a direct effect of deprescribing.

Preventive medication deprescribing in advanced cancer patients approaching end of life

Previous reports indicated many patients with advanced cancer and limited life expectancy have ongoing preventive medication prescription (PMP) of uncertain benefit and increased risk. Our review of palliative care oncology admissions found high rates of PMP (69%) at time of first palliative care admission, despite high rates of inpatient deprescription (88%) and death at a median of 16 days (interquartile range 10-45) following admission. Rates of PMPs did not vary by time from last systemic treatment (P = 0.29) or by prior palliative care involvement (P = 0.82). Physicians and the wider multidisciplinary care team may be missing deprescription opportunities for terminally ill patients.

Pharmacist-led deprescribing interventions for cancer patients in a specialist palliative care setting

PURPOSE

This study aimed to determine the prevalence of potentially inappropriate medications (PIMs) among adult cancer patients in palliative care, the rate at which physicians implemented pharmacists' deprescribing recommendations, and some cost implications of deprescribing.

METHODS

Medication reconciliation was performed for each eligible patient, with both the OncPal deprescribing guideline and clinical judgement applied to identify PIMs. PIM prevalence was evaluated for each medication class. The physician recommendation implementation rate and medication cost savings were calculated.

RESULTS

In the 48 included patients, 25.2% of medications were PIMs (mean 2.4/patient) - with 86.7% OncPal-defined PIMs, most commonly vitamins, medications for gastro-oesophageal reflux disease (GORD), and lipid-modifying agents. Pharmacist deprescribing recommendations were implemented 71.7% of the time, equivalent to 1.7 fewer medications per patient. The 28-day cost was €948.27 for deprescribed PIMs. Implementation rates varied based on patient admission type, with a significantly higher (p<0.05) rate in those admitted for end-of-life care (83.3%) versus symptom control (65.1%) and respite (30%) admissions. Recommendations to deprescribe GORD medications had a significantly lower rate of implementation (26.7%) compared to all other medications (p<0.0001).

CONCLUSION

This study underscores the benefits of pharmacist-led deprescribing in inpatient palliative care, resulting in cost savings and reduced medication burden. There is a notable need for proactive deprescribing before reaching inpatient care. Different deprescribing rates across medication types highlight the significance of reviewing medications which may have a role in symptom management. The omission of some medications from OncPal emphasises the importance in refining future deprescribing guidelines in palliative care.

Medication Prescriptions for Chronic Diseases in Terminal Cancer Patients in Korea: A Real-World Study

Purpose

This study aimed to investigate the prescribing patterns of medications for chronic diseases in patients with terminal cancer in South Korea as their life expectancy declined.

Methods

This study analyzed data on cancer patients from the National Health Insurance Service (NHIS) database in South Korea. It included a total of 89,606 patients who died of cancer in 2021. We evaluated prescriptions for dyslipidemia, hypertension, diabetes, and osteoporosis at 52, 12, 4, and 1 week prior to death.

Results

A significant proportion of patients nearing death continued to receive prescriptions for chronic disease medications, despite guidelines suggesting that these medications can be discontinued when life expectancy is limited. For instance, 2.6% of patients were prescribed medications for dyslipidemia just 1 week before death, highlighting a discrepancy between clinical practice and recommended guidelines.

Conclusion

These findings underscore the need to reevaluate prescription practices for terminal cancer patients. Optimizing medication use can decrease polypharmacy, reduce adverse drug reactions, and increase the quality of life (QOL) for these individuals.

Medication management: supportive care medications in older adults with cancer

PURPOSE OF REVIEW

This review raises awareness regarding the lack of data available for healthcare professionals caring for older adults with cancer when using supportive care medications.

RECENT FINDINGS

Guidelines for supportive cancer care lack concrete recommendations on the appropriate use of medications in older adults with cancer. Some guidelines, such as the National Comprehensive Cancer Network Older Adult Oncology guideline, contain vital information for prescribers to consider when choosing a supportive care medication. Information at present in most guidelines is generally vague, identifying areas where caution is required in older adults, without specific details.

SUMMARY

Research is needed to assess the efficacy and safety of supportive cancer care medications in older adults.

Understanding European patterns of deprescribing antithrombotic medication during end-of-life care in patients with cancer

BACKGROUND

Even though antithrombotic therapy (ATT) probably has little or even negative effect on the well-being of patients with cancer near the end of life, it is often continued until death, possibly leading to excess bleeding complications, increased disease burden, reduced quality of life and higher healthcare costs.

AIM

To explore and describe European practice patterns and perspectives of healthcare professionals from different disciplines and specialties on ATT in the end-of-life care (EOLC) of patients with cancer.

METHODS

We performed a two-week international cross-sectional survey study using flash-mob research methodology. Eligible were healthcare professionals from different institutions across Europe, who prescribed ATT and/or dealt with EOLC of patients with cancer. The survey comprised three parts, including a series of choice sets (hypothetical scenarios involving a set of characteristics changing in level [e.g., high vs. low thrombotic risk]) on ATT management in EOLC. The discrete choice experiment analysis was conducted using multinomial logistic regression.

RESULTS

Out of 467 pre-registrants, 208 participated in the survey from 4 to 18 July 2023. The majority (53 %) considered a patient with cancer as in EOLC when life expectancy is below 3 months. Respondents reported seeing or treating 20 patients with cancer on ATT in EOLC per year (IQR 10-50). The median estimated frequency of considering ATT deprescription per healthcare professional was 10 times per year (IQR 4-10), while the frequency of actual deprescription was 5 times per year (IQR 2-10). Twenty percent of respondents had never deprescribed ATT in the context of EOLC. Across the eight choice sets, five respondents (2.7 %) found deprescribing inappropriate in any scenario. Deprescribing was more often considered in patients with poor ECOG-performance status, high bleeding risk and low-molecular-weight heparin use as opposed to oral ATT. Haemato-oncology and cardiovascular medicine specialists were more inclined to deprescribe antiplatelet therapy than other specialties.

CONCLUSION

Our study describes medical decision-making regarding ATT in EOLC of patients with cancer. Healthcare professionals' perspectives and practice patterns vary, and some preferences appear associated with the therapists' professional focus and region of practice.

Beyond Index Conditions: Applying a Multimorbidity Approach to Renal Cancer Nursing

OBJECTIVE

This article aims to describe the key components of renal cancer nursing and multimorbidity nursing, and reflects on how adopting a multimorbidity approach to renal cancer nursing can help nurses provide holistic patient care.

METHODS

This is a discussion paper drawing on relevant evidence and theory.

RESULTS

Renal cancer nurses have a highly specialised knowledge base and are able to use this expertise to deliver excellent care to people with cancer. However, lots of people with cancer have other conditions as well. Adopting a multimorbidity approach to nursing care provides a more holistic framework for care delivery.

CONCLUSIONS

Cancer nurses are ideally placed to support patients in this way, so they are able to deliver care which accounts for factors such as treatment burden and how this impacts on patients and carers.

IMPLICATIONS FOR NURSING PRACTICE

Nurses who care for people with renal cancer should view their patients through the lens of multimorbidity. This involves screening for other chronic conditions, considering polypharmacy, providing emotional support and continuity of care, and coordinating care in a way that accounts for the potentially burdensome nature of the patient's interactions with health care.

Comparison of four criteria for potentially inappropriate medications in older patients with newly diagnosed non-small cell lung cancer

BACKGROUND

Potentially inappropriate medication (PIM) use is a common problem among older patients. This study aimed to compare the prevalence of PIMs in older patients with newly diagnosed non-small cell lung cancer (NSCLC), and to identify the correlates of PIMs.

RESEARCH DESIGN AND METHODS

A secondary analysis of a prospective cohort study was conducted. Patients were enrolled from January 2014 to December 2020 and information were extracted from patients' electronic medical records (EMRs). We evaluated the PIMs using four different PIM criteria. The concordance among the four PIM criteria was calculated using kappa tests. The possible risk factors associated with PIMs were analyzed by multivariate logistic regression.

RESULTS

The prevalence of at least one PIM identified by the four criteria ranged from 25.1% to 48.2% among 514 patients. There was moderate consistency between the GO-PIM scale and the AGS/Beers criteria, while poor consistency with the other criteria (the STOPP criteria and the Chinese criteria). Polypharmacy was found to be significantly associated with the occurrence of PIMs in all criteria (p < 0.001).

