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Volberg C, Corzilius J, Maul J, Morin A, Gschnell M. [Pain management in German specialized outpatient palliative care : A cross-sectional study to present the current pain management of palliative patients in the home environment]. Schmerz 2024; 38:317-327. [PMID: 36752874 PMCID: PMC11420377 DOI: 10.1007/s00482-023-00693-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 12/18/2022] [Accepted: 12/28/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND With the help of specialized outpatient palliative care teams (German abbreviation: SAPV), seriously ill and dying patients in Germany can be adequately cared for in their home environment until the end of their lives; however, there are no uniform standards or guidelines for well-executed pain management right now. OBJECTIVE This approach serves as basic research in the field of public health research. This is intended to present which methods (use of different professional groups, use of pain medications, alternative medical treatment etc.) the individual SAPV teams use for pain management. From this it can be deduced which procedures can be considered particularly effective. MATERIAL AND METHODS This cross-sectional study was conducted in May 2021. All German SAPV teams (n = 307) listed on the homepage of the German Association for Palliative Medicine (DGP) were contacted by post and invited to participate. A total of 175 teams (57%) responded to the request and were included in the evaluation. A descriptive data analysis was performed. RESULTS Pain management in the German outpatient care of palliative patients is based on several components. All common pain medications are used, but primarily metamizole (99.4%) as a non-opioid analgesic, morphine (98.3%) from the opiate series and pregabalin (96.6%) as a co-analgesic are mainly prescribed. If pain therapy fails, 22.5% of the SAPV teams perform palliative sedation for symptom control on a regular basis. CONCLUSION This cross-sectional study is the first of its kind to provide a general overview of the treatment options for pain management in German outpatient palliative care. In comparison with international studies, the question arises as to whether uniform therapy schemes and a reduction in the medication available in the individual SAPV teams could lead to an improvement in patient care.
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Affiliation(s)
- Christian Volberg
- Klinik für Anästhesie und Intensivtherapie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Marburg, Deutschland.
- AG Ethik in der Medizin, Fachbereich 20, Dekanat Humanmedizin, Philipps-Universität Marburg, Marburg, Deutschland.
| | - Julien Corzilius
- Klinik für Anästhesie und Intensivtherapie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Marburg, Deutschland
| | - Julian Maul
- Klinik für Anästhesie und Intensivtherapie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Marburg, Deutschland
| | - Astrid Morin
- Klinik für Anästhesie und Intensivtherapie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Marburg, Deutschland
| | - Martin Gschnell
- Klinik für Dermatologie und Allergologie, Hauttumorzentrum, Universitätsklinikum Marburg, Philipps-Universität Marburg, Marburg, Deutschland
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Mendis R, Wong A, Frenkel S, Southcott AM, Selman CJ, Martin J, Grobler A, Currow D, Agar M, Le B, Philip J. Temazepam or Melatonin Versus Placebo for the Treatment of Insomnia in Advanced Cancer: A Three-Arm, Double-Blind, Phase III, Multicenter, Randomized Clinical Trial. J Palliat Med 2024. [PMID: 39304187 DOI: 10.1089/jpm.2024.0151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2024] Open
Abstract
Background: Sleep disturbance has a prevalence of 30-78% in patients with advanced cancer. While pharmacotherapy is common, randomized controlled studies (RCTs) investigating available agents are limited. This study examines the efficacy and safety of temazepam or melatonin versus placebo for sleep in advanced cancer. Methods: This is a multicenter, randomized, double-blind, placebo-controlled study of temazepam, melatonin prolonged release (PR) or placebo for insomnia in patients with advanced cancer, and an insomnia severity index (ISI) score of >11. Results: Twenty-one participants were randomized: nine to temazepam, eight to melatonin, and four to placebo. Baseline characteristics between groups were similar. The adjusted mean difference in day 8 ISI score versus placebo was -9.1 (95% confidence interval [CI] -17.5, 0.7, p = 0.04) for temazepam and -9.6 (95% CI -18,-1.2, p = 0.03) for melatonin PR. There was no improvement in global quality of life. Both agents were well tolerated. Conclusion: Temazepam and melatonin PR were associated with a clinically significant improvement in patient-reported insomnia severity compared with placebo. Findings need confirmation with larger patient numbers.