CONCLUSIONS

Our results showed a high prevalence of PIMs in older patients with NSCLC, which was significantly associated with polypharmacy, and the consistency across the four criteria was poor-to-moderate.

Recommendations for Deprescribing of Medication in the Last Phase of Life: An International Delphi Study

CONTEXT

Medications may become inappropriate for patients in the last phase of life and may even compromise their quality of life.

OBJECTIVE

To find consensus on recommendations regarding deprescribing of medications for adult patients with a life expectancy of six months or less.

METHODS

Experts working in palliative care or other relevant disciplines were asked to participate in this international Delphi study. Existing tools for deprescribing of medication in the last phase of life were integrated in a list of 42 recommendations regarding potential deprescription of various medication types. In two Delphi rounds, experts were asked to rate their agreement with each recommendation on a 5-point Likert-scale (strongly agree-strongly disagree). Recommendations were accepted, if at least 70% of the experts (strongly) agreed, the interquartile range (IQR) was one or less, and less than 10% strongly disagreed.

RESULTS

About 47 experts from 10 countries participated (response rate 53%). In most cases (76%), consensus was reached on deprescribing recommendations for patients with a life expectancy of six months or less. The highest level of consensus was reached for recommendations on the deprescription of diuretics in case of decreasing fluid intake or increasing fluid loss, lipid modifying agents if prescribed for primary prevention, and vitamin K antagonists and direct oral anticoagulants in case of high bleeding risk.

CONCLUSION

A high level of consensus was reached on recommendations on potential deprescription of several medications for patients with a life expectancy of six months or less.

Deprescribing in hospitalized patients with cancer: A clinical pharmacist-initiated multidisciplinary intervention

PURPOSE

To examine the feasibility and utility of a clinical pharmacist-led multidisciplinary deprescribing intervention in hospitalized cancer patients.

METHODS

We performed a retrospective cohort study among cancer patients hospitalized in oncology department who underwent a medication review by a clinical pharmacist. The pharmacist's recommendations were evaluated by a multidisciplinary team. We collected demographic and clinical information, including information on medication burden before and after intervention and number and types of deprescribing recommendations and their acceptance, and compared them among patients with different estimated life expectancies.

RESULTS

During a 2-year study period, 392 patients evaluated by the clinical pharmacist received 2808 prescriptions (median, 7 per patient). The clinical pharmacist recommended deprescribing of 559 medications (19.9%; 95 CI, 18.4-21.4%), at least 1 medication in 321 patients (82%). The multidisciplinary team accepted 89.6% of deprescribing recommendations, resulting in a reduction of the medication burden by 501 medications (P < 0.001). 12.8% of deprescriptions addressed clinically manifested adverse drug effects in 15.1% of patients. The estimation of life expectancy by the senior oncologist was reasonably accurate, but did not affect deprescribing rate.

CONCLUSIONS

A clinical pharmacist-led deprescribing intervention within a multidisciplinary team effectively reduces medication burden and addresses adverse drug effects in cancer patients. Deprescribing interventions should be incorporated in cancer patients at any stage of the disease.

Adverse drug reactions and drug-related problems with supportive care medications among the oncological population

AIM

The current study emphasizes the impact of adverse drug reactions (ADRs) and Drug-Related Problems (DRPs) caused by supportive care medications administered with chemotherapy.

METHOD

This is a longitudinal observational study carried out at the Ramaiah Medical College Hospital in Bengaluru, Karnataka, India, at the Department of Oncology. The data was recorded using a specifically created data collecting form. Based on the PCNE (Pharmaceutical Care Network Europe), DRPs are identified. The WHO probability scale, Modified Hartwig and Siegel for ADR severity assessment, Naranjo's algorithm for causality assessment, Rawlins and Thompson for predictability assessment, and Modified Shumock and Thornton for preventability assessment were all utilized. The OncPal guideline was considered in terms of the precision of supportive care medications regarding the reduction of ADRs in cancer patients.

RESULT

We enrolled 302 patients,166 (55%) female and 136 (45%) male (SD 14.378) (mean 49.97), patients with one comorbidity 59(19.6%) and multimorbidity (two or more) 45(14.9%), the DRPs identified were found to be 153 (50.6%); only P2 (safeties of drug therapy PCNE) were considered in this study. ADRs which are identified 175(57.9%) contributed/caused by the supportive care medications. WHO probability scale: 97 (32.1%) possible and 60 (19.9%) unlikely; Naranjo's algorithm: 97 (32.1%) unlikely and 69 (22.8%) possible; ADR severity assessment scale (Modified Hartwig and Siegel): 95 (31.5%) mild and 63 (20.9%) moderates; Rawlins and Thompson for determining predictability of an ADR: 33 (10.9%) predictable and 137 (45.5%) non-predictable; and Modified Shumock and Thornton for determining preventability of an ADR: 81 (26.8%) probably preventable and 90 (29.8%) non-preventable. The statistical comparison through preforming t-test and measuring Chi-Square between group with ADRs and without ADRs shows in some variables, significantly (Alcohol consumption status, P = .019) and Easter Cooperative Oncology Group (ECOG) performance status P < 0.001.

CONCLUSION

Comprehensive assessment of supportive medications in cancer patients would enhance the patient management and therapeutic outcome. The potential adverse drug reactions (ADRs) caused by supportive care medications can contribute to longer hospital stays and interact with the systemic anti-cancer treatment. The health care professionals should be informed to monitor the patients clinically administered with supportive medications.

Polypharmacy and Potentially Inappropriate Medications in Patients With Advanced Cancer: Prevalence and Associated Factors at the End of Life

Background: Polypharmacy and potentially inappropriate medications (PIMs) impose a burden on patients with advanced cancer near the end of their lives. However, only a few studies have addressed factors associated with PIMs in such patients. Objective: To examine polypharmacy and factors associated with PIMs in end-of-life patients with advanced cancer. Design: Retrospective chart review. Setting/Subjects: We analyzed 265 patients with advanced cancer who died in a palliative care unit (PCU) or at home in a home medical care (HMC) from April 2018 to December 2022 in Japan. Measurements: Sociodemographic, clinical, and prescription data at the time of PCU admission or HMC initiation were collected from electronic medical records. PIMs were assessed using OncPal Deprescribing Guidelines. Results: Patients with advanced cancer with an average age of 76.3 years and median survival days of 20 were included in the analyses. The average number of medications was 6.4 (standard deviation = 3.4), and PIMs were prescribed to 50.2%. Frequent PIMs included antihypertensive medications, peptic ulcer prophylaxis, and dyslipidemia medications. A multivariate logistic regression analysis revealed that age ≥75 years (adjusted odds ratio [aOR] = 2.30, 95% confidence interval [CI] = 1.30-4.05), referral from an outpatient setting compared with inpatient setting (aOR = 2.06, 95% CI = 1.12-3.80), more than two comorbidities (aOR = 1.88, 95% CI = 1.08-3.29), and more than five medications (aOR = 1.84, 95% CI = 1.03-3.28) were associated with PIMs. Conclusions: Medication reconciliation is recommended at the time of transition to a PCU or HMC, especially for older patients with advanced cancer who were referred from an outpatient setting and present more comorbidities and prescriptions.

Appropriate use of medication among home care adult cancer patients at end of life: a retrospective observational study

BACKGROUND

Medications are commonly used for symptom control in cancer patients at the end of life. This study aimed to evaluate medication utilization among home care palliative patients with cancer at the end of life and assess the appropriateness of these medications.

METHOD

This retrospective observational study included adult cancer patients who received home care in 2020. Medications taken during the last month of the patient's life were reviewed and classified into three major categories: potentially avoidable, defined as medications that usually have no place at the end of life because the time to benefit is shorter than life expectancy; medications of uncertain appropriateness, defined as medications that need case-by-case evaluation because they could have a role at the end of life; and potentially appropriate, defined as medications that provide symptomatic relief.

RESULTS

In our study, we enrolled 353 patients, and 2707 medications were analyzed for appropriateness. Among those, 1712 (63.2%) were classified as potentially appropriate, 755 (27.9%) as potentially avoidable, and 240 (8.9%) as medications with uncertain appropriateness. The most common potentially avoidable medications were medications for peptic ulcers and gastroesophageal reflux disease (30.5%), vitamins (14.6%), beta-blockers (9.8%), anticoagulants (7.9%), oral antidiabetics (5.4%) and insulin products (5.3%). Among the potentially appropriate medications, opioid analgesics were the most frequently utilized medications (19.5%), followed by laxatives (19%), nonopioid analgesics (14.4%), gamma-aminobutyric acid analog analgesics (7.7%) and systemic corticosteroids (6%).

CONCLUSION

In home care cancer patients, approximately one-third of prescribed medications were considered potentially avoidable. Future measures to optimize medication use in this patient population are essential.

Statin use in older adults with cancer - Experience from a dedicated geriatric oncology service

INTRODUCTION

The increase in statin use, since their introduction, has been rapid and the broadening of indications has occurred seemingly without restriction. Once established on statin therapy, there is sparse research on discontinuation. Trials do not often address benefit in later life, or the impact of a life-limiting diagnosis. Data on primary prevention suggest that 100 patients need treatment for 2.5 years to prevent one major adverse cardiovascular event. Acknowledging this, we sought to determine the use of statins in a cohort of older adults with cancer, to highlight prevalence, and suggest a role for deprescribing.

MATERIALS AND METHODS

Data were retrospectively collected from a prospectively maintained database of patients attending a single centre Geriatric Oncology clinic. Data collected included sex, age, cancer type and stage, systemic anti-cancer therapy (SACT) recommendation, comorbidities, non-SACT medications, and overall survival. For those receiving statin therapy, data were separated into primary prevention and stage IV cancer.

RESULTS

In the group studied (n = 230), 135 (59%) were prescribed a statin, with 79 (58%) for primary prevention. Ninety-three (40%) had stage IV cancer. Of the 230 patients, 134 (58%) were recommended SACT. Within the primary prevention group, the median age was 79 years. Twenty-seven patients (34%) had stage III disease, while 36 (46%) had stage IV disease. Thirteen (16%) had diabetes mellitus. The median number of medications was seven (Interquartile range 5). Fifty patients (63%) were recommended SACT. In terms of survival, 31 (50%) were alive at one year, 18 (29%) alive at two years, and 14 (23%) alive beyond two and a half years. Within the stage IV disease group, 59 out of 93 (63%) were receiving statin therapy; 35 (59%) for primary prevention and seven (8%) for diabetes mellitus. Fifty-eight (63%) were recommended SACT. Twenty-four (29%) were alive at one year, 17 (21%) alive at two years, and 13 (16%) alive beyond two and a half years.

DISCUSSION

Statin therapy is prevalent and continues into older age. Available data regarding statin therapy in older adults and survival seen in this study support deprescribing in primary prevention and life-limiting illness, such as stage IV cancer.

Medication review and deprescribing in different healthcare settings: a position statement from an Italian scientific consortium

Recent medical advancements have increased life expectancy, leading to a surge in patients affected by multiple chronic diseases and consequent polypharmacy, especially among older adults. This scenario increases the risk of drug interactions and adverse drug reactions, highlighting the need for medication review and deprescribing to reduce inappropriate medications and optimize therapeutic regimens, with the ultimate goal to improving patients' health and quality of life. This position statement from the Italian Scientific Consortium on medication review and deprescribing aims to describe key elements, strategies, tools, timing, and healthcare professionals to be involved, for the implementation of medication review and deprescribing in different healthcare settings (i.e., primary care, hospital, long-term care facilities, and palliative care). Challenges and potential solutions for the implementation of medication review and deprescribing are also discussed.

Decreasing polypharmacy in older adults with cancer: A pilot cluster-randomized trial protocol

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.

Validated medication deprescribing instruments for patients with palliative care needs palliative care: A systematic review

OBJECTIVES

Patients with life-limiting illnesses are prone to unnecessary polypharmacy. Deprescribing tools may contribute to minimizing negative outcomes. Thus, the aims of the study were to identify validated instruments for deprescribing inappropriate medications for patients with palliative care needs and to assess the impact on clinical, humanistic, and economic outcomes.

METHODS

A systematic review was conducted in LILACS, PUBMED, EMBASE, COCHRANE, and WEB OF SCIENCE databases (until May 2021). A manual search was performed in the references of enrolled articles. The screening, eligibility, extraction, and bias risk assessment were carried out by two independent researchers. Experimental and observational studies were eligible for inclusion.

RESULTS

Out of the 5,791 studies retrieved, after excluding duplicates (n = 1,050), conducting title/abstract screening (n = 4,741), and full reading (n = 41), only one study met the inclusion criteria. In this included study, a randomized controlled trial was conducted, which showed a high level of bias risk overall. Adults 75 years or older (n = 130) with limited life expectancy and polypharmacy were allocated to two groups [intervention arm (deprescribing); and control arm (usual care)]. Deprescribing was performed with the aid of the STOPPFrail tool. The mean number of inappropriate medications and monthly medication costs were significantly lower in the intervention arm. No statistically significant differences were found in terms of unscheduled hospital presentations, falls, fractures, mortality, and quality of life.

CONCLUSIONS

Despite the availability of several instruments to support deprescribing in patients with palliative care needs, only one of them has undergone validation and robust assessment for effectiveness in clinical practice. The STOPPFrail tool appears to reduce the number of inappropriate medications for older people with limited life expectancy (and probably palliative care needs) and decrease the monthly costs of pharmacotherapy. Nevertheless, the impact on patient safety and humanistic outcomes remain unclear.

Validated medication deprescribing instruments for patients with palliative care needs: a systematic review

OBJECTIVES

Patients with life-limiting illnesses are prone to unnecessary polypharmacy. Deprescribing tools may contribute to minimizing negative outcomes. Thus, the aims of the study were to identify validated instruments for deprescribing inappropriate medications for patients with palliative care needs and to assess the impact on clinical, humanistic, and economic outcomes.

METHODS

A systematic review was conducted in LILACS, PUBMED, EMBASE, COCHRANE, and WEB OF SCIENCE databases (until May 2021). A manual search was performed in the references of enrolled articles. The screening, eligibility, extraction, and bias risk assessment were carried out by 2 independent researchers. Experimental and observational studies were eligible for inclusion.

RESULTS

Out of the 5791 studies retrieved, after excluding duplicates (n = 1050), conducting title/abstract screening (n = 4741), and full reading (n = 41), only 1 study met the inclusion criteria. In this included study, a randomized controlled trial was conducted, which showed a high level of bias risk overall. Adults 75 years or older (n = 130) with limited life expectancy and polypharmacy were allocated to 2 groups [intervention arm (deprescribing); and control arm (usual care)]. Deprescribing was performed with the aid of the STOPPFrail tool. The mean number of inappropriate medications and monthly medication costs were significantly lower in the intervention arm. No statistically significant differences were found in terms of unscheduled hospital presentations, falls, fractures, mortality, and quality of life.

CONCLUSIONS

Despite the availability of several instruments to support deprescribing in patients with palliative care needs, only 1 of them has undergone validation and robust assessment for effectiveness in clinical practice. The STOPPFrail tool appears to reduce the number of inappropriate medications for older people with limited life expectancy (and probably palliative care needs) and decrease the monthly costs of pharmacotherapy. Nevertheless, the impact on patient safety and humanistic outcomes remain unclear.

A Tool for Deprescribing Antithrombotic Medication in Palliative Cancer Patients: A Retrospective Evaluation

Treating palliative cancer patients with antithrombotics is challenging because of the higher risk for both venous thromboembolism and major bleeding. There is a lack of available guidelines on deprescribing potentially inappropriate antithrombotics. We have therefore created an antithrombotics scheme to aid in (de)prescribing antithrombotics. A retrospective single-center clinical cohort observational study was performed to evaluate it. Patients with solid tumors with a life expectancy of less than 3 months seen by the palliative team were included. Comparisons were made between patients who were treated according to the antithrombotics scheme and those who were not. 47.6% of patients used antithrombotics. One hundred and eleven patients were included for analysis. Most patients used antithrombotics according to the scheme (n = 80, 72.1%). Eleven patients experienced a clinical event, seven patients in the scheme adherence group (9.9%) and four in the no scheme adherence group (13.8%), which was not statistically significant (p = 0.726). The higher frequency of clinical events in the group without scheme adherence suggests that (de)prescribing antithrombotics according to the antithrombotics scheme is safe. The results of this study suggest that the antithrombotics scheme could aid healthcare professionals identifying possible inappropriate antithrombotics in palliative cancer patients. Further prospective research is needed to investigate this tool.