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Affiliation(s)
- Ruwani Mendis
- Department of Cancer Services, Western Health, Melbourne, Australia, Honorary Fellow, The University of Melbourne, Melbourne, Australia
| | - Aaron Wong
- Peter MacCallum Cancer Centre, Melbourne, Australia, The Royal Melbourne Hospital Melbourne, Australia and The University of Melbourne, Melbourne, Australia
| | - Simon Frenkel
- Department of Respiratory and Sleep Disorders Medicine, Western Health, Melbourne, Australia
| | - Anne Marie Southcott
- Department of Respiratory and Sleep Disorders Medicine, Western Health, Melbourne, Australia
| | - Chris J Selman
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, Australia
| | - Jennifer Martin
- School of Medicine and Public Health, The University of Newcastle, NSW, Australia
| | - Anneke Grobler
- Murdoch Children's Research Institute, Melbourne, Australia and The Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - David Currow
- Graduate School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Australia
| | - Meera Agar
- Palliative Medicine, University of Technology Sydney (UTS), Sydney, Australia, Centre for Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Sydney, Australia and the Southwest Sydney Local Health District Palliative Care Service, Sydney, Australia
| | - Brian Le
- The Royal Melbourne Hospital, Melbourne, Australia, Peter MacCallum Cancer Centre, Melbourne, Australia, The University of Melbourne, Melbourne, Australia, University of Technology Sydney (UTS), Sydney, Australia and the Palliative Care Clinical Studies Collaborative, Sydney, Australia
| | - Jennifer Philip
- Palliative Medicine, Centre for Cancer Research, Faculty of Medicine, Dentistry and Health Sciences, St Vincent's Hospital and The University of Melbourne, Melbourne, Australia
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Xiao S, Yin H, Lv X, Wang Z, Jiang L, Xia Y, Liu Y. Inhibition of human UDP-glucuronosyltransferase (UGT) enzymes by darolutamide: Prediction of in vivo drug-drug interactions. Chem Biol Interact 2024; 403:111246. [PMID: 39278459 DOI: 10.1016/j.cbi.2024.111246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 09/02/2024] [Accepted: 09/12/2024] [Indexed: 09/18/2024]
Abstract
Darolutamide is a potent second-generation, selective nonsteroidal androgen receptor inhibitor (ARI), which has been approved by the US Food and Drug Administration (FDA) in treating castrate-resistant, non-metastatic prostate cancer (nmCRPC). Whether darolutamide affects the activity of UDP-glucuronosyltransferases (UGTs) is unknown. The purpose of the present study is to evaluate the inhibitory effect of darolutamide on recombinant human UGTs and pooled human liver microsomes (HLMs), and explore the potential for drug-drug interactions (DDIs) mediated by darolutamide through UGTs inhibition. The product formation rate of UGTs substrates with or without darolutamide was determined by HPLC or UPLC-MS/MS to estimate the inhibitory effect and inhibition modes of darolutamide on UGTs were evaluated by using the inhibition kinetics experiments. The results showed that 100 μM darolutamide exhibited inhibitory effects on most of the 12 UGTs tested. Inhibition kinetic studies of the enzyme revealed that darolutamide noncompetitively inhibited UGT1A1 and competitively inhibited UGT1A7 and 2B15, with the Ki of 14.75 ± 0.78 μM, 14.05 ± 0.42 μM, and 6.60 ± 0.08 μM, respectively. In particular, it also potently inhibited SN-38, the active metabolite of irinotecan, glucuronidation in HLMs with an IC50 value of 3.84 ± 0.46 μM. In addition, the in vitro-in vivo extrapolation (IVIVE) method was used to quantitatively predict the risk of darolutamide-mediated DDI via inhibiting UGTs. The prediction results showed that darolutamide may increase the risk of DDIs when administered in combination with substrates of UGT1A1, UGT1A7, or UGT2B15. Therefore, the combined administration of darolutamide and drugs metabolized by the above UGTs should be used with caution to avoid the occurrence of potential DDIs.
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Affiliation(s)
- Shichao Xiao
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin, 124221, China
| | - Hang Yin
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin, 124221, China
| | - Xin Lv
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin, 124221, China
| | - Zhen Wang
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin, 124221, China
| | - Lili Jiang
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin, 124221, China
| | - Yangliu Xia
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin, 124221, China.
| | - Yong Liu
- School of Chemical Engineering, Ocean and Life Sciences, Dalian University of Technology, Panjin, 124221, China.
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Aapro M, Fogli S, Morlion B, Danesi R. Opioid metabolism and drug-drug interaction in cancer. Oncologist 2024:oyae094. [PMID: 38780124 DOI: 10.1093/oncolo/oyae094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/11/2024] [Indexed: 05/25/2024] Open
Abstract
Concomitant use of multiple drugs in most patients with cancer may result in drug-drug interactions (DDIs), potentially causing serious adverse effects. These patients often experience unrelieved cancer-related pain (CRP) during and after cancer treatment, which can lead to a reduced quality of life. Opioids can be used as part of a multimodal pain management strategy when non-opioid analgesics are not providing adequate pain relief, not tolerated, or are contraindicated. However, due to their narrow therapeutic window, opioids are more susceptible to adverse events when a DDI occurs. Clinically relevant DDIs with opioids are usually pharmacokinetic, mainly occurring via metabolism by cytochrome P450 (CYP). This article aims to provide an overview of potential DDIs with opioids often used in the treatment of moderate-to-severe CRP and commonly used anticancer drugs such as chemotherapeutics, tyrosine kinase inhibitors (TKIs), or biologics. A DDI-checker tool was used to contextualize the tool-informed DDI assessment outcomes with clinical implications and practice. The findings were compared to observations from a literature search conducted in Embase and PubMed to identify clinical evidence for these potential DDIs. The limited results mainly included case studies and retrospective reviews. Some potential DDIs on the DDI-checker were aligned with literature findings, while others were contradictory. In conclusion, while DDI-checkers are useful tools in identifying potential DDIs, it is necessary to incorporate literature verification and comprehensive clinical assessment of the patient before implementing tool-informed decisions in clinical practice.