Antidepressant deprescribing: State of the art and recommendations-A literature overview

INTRODUCTION

In recent years, the consumption of antidepressants has arisen. However, deprescribing antidepressant therapy is very complicated. The aim of this study was to implement practical recommendations for the development of guidelines to be used for antidepressant deprescription in clinical practice.

MATERIALS AND METHODS

The literature search has been conducted on March 13, 2023, using Scopus and PubMed databases. The following search string has been used: "antidepressants AND (deprescribing OR deprescription)". All studies reporting a deprescribing intervention for antidepressant medication, regardless of the study design, have been included. Studies that did not report antidepressant drug deprescription interventions and non-English-language papers have been excluded.

RESULTS

From the literature search, a total of 230 articles have been extracted. Applying the exclusion criteria, 26 articles have been considered eligible. Most of the analyzed studies (16, 61%) have been carried out in the real world, 3 (11%) were RCTs, 5 (19%) were qualitative studies, in particular expert opinions, 1 (4%) was a literature review, and 1 (4%) was a post-trial observational follow-up of an RCT. In 8 out of 26 studies (31%), the analyzed antidepressants have been specified: 2 (8%) focused on anticholinergics, 2 (8%) on SSRIs, 3 (11%) on tricyclic antidepressants, and 1 (4%) on esketamine. Nineteen out of 26 studies (73%) did not stratify antidepressants by therapeutic class. The sample sizes analyzed in the studies ranged from a minimum of 4 patients to a maximum of 113,909, and 12 studies included geriatric age as an inclusion criterion. A patient's therapy review has been the main deprescribing intervention, and it has been identified in 14 (54%) articles. Interventions have been carried out by clinicians in 4 (15%) studies, general practitioners in 5 (19%) studies, nurses in 2 (8%) studies, pharmacists in 4 (15%) studies, multidisciplinary teams in 10 (38%) studies, and patients in 1 (4%) study.

CONCLUSIONS

From the literature review, it emerged that there is no clear evidence useful to support clinicians in antidepressant deprescribing interventions.

Non-steroidal anti-inflammatory drugs for pain in hospice/palliative care: an international pharmacovigilance study

OBJECTIVES

To describe the current, real-world use of non-steroidal anti-inflammatory drugs for pain and the associated benefits and harms.

METHODS

A prospective, multicentre, consecutive cohort pharmacovigilance study conducted at 14 sites across Australia, Aotearoa/New Zealand and the UK including hospital, hospice inpatient and outpatient services. Pain scores and harms were graded using the National Cancer Institute Common Terminology Criteria for Adverse Events at baseline, 2 days and 14 days. Ad-hoc safety reporting continued until day 28.

RESULTS

Data were collected from 92 patients between March 2018 and October 2021. Most patients had cancer (91%) and were coprescribed opioids (90%). At 14 days, 83% of patients had benefit from non-steroidal anti-inflammatory drugs and 22% had harm. The most common harms were nausea (8%), vomiting (3%), acute kidney injury (3%) and non-gastrointestinal bleeding (3%); only 2% were severe and no patients ceased their non-steroidal anti-inflammatory drugs due to toxicity. Overall, 65% had benefit without harm and 3% had harm without benefit.

CONCLUSIONS

Most patients benefited from non-steroidal anti-inflammatory drugs with only one in five patients experiencing tolerable harm. This suggests that short-term use of non-steroidal anti-inflammatory drugs in patients receiving palliative care is safer than previously thought and may be underused.

Appropriate medication use in Dutch terminal care: study protocol of a multicentre stepped-wedge cluster randomized controlled trial (the AMUSE study)

BACKGROUND

Polypharmacy is common among patients with a limited life expectancy, even shortly before death. This is partly inevitable, because these patients often have multiple symptoms which need to be alleviated. However, the use of potentially inappropriate medications (PIMs) in these patients is also common. Although patients and relatives are often willing to deprescribe medication, physicians are sometimes reluctant due to the lack of evidence on appropriate medication management for patients in the last phase of life. The aim of the AMUSE study is to investigate whether the use of CDSS-OPTIMED, a software program that gives weekly personalized medication recommendations to attending physicians of patients with a limited life expectancy, improves patients' quality of life.

METHODS

A multicentre stepped-wedge cluster randomized controlled trial will be conducted among patients with a life expectancy of three months or less. The stepped-wedge cluster design, where the clusters are the different study sites, involves sequential crossover of clusters from control to intervention until all clusters are exposed. In total, seven sites (4 hospitals, 2 general practices and 1 hospice from the Netherlands) will participate in this study. During the control period, patients will receive 'care as usual'. During the intervention period, CDSS-OPTIMED will be activated. CDSS-OPTIMED is a validated software program that analyses the use of medication based on a specific set of clinical rules for patients with a limited life expectancy. The software program will provide the attending physicians with weekly personalized medication recommendations. The primary outcome of this study is patients' quality of life two weeks after baseline assessment as measured by the EORTC QLQ-C15-PAL questionnaire, quality of life question.

DISCUSSION

This will be the first study investigating the effect of weekly personalized medication recommendations to attending physicians on the quality of life of patients with a limited life expectancy. We hypothesize that the CDSS-OPTIMED intervention could lead to improved quality of life in patients with a life expectancy of three months or less.

TRIAL REGISTRATION

This trial is registered at ClinicalTrials.gov (NCT05351281, Registration Date: April 11, 2022).

Prescribing and deprescribing in older people with life-limiting illnesses receiving hospice care at the end of life: A longitudinal, retrospective cohort study

BACKGROUND

Although prescribing and deprescribing practices in older people have been the subject of much research generally, there are limited data in older people at the end of life. This highlights the need for research to determine prescribing and deprescribing patterns, as a first step to facilitate guideline development for medicines optimisation in this vulnerable population.

AIMS

To examine prescribing and deprescribing patterns in older people at the end of life and to determine the prevalence of potentially inappropriate medication use.

DESIGN

A longitudinal, retrospective cohort study where medical records of eligible participants were reviewed, and data extracted. Medication appropriateness was assessed using two sets of consensus-based criteria; the STOPPFrail criteria and criteria developed by Morin et al.

SETTING/PARTICIPANTS

Decedents aged 65 years and older admitted continuously for at least 14 days before death to three inpatient hospice units across Northern Ireland, who died between 1st January and 31st December 2018, and who had a known diagnosis, known cause of death and prescription data. Unexpected/sudden deaths were excluded.

RESULTS

Polypharmacy was reported to be continued until death in 96.2% of 106 decedents (mean age of 75.6 years). Most patients received at least one potentially inappropriate medication at the end of life according to the STOPPFrail and the criteria developed by Morin et al. (57.5 and 69.8% respectively). Limited prevalence of proactive deprescribing interventions was observed.

CONCLUSIONS

In the absence of systematic rationalisation of drug treatments, a substantial proportion of older patients continued to receive potentially inappropriate medication until death.

The potential for deprescribing in a palliative oncology patient population: a cross-sectional study

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.

The role of pharmacists in deprescribing benzodiazepines: A scoping review

Background

Polypharmacy can increase the risk of adverse drug events, hospitalisation, and unnecessary healthcare costs. Evidence indicates that discontinuing certain medications, such as benzodiazepines, can improve health outcomes, by resolving adverse drug effects. This scoping review aims to explore the pharmacists' role in deprescribing benzodiazepines.

Method

A scoping review has been conducted to distinguish and map the literature, discover research gaps, and focus on targeted areas for future studies and research. A systematic search strategy was conducted to identify relevant studies from PubMed, Medline, and EMBASE databases. The eligibility criteria involved studies that focused on the role of pharmacists in benzodiazepine deprescribing, quantitative and qualitative studies conducted in humans, full-text articles published in English.

Results

Twenty studies were identified, revealing three themes: 1) pharmacists' involvement in benzodiazepine deprescribing, 2) the impact of their involvement, and 3) obstacles impeding the process. Pharmacists involved in deprescribing procedures, mainly through completing medication reviews, collaborative work with other healthcare providers, and education. Pharmacists' involvement in benzodiazepine deprescribing intervention led to better health and economic outcomes. Withdrawal symptoms after medication discontinuation, dependence on medication, and lack of time and guidelines were identified in the literature as barriers to deprescribing.

Conclusion

Pharmacists' involvement in deprescribing benzodiazepines is crucial for optimizing medication therapy. This scoping review examines the pharmacists' role in benzodiazepine deprescribing. The findings contribute to enhancing healthcare outcomes and guiding future research in this area.

Rationalizing prescription via deprescribing in oncology practice

OBJECTIVE

To provide an integrated approach for deprescribing practice in oncology setting.

DATA SOURCES

The data on deprescribing in oncology settings has been retrieved from the PubMed, Scopus and Google Scholar. We used "deprescribing," "potentially inappropriate medication" and "cancer" as a keyword for the conducting general search. The articles relevant to guidelines or tools used to deprescribe in cancer care were included.

DATA SUMMARY

The nature of cancer, its treatment strategies, adverse effects of therapy and multimorbidity impact negatively on quality of life (QoL). Further, they invite polypharmacy which puts the patient at higher risk of drug-related problems like drug interactions, adverse drug reactions and addition of potentially improper medications, etc. In older adults with cancer, the incidence of potentially inappropriate medications (PIMs) was between 41% and 52%. Over the decades, multiple strategies have been developed to assess the appropriateness of therapy. One such approach is deprescribing. OncPal and oncoSTRIP (Systematic Tool to Reduce Inappropriate Prescribing) are the cancer specific guidelines whereas BEERs criteria, Screening Tool to Alert to Right Treatment/Screening Tool of Older Person's Prescriptions criteria (START/STOPP criteria), medication appropriateness index (MAI) are the cancer nonspecific tools to identify PIM among cancer patients. Here, we provided an integrative approach and algorithm for deprescribing in oncology setting which includes patient and caregiver goals, life expectancy (LE), review of medications, determining medication appropriateness, assessment of time to benefit (TTB), symptomatic and asymptomatic care, identifying medications to cease, implementation of the plan, monitoring and reviewing.

CONCLUSION

Deprescribing in oncology setting is a novel and effective patient-centric approach to counteract the use of PIM, which helps to mitigate polypharmacy, drug-drug interactions, and adverse effects.

Deprescribing: A Prime Opportunity to Optimize Care of Cancer Patients

Patients with incurable cancers have an increasing number of comorbidities, which can lead to polypharmacy and its associated adverse events (drug-to-drug interaction, prescription of a potentially inappropriate medication, adverse drug event). Deprescribing is a patient-centered process aimed at optimizing patient outcomes by discontinuing medication(s) deemed no longer necessary or potentially inappropriate. Improved patient quality of life, risk reduction of side effects or worse clinical outcomes, and a decrease in healthcare costs are well-documented benefits of deprescribing. Deprescribing and advance care planning both require consideration of patients' values, preferences, and care goals. Here, we provide an overview of comorbidities and associated polypharmacy risks in cancer patients, as well as useful tools and resources for deprescribing in daily practice, and we shed light on how deprescribing can facilitate advance care planning discussions with patients who have advanced cancer or a limited life expectancy.

Medication optimization in older adults with advanced cancer and a limited life expectancy: A prospective observational study

INTRODUCTION

Polypharmacy is common in older adults with cancer and is associated with drug related problems (DRPs) and potentially inappropriate medication (PIM). We introduced a medication optimization care pathway for older adults with advanced cancer and a limited life expectancy and studied the prevalence of DRPs and PIMs as well as the adherence to medication-related recommendations and the patient satisfaction.

MATERIALS AND METHODS

A medication review was performed in patients aged ≥65 years with polypharmacy and a life expectancy of <24 months. Recommendations on adjustments of medication were discussed in a multidisciplinary team including a pharmacist, an oncologist, and a geriatrician. Implementation of the recommendations was left to the discretion of the oncologist. Four weeks after the implementation, the patient filled a questionnaire to assess satisfaction.

RESULTS

One hundred twenty patients were included. The mean age was 75 years and 39% were female. A mean of 12 medications was used. The median number of DRP was 6.0 per patient and median number of PIMs was 3.0 per patient. Overtreatment accounted for 26% of DRP and the most frequently involved drug classes were antihypertensive medication (22%), non-opioid analgesics (22%), and antilipemics (12%). The multidisciplinary team accepted 78% of the recommendations of the pharmacist and the oncologist implemented 54% of the recommendations. Overall, patients were satisfied or very satisfied with the intervention.

DISCUSSION

DRPs and PIMs are highly prevalent in this population and can be reduced by a multidisciplinary medication optimization intervention. Patients appreciate the medication optimization intervention and are satisfied with the intervention.

Emotional barriers and facilitators of deprescribing for older adults with cancer and polypharmacy: a qualitative study

PURPOSE

To describe emotional barriers and facilitators to deprescribing (the planned reduction or discontinuation of medications) in older adults with cancer and polypharmacy.

METHODS

Virtual focus groups were conducted over Zoom with 5 key informant groups: oncologists, oncology nurses, primary care physicians, pharmacists, and patients. All groups were video- and audio-recorded and transcribed verbatim. Focus group transcripts were analyzed using inductive content analysis, and open coding was performed by two coders. A codebook was generated based on the initial round of open coding and updated throughout the analytic process. Codes and themes were discussed for each transcript until consensus was reached. Emotion coding (identifying text segments expressing emotion, naming the emotion, and assigning a label of positive or negative) was performed by both coders to validate the open coding findings.

RESULTS

All groups agreed that polypharmacy is a significant problem. For clinicians, emotional barriers to deprescribing include fear of moral judgment from patients and colleagues, frustration toward patients, and feelings of incompetence. Oncologists and patients expressed ambivalence about deprescribing due to role expectations that physicians "heal with med[ication]s." Emotional facilitators of deprescribing included the involvement of pharmacists, who were perceived to be neutral, discerning experts. Pharmacists described emotionally aware communication strategies when discussing deprescribing with other clinicians and expressed increased awareness of patient context.

CONCLUSION

Deprescribing can elicit strong and predominantly negative emotions among clinicians and patients which could inhibit deprescribing interventions. The involvement of pharmacists in deprescribing interventions could mitigate these emotional barriers.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05046171 . Date of registration: September 16, 2021.

Better drug use in advanced disease: an international Delphi study

Patients with a limited life expectancy use many medications, some of which may be questionable. OBJECTIVES : To identify possible solutions for difficulties concerning medication management and formulate recommendations to improve medication management at the end of life. METHODS : A two-round Delphi study with experts in the field of medication management and end-of-life care (based on ranking in the citation index in Web of Science and relevant publications). We developed a questionnaire with 58 possible solutions for problems regarding medication management at the end of life that were identified in previously performed studies. RESULTS : A total of 42 experts from 13 countries participated. Response rate in the first round was 93%, mean agreement between experts for all solutions was 87 % (range 62%-100%); additional suggestions were given by 51%. The response rate in the second round was 74%. Awareness, education and timely communication about medication management came forward as top priorities for guidelines. In addition, solutions considered crucial by many of the experts were development of a list of inappropriate medications at the end of life and incorporation of recommendations for end-of-life medication management in disease-specific guidelines. CONCLUSIONS : In this international Delphi study, experts reached a high level of consensus on recommendations to improve medication management in end-of-life care. These findings may contribute to the development of clinical practice guidelines for medication management in end-of-life care.

TOP-PIC: a new tool to optimize pharmacotherapy and reduce polypharmacy in patients with incurable cancer

PURPOSE

Polypharmacy is a significant problem in patients with incurable cancer and a method to optimize pharmacotherapy in this patient group is lacking. Therefore, a drug optimization tool was developed and tested in a pilot test.

METHODS

A multidisciplinary team of health professionals developed a "Tool to Optimize Pharmacotherapy in Patients with Incurable Cancer" (TOP-PIC) for patients with a limited life expectancy. The tool consists of five sequential steps to optimize medications, including medication history, screening for medication appropriateness and drug interactions, a benefit-risk assessment using the TOP-PIC Disease-based list, and shared decision-making with the patient. For pilot testing of the tool, 8 patient cases with polypharmacy were analyzed by 11 oncologists before and after training with the TOP-PIC tool.

RESULTS

TOP-PIC was considered helpful by all oncologists during the pilot test. The median additional time required to administer the tool was 2 min per patient (P < 0.001). For 17.4% of all medications, different decisions were made by using TOP-PIC. Among possible treatment decisions (discontinuation, reduction, increase, replacement, or addition of a drug), discontinuation of medications was the most common. Without TOP-PIC, physicians were uncertain in 9.3% of medication changes, compared with only 4.8% after using TOP-PIC (P = 0.001). The TOP-PIC Disease-based list was considered helpful by 94.5% of oncologists.

CONCLUSIONS

TOP-PIC provides a detailed, disease-based benefit-risk assessment with recommendations specific for cancer patients with limited life expectancy. Based on the results of the pilot study, the tool seems practicable for day-to-day clinical decision-making and provides evidence-based facts to optimize pharmacotherapy.

Towards optimal use of antithrombotic therapy of people with cancer at the end of life: A research protocol for the development and implementation of the SERENITY shared decision support tool

BACKGROUND

Even though antithrombotic therapy has probably little or even negative effects on the well-being of people with cancer during their last year of life, deprescribing antithrombotic therapy at the end of life is rare in practice. It is often continued until death, possibly resulting in excess bleeding, an increased disease burden and higher healthcare costs.

METHODS

The SERENITY consortium comprises researchers and clinicians from eight European countries with specialties in different clinical fields, epidemiology and psychology. SERENITY will use a comprehensive approach combining a realist review, flash mob research, epidemiological studies, and qualitative interviews. The results of these studies will be used in a Delphi process to reach a consensus on the optimal design of the shared decision support tool. Next, the shared decision support tool will be tested in a randomised controlled trial. A targeted implementation and dissemination plan will be developed to enable the use of the SERENITY tool across Europe, as well as its incorporation in clinical guidelines and policies. The entire project is funded by Horizon Europe.

RESULTS

SERENITY will develop an information-driven shared decision support tool that will facilitate treatment decisions regarding the appropriate use of antithrombotic therapy in people with cancer at the end of life.

CONCLUSIONS

We aim to develop an intervention that guides the appropriate use of antithrombotic therapy, prevents bleeding complications, and saves healthcare costs. Hopefully, usage of the tool leads to enhanced empowerment and improved quality of life and treatment satisfaction of people with advanced cancer and their care givers.

Increasing trend in hospitalisation due to adverse drug reactions: can we stem the tide?

Living with multiple long-term health conditions (multimorbidity) is increasingly common in older age. The more long-term conditions that an individual has, the more medicines they are likely to take. Hospitalisation as a consequence of medication-related harm is increasing and a concerted effort is needed to reduce the burden of harm caused by medication. However, making decisions about the balance between benefit and harm for an older person with multimorbidity and polypharmacy is very complex. There are various clinical tools that can help to identify patients at higher risk of harm and numerous strategies, including medicines optimisation reviews that incorporate personalised health information, to try to reduce risk. Further education and training of the healthcare professionals is needed to equip the multidisciplinary workforce with the skills and knowledge to address these challenges. This article discusses some of the changes that can be implemented now and highlights areas that will require more research before they can be introduced, in order to help patients to get the best out of their medicines.

Perspectives on deprescribing in palliative care

INTRODUCTION

Pharmacotherapy plays a critical role in the delivery of high-quality palliative care, but the intersection of palliative care and deprescribing has received little attention.

AREAS COVERED

We conducted a scoping review of English language articles using PubMed to identify relevant publications between 1 January 2000 to 31 July 2022 using search terms of deprescribing, palliative care, end of life, and hospice. We summarize current definitions and developments in palliative care and deprescribing from both clinical and research perspectives. We highlight key challenges and outline proposed solutions and needed research.

EXPERT OPINION

The future of deprescribing in palliative care requires the development and adoption of individualized approaches to medication management, including a reconsidered approach to communication about deprescribing. Evidence from high-quality clinical outcomes studies is lacking, and the field needs new approaches to coordination of care delivery. This review article will be of interest to both clinical and research-based pharmacists, physicians, and nurses interested in improving care for patients with serious illness.

Potentially inappropriate medication use based on two deprescribing criteria and related factors in patients with terminal cancer: A cross-sectional study

INTRODUCTION

We aimed to estimate the nationwide prevalence of potentially inappropriate medication (PIM) use in patients with terminal cancer according to two deprescribing criteria for patients with a limited lifespan.

MATERIALS AND METHODS

This cross-sectional study evaluated the prevalence of PIM use using two datasets: national claims data and single-tertiary hospital data. In the claims data, patients with terminal cancer were defined as patients with cancers who died between April and June 2018 and were prescribed opioid analgesics or megestrol or were hospitalized for >90 days before the date of death. Using hospital data, patients who were enrolled in hospice care in 2019 were identified. PIM was defined according to the adjusted criteria from the Screening Tool for Older Persons' Prescriptions in frail adults with limited life expectancy (STOPPFrail) versions 1 and 2 and oncological palliative care deprescribing guidelines (OncPal) guidelines.

RESULTS

From the national claims data and single-tertiary hospital data, 1,558 patients and 1,243 patients were included in the analysis, respectively. In both datasets, over 60% of patients used five or more medications (claims data: 67.7%; hospital data: 63.9%), and approximately half of them used at least one PIM (claims data: 51.5%; hospital data: 43.2%). Lipid-lowering agents, acid suppressors, and hypoglycemics were common PIMs. Polypharmacy, age, and comorbid conditions, including diabetes, were associated with PIM use.

DISCUSSION

Approximately two-thirds and half of the patients with terminal cancer were exposed to polypharmacy and at least one PIM based on the STOPPFrail and OncPal criteria, respectively; therefore, deprescribing PIM in patients with terminal cancer is an urgent issue.

Treatment patterns and out-of-hospital healthcare resource utilisation by patients with advanced cancer living with pain: An analysis from the Stop Cancer PAIN trial

BACKGROUND

About 70% of patients with advanced cancer experience pain. Few studies have investigated the use of healthcare in this population and the relationship between pain intensity and costs.

METHODS

Adults with advanced cancer and scored worst pain ≥ 2/10 on a numeric rating scale (NRS) were recruited from 6 Australian oncology/palliative care outpatient services to the Stop Cancer PAIN trial (08/15-06/19). Out-of-hospital, publicly funded services, prescriptions and costs were estimated for the three months before pain screening. Descriptive statistics summarize the clinico-demographic variables, health services and costs, treatments and pain scores. Relationships with costs were explored using Spearman correlations, Mann-Whitney U and Kruskal-Wallis tests, and a gamma log-link generalized linear model.

RESULTS

Overall, 212 participants had median worst pain scores of five (inter-quartile range 4). The most frequently prescribed medications were opioids (60.1%) and peptic ulcer/gastro-oesophageal reflux disease (GORD) drugs (51.6%). The total average healthcare cost in the three months before the census date was A$6,742 (95% CI $5,637, $7,847), approximately $27,000 annually. Men had higher mean healthcare costs than women, adjusting for age, cancer type and pain levels (men $7,872, women $4,493, p<0.01) and higher expenditure on prescriptions (men $5,559, women $2,034, p<0.01).

CONCLUSIONS

In this population with pain and cancer, there was no clear relationship between healthcare costs and pain severity. These treatment patterns requiring further exploration including the prevalence of peptic ulcer/GORD drugs, and lipid lowering agents and the higher healthcare costs for men.

TRIAL REGISTRATION

ACTRN12615000064505. World Health Organisation unique trial number U1111-1164-4649. Registered 23 January 2015.

National trends in osteoporosis medication use among Medicare beneficiaries with and without Alzheimer's disease/related dementias

BACKGROUND

Osteoporotic fractures  are a leading cause of disability and premature death in the elderly. Patients with Alzheimer's and related dementia (ADRD) have high rates of osteoporosis (OP) and substantial risk of osteoporotic fractures. Yet research is sparse on trends and predictors of OP medication use in ADRD.

METHODS

Medicare beneficiaries with OP aged ≥ 67 years have Medicare parts A/B/D without HMO from 2016 to 2018. Our outcome was receipt of OP medications in 2018. A multivariable logistic regression assessed association between ADRD and OP drug prescribing, adjusted for age, sex, race, region, Medicare entitlement, dual Medicaid eligibility, chronic conditions, number of provider visits/hospitalizations, and nursing home (NH) resident status. Age/ADRD and NH residency/ADRD interactions were tested.

RESULTS

Our sample consisted of 47,871 people with OP and ADRD and 201,840 with OP without ADRD. OP drug use was 38.6% in ADRD patients vs. 52.7% in non-ADRD. After adjustment for demographics, chronic conditions, and previous hospitalizations/physician visits, the OR for OP drug in ADRD vs. non-ADRD was 0.85 (95% CI: 0.83-0.87). NH residents had lower odds for OP medication (OR: 0.61, 95% CI: 0.58-0.64). There were significant interactions between ADRD and age, and between ADRD and NH residency. The OR for OP drug use associated with ADRD was 0.88 (95% CI: 0.86-0.90) among community-dwelling elders and 0.66 (95% CI: 0.64-0.69) among NH residents.

CONCLUSIONS

ADRD patients received OP drugs at a lower rate than their non-ADRD counterparts. More research is needed on when to prescribe or deprescribe OP drugs in the context of different ADRD severity, patient preferences, remaining life expectancy, and time-to-benefit from OP drugs.

Potentially inappropriate prescribing in older adults with cancer receiving specialist palliative care: a retrospective observational study

BACKGROUND

Older adults (≥ 65 years) with cancer receiving palliative care often have other health conditions requiring multiple medications.

AIM

To describe and assess the appropriateness of prescribing for older adults with cancer in the last seven days of life in an inpatient palliative care setting.

METHOD

Retrospective observational study of medical records for 180 patients (60.6% male; median age: 74 years; range 65-94 years) over a two-year period. Medication appropriateness was assessed using: STOPPFrail, OncPal deprescribing guideline and criteria for identifying Potentially Inappropriate Prescribing in older adults with Cancer receiving Palliative Care (PIP-CPC).

RESULTS

94.5% of patients had at least one other health condition (median 3, IQR 2-5). The median number of medications increased from five (IQR 3-7) seven days before death, to 11 medications on the day of death (IQR 9-15). The prevalence of PIP varied depending on the tool used: STOPPFrail (version 1: 17.2%, version 2: 19.4%), OncPal (12.8%), PIP-CPC (30%). However, the retrospective nature of the study limited the applicability of the tools. Increasing number of medications had a statistically significant effect on risk of PIP across all tools (STOPPFrail (version 1: 1.29 (1.13-1.37), version 2: 1.30 (1.16-1.48)); OncPal 1.13 (1.01-1.27); PIP-CPC 0.70 (0.61-0.82)).

CONCLUSION

This study found that the number of medications prescribed to older adults with cancer increased as time to death approached, and the prevalence of PIP varied with the application of different tools. The study also highlights the difficulties of examining PIP in this patient cohort.

Optimizing Medication Use in Older Adults With Rheumatic Musculoskeletal Diseases: Deprescribing as an Approach When Less May Be More

The world population is aging, and the rheumatology workforce must be prepared to care for medically complex older adults. We can learn from our colleagues and experts in geriatrics about how to best manage multimorbidity, polypharmacy, geriatric syndromes, and shifting priorities of older adults in the context of delivering care for rheumatic and musculoskeletal diseases (RMDs). Polypharmacy, a common occurrence in an aging population with multimorbidity, affects half of older adults with RMDs and is associated with increased risk of morbidity and mortality. In addition, potentially inappropriate medications that should be avoided under most circumstances is common in the RMD population. In recent years, deprescribing, known as the process of tapering, stopping, discontinuing, or withdrawing drugs, has been introduced as an approach to improve appropriate medication use among older adults and the outcomes that are important to them. As the rheumatology patient population ages globally, it is imperative to understand the burden of polypharmacy and the potential of deprescribing to improve medication use in older adults with RMDs. We encourage the rheumatology community to implement geriatric principles, when possible, as we move toward becoming an age-friendly health care specialty.

Deprescribing Interventions by Palliative Care Clinical Pharmacists Surrounding Goals of Care Discussions

Background: Palliative care (PC) pharmacists can play an important role in optimizing medications for patients with serious illnesses by aligning patients' goals with their treatment regimens. Objectives: The objectives of this study were to (1) quantify successful pharmacist deprescribing interventions incorporated in the hospital discharge plan and (2) describe deprescribing interventions by medication class, reason for discontinuation, and perception of patient/caregiver understanding and acceptance. Methods: This pilot study included 45 inpatient PC consultations and collected data on deprescribing interventions performed by PC clinical pharmacists in Maryland and Washington, D.C., U.S. Descriptive statistics were used to analyze outcomes. Results: Eighty-two percent of recommendations were successfully implemented during hospitalization and included in the discharge plan. Medication classes recommended for discontinuation included vitamins/supplements (20%), antidiabetics (13%), antiplatelets (10%), anticoagulants (10%), statins (10%), antihypertensives (7%), proton pump inhibitors/H2 blockers (7%), antibiotics (5%), dementia medications (1%), and antidepressants (1%). Top reasons for discontinuation included pill burden, unacceptable treatment burden, and potential harm outweighs potential benefit. Conclusions: Results of this study demonstrate PC pharmacists' deprescribing recommendations have a high rate of successful implementation by the primary inpatient care team.

Hospice Care Improves Patients' Self-Decision Making and Reduces Aggressiveness of End-of-Life Care for Advanced Cancer Patients

The aim of the current study is to evaluate the different degrees of hospice care in improving patients' autonomy in decision-making and reducing aggressiveness of cancer care in terminal-stage cancer patients, especially in reducing polypharmacy and excessive life-sustaining treatments. This was a retrospective cross-sectional study conducted in a single medical center in Taiwan. Patients with advanced cancer who died in 2010-2019 were included and classified into three subgroups: hospice ward admission, hospice shared care, and no hospice care involvement. In total, 8719 patients were enrolled, and 2097 (24.05%) admitted to hospice ward; 2107 (24.17%) received hospice shared care, and 4515 (51.78%) had no hospice care. Those admitted to hospice ward had significantly higher rates of having completed do-not-resuscitate order (100%, p < 0.001) and signed the do-not-resuscitate order by themselves (48.83%, p < 0.001), and they had lower aggressiveness of cancer care (2.2, p < 0.001) within the 28 days before death. Hospice ward admission, hospice shared care, and age > 79 years were negatively associated with aggressiveness of cancer care. In conclusion, our study showed that patients with end-of-life hospice care related to higher patient autonomy in decision-making and less excessively aggressive cancer care; the influence of care was more overt in patients approaching death. Further clinical efforts should be made to clarify the patient and the families' satisfaction and perceptions of quality after hospice care involvement.

Application of a person-centered prescription model improves pharmacotherapeutic indicators and reduces costs associated with pharmacological treatment in hospitalized older patients at the end of life

Objective

This study sought to investigate whether applying an adapted person-centered prescription (PCP) model reduces the total regular medications in older people admitted in a subacute hospital at the end of life (EOL), improving pharmacotherapeutic indicators and reducing the expense associated with pharmacological treatment.

Design

Randomized controlled trial. The trial was registered with ClinicalTrials.gov (NCT05454644).

Setting

A subacute hospital in Basque Country, Spain.

Subjects

Adults ≥65 years (n = 114) who were admitted to a geriatric convalescence unit and required palliative care.

Intervention

The adapted PCP model consisted of a systematic four-step process conducted by geriatricians and clinical pharmacists. Relative to the original model, this adapted model entails a protocol for the tools and assessments to be conducted on people identified as being at the EOL.

Measurements

After applying the adapted PCP model, the mean change in the number of regular drugs, STOPPFrail (Screening Tool of Older Persons' Prescriptions in Frail adults with limited life expectancy) criteria, drug burden index (DBI), drug-drug interactions, medication regimen complexity index (MRCI) and 28-days medication cost of chronic prescriptions between admission and discharge was analyzed. All patients were followed for 3 months after hospital discharge to measure the intervention's effectiveness over time on pharmacotherapeutic variables and the cost of chronic medical prescriptions.

Results

The number of regular prescribed medications at baseline was 9.0 ± 3.2 in the intervention group and 8.2 ± 3.5 in the control group. The mean change in the number of regular prescriptions at discharge was -1.74 in the intervention group and -0.07 in the control group (mean difference = 1.67 ± 0.57; p = 0.007). Applying a PCP model reduced all measured criteria compared with pre-admission (p < 0.05). At discharge, the mean change in 28-days medication cost was significantly lower in the intervention group compared with the control group (-34.91€ vs. -0.36€; p < 0.004).

Conclusion

Applying a PCP model improves pharmacotherapeutic indicators and reduces the costs associated with pharmacological treatment in hospitalized geriatric patients at the EOL, continuing for 3 months after hospital discharge. Future studies must investigate continuity in the transition between hospital care and primary care so that these new care models are offered transversally and not in isolation.

Prescription Trends in Hospice Care: A Longitudinal Retrospective and Descriptive Medication Analysis

BACKGROUND

In hospice and palliative care, drug therapy is essential for symptom control. However, drug regimens are complex and prone to drug-related problems. Drug regimens must be simplified to improve quality of life and reduce risks associated with drug-related problems, particularly at end-of-life. To support clinical guidance towards a safe and effective drug therapy in hospice care, it is important to understand prescription trends.

OBJECTIVES

To explore prescription trends and describe changes to drug regimens in inpatient hospice care.

DESIGN

We performed a retrospective longitudinal and descriptive analysis of prescriptions for regular and as-needed (PRN) medication at three timepoints in deceased patients of one Swiss hospice.

SETTING/SUBJECTS

Prescription records of all patients (≥ 18 years) with an inpatient stay of three days and longer (admission and time of death in 2020) were considered eligible for inclusion.

RESULTS

Prescription records of 58 inpatients (average age 71.7 ± 12.8 [37-95] years) were analyzed. The medication analysis showed that polypharmacy prevalence decreased from 74.1% at admission to 13.8% on the day of death. For regular medication, overall numbers of prescriptions decreased over the patient stay while PRN medication decreased after the first consultation by the attending physician and increased slightly towards death.

CONCLUSIONS

Prescription records at admission revealed high initial rates of polypharmacy that were reduced steadily until time of death. These findings emphasize the importance of deprescribing at end-of-life and suggest pursuing further research on the contribution of clinical guidance towards optimizing drug therapy and deprescribing in inpatient hospice care.

Identification and characterisation of deprescribing tools for older patients: A scoping review

BACKGROUND

Deprescription is the revision of the therapeutic plan with the aim of simplifying it, taking into account patient preferences, prognosis and environment. This strategy is particularly relevant in older patients, mostly polymedicated individuals, since they are exposed to numerous adverse effects and interactions and tend to have less adherence to treatments.

OBJECTIVE

To identify the deprescribing tools for older patients available in the scientific literature, classify them according to their design and describe their main features and potential applicability in clinical practice.

METHODS

A search was conducted in PubMed and EMBASE for relevant literature published before July 2021. The PRISMA-ScR method was applied, extracting variables related to study and tool characteristics as well as potential clinical applicability. The main inclusion criteria were studies focused on designing or developing deprescribing tools for older patients and those that indicated the features of the deprescribing tool used in detail.

RESULTS

Fourteen of 723 papers met the inclusion criteria, and 12 tools were identified: 6 "algorithm-based tools" and 6 "criterion-based tools". Though all tools are aimed at older patients, there are certain peculiarities regarding their design, population, application setting and variables included. Of the 6 criterion-based tools found, 4 used the Delphi method for their design and development. Furthermore, most of them agree on the pharmacological groups that are likely to be deprescribed.

CONCLUSIONS

Taking into account the importance of the clinical situation and priorities in the care plan in the deprescribing process, the authors believe that tools which help to evaluate these aspects are the most suitable for application in clinical practice. However, it is necessary to continue studying applicability in real-life clinical scenarios and to obtain health results.

Prescription trends at the end of life in a palliative care unit: observational study

Background

Symptomatic control is essential in palliative care, particularly in end-of-life, in which the pathophysiological changes that characterize this last phase of life strengthen the need to carry out an early therapeutic review. Hence, we aim to evaluate the prescribing pattern at a palliative care unit at two different time points: on admission and the day of the patient’s death.

Methods

Quantitative, analytic, longitudinal, retrospective and observational study. Participants were adult patients who were admitted and died in a palliative care unit, in Portugal. Sociodemographic, clinical and pharmacological data were collected, including frequencies and routes of administration of schedule prescribed drugs and rescue drugs, from the day of admission until the day of death.

Results

115 patients were included with an average age of 70.0 ± 12.9 years old, 53.9 were male, mostly referred by the Hospital Palliative Care Support Teams. The most common pathology was cancer, mainly in advanced stage. On admission, the median scheduled prescription was seven and “as needed” was three drugs. On the day of death, a decrease of prescriptions was observed. Opioids were always the most prescribed drugs. Near death, there was a higher tendency to prescribe butylscopolamine, midazolam, diazepam and levomepromazine. The most frequent route of drug administration was oral on admission and subcutaneous on the day of death.

Conclusions

Polypharmacy is a reality in palliative care despite specialist palliative care teams. A reduction of prescribed drugs was verified, essentially due less comorbidity-oriented drugs. Further studies are required to analyse the importance of Hospital Palliative Care Support Teams.

Deprescribing in Palliative Cancer Care

The aim of palliative care is to maintain as high a quality of life (QoL) as possible despite a life-threatening illness. Thus, the prescribed medications need to be evaluated and the benefit of each treatment must be weighed against potential side effects. Medications that contribute to symptom relief and maintained QoL should be prioritized. However, studies have shown that treatment with preventive drugs that may not benefit the patient in end-of-life is generally deprescribed very late in the disease trajectory of cancer patients. Yet, knowing how and when to deprescribe drugs can be difficult. In addition, some drugs, such as beta-blockers, proton pump inhibitors, anti-depressants and cortisone need to be scaled down slowly to avoid troublesome withdrawal symptoms. In contrast, other medicines, such as statins, antihypertensives and vitamins, can be discontinued directly. The aim of this review is to give some advice according to when and how to deprescribe medications in palliative cancer care according to current evidence and clinical praxis. The review includes antihypertensive drugs, statins, anti-coagulants, aspirin, anti-diabetics, proton pump inhibitors, histamin-2-blockers, bisphosphonates denosumab, urologicals, anti-depressants, cortisone, thyroxin and vitamins.

Polypharmacy, Potentially Inappropriate Medications, and Drug-Drug Interactions in Vulnerable Older Adults With Advanced Cancer Initiating Cancer Treatment

PURPOSE

Polypharmacy is prevalent in older adults starting cancer treatment and associated with potentially inappropriate medications (PIM), potential drug-drug interactions (DDI), and drug-cancer treatment interactions (DCI). For a large cohort of vulnerable older adults with advanced cancer starting treatment, we describe patterns of prescription and nonprescription medication usage, the prevalence of PIM, and the prevalence, severity, and type of DDI/DCI.

METHODS

This secondary analysis used baseline data from a randomized study enrolling patients aged ≥70 years with advanced cancer starting a new systemic cancer treatment (University of Rochester Cancer Center [URCC] 13059; PI: Mohile). PIM were categorized using 2019 Beers criteria and Screening Tool of Older Persons' Prescriptions. Potential DDI/DCI were evaluated using Lexi-Interact Online. Medication classification followed the World Health Organization Anatomical Therapeutic Chemical system. Bivariate associations were evaluated between sociodemographic and geriatric assessment (GA) measures and medication measures. Chord diagrams and network analysis were used to understand and describe DDI/DCI.

RESULTS

Among 718 patients (mean age 77.6 years), polypharmacy (≥5 medications), excessive polypharmacy (≥10 medications), and ≥1 PIM were identified in 61.3%,14.5%, and 67.1%, respectively. Cardiovascular medications were the most prevalent (47%), and nonprescription medications accounted for 26% of total medications and 40% of PIM. One-quarter of patients had ≥1 potential major DDI not involving cancer treatment, and 5.4% had ≥1 potential major DCI. Each additional medication increased the odds of a potential major DDI and DCI by 39% and 12%, respectively. Polypharmacy and PIM are associated with multiple GA domains.

CONCLUSION

In a cohort of vulnerable older adults with advanced cancer starting treatment, polypharmacy, PIM, and potential DDI/DCI are very common. Nonprescription medications are frequently PIMs and/or involved in potential DDI/DCI.

Functional Decline in the Cancer Patient: A Review

A decline in functional status, an individual's ability to perform the normal activities required to maintain adequate health and meet basic needs, is part of normal ageing. Functional decline, however, appears to be accelerated in older patients with cancer. Such decline can occur as a result of a cancer itself, cancer treatment-related factors, or a combination of the two. The accelerated decline in function seen in older patients with cancer can be slowed, or even partly mitigated through routine assessments of functional status and timely interventions where appropriate. This is particularly important given the link between functional decline and impaired quality of life, increased mortality, comorbidity burden, and carer dependency. However, a routine assessment of and the use of interventions for functional decline do not typically feature in the long-term care of cancer survivors. This review outlines the link between cancer and subsequent functional decline, as well as potential underlying mechanisms, the tools that can be used to assess functional status, and strategies for its prevention and management in older patients with cancer.