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Affiliation(s)
- Matti Aapro
- Genolier Cancer Centre, Clinique de Genolier, 1272 Genolier, Switzerland
| | - Stefano Fogli
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa PI, Italy
| | - Bart Morlion
- Department of Cardiovascular Sciences, Section Anesthesiology and Algology, University of Leuven, 3000 Leuven, Belgium
| | - Romano Danesi
- Department of Oncology and Hemato-Oncology, University of Milano, 20122 Milano MI, Italy
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Makihara K, Yamamoto Y, Miyazaki M, Taguchi M, Sato J, Takase H, Uezono Y. A Multicenter Retrospective Observational Study Analyzing the Effect of Polypharmacy on Oxycodone Tolerability. J Pain Palliat Care Pharmacother 2024; 38:3-12. [PMID: 38227839 DOI: 10.1080/15360288.2023.2301341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 12/28/2023] [Indexed: 01/18/2024]
Abstract
Polypharmacy is becoming increasingly troublesome in the treatment of cancer. The aim of this study was to explore the effects of concomitant polypharmacy comprising drugs that inhibit CYP3A4 and/or CYP2D6 on the oxycodone tolerability in patients with cancer. We conducted a multicenter retrospective study encompassing 20 hospitals. The data used for the study were obtained during the first 2 wk of oxycodone administration. The incidence of oxycodone discontinuation or dose reductions due to side effects and oxycodone-induced nausea and vomiting (OINV) were compared between patients not treated with either inhibitor and those treated with concomitant CYP3A4 or CYP2D6 inhibitors. The incidence of oxycodone discontinuation or dose reductions in patients treated with ≥3 concomitant CYP2D6 inhibitors (18.2%) tended to be higher than that in patients without this treatment (8.2%; p = 0.09). Moreover, the incidence of OINV in patients treated with 2 concomitant CYP3A4 inhibitors (29.8%) was significantly higher than that in patients without this treatment (15.5%; p = 0.049). Multivariate analysis showed that more than two concomitant CYP3A4 inhibitors and no concomitant use of naldemedine were independent risk factors for OINV. Concomitant polypharmacy involving CYP3A4 inhibitors increases the risk of OINV. Therefore, medications concomitantly used with oxycodone should be optimized.
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Affiliation(s)
- Katsuya Makihara
- Department of Pharmacy, Yodogawa Christian Hospital, Osaka, Japan
| | - Yoshihiro Yamamoto
- Departments of Pharmacy, Komaki City Hospital, Komaki City, Aichi, Japan
| | - Masayuki Miyazaki
- Department of Pharmacy, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Maho Taguchi
- Laboratory of Regulatory Sciences, Yokohama University of Pharmacy, Yokohama, Kanagawa, Japan
| | - Junya Sato
- Department of Pharmacy, International University of Health and Welfare Hospital, Nasushiobara City, Tochigi, Japan
| | - Hisamitsu Takase
- Nippon Medical School Tama-Nagayama Hospital, Tama, Tokyo, Japan
| | - Yasuhito Uezono
- Department of Pain Control Research, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
- Supportive and Palliative Care Research Support Office, National Center Hospital East, Kashiwa-City, Chiba, Japan
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McNeill R, Boland JW, Wilcock A, Sinnarajah A, Currow DC. Non-steroidal anti-inflammatory drugs for pain in hospice/palliative care: an international pharmacovigilance study. BMJ Support Palliat Care 2024; 13:e1249-e1257. [PMID: 36720587 DOI: 10.1136/spcare-2022-004154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 01/10/2023] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Richard McNeill
- Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
- Palliative Medicine, Care Plus Group and St Andrew's Hospice, UK
| | - Andrew Wilcock
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- Faculty of Medicine and Health Sciences, Nottingham University, Nottingham, UK
| | - Aynharan Sinnarajah
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
- Department of Medicine, Lakeridge Health, Oshawa, Ontario, Canada
| | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
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7
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Admane S, Clark M, Reddy A, Narayanan S, Bruera E. Safely Prescribing Opioids With Nirmatrelvir/Ritonavir - Case Report and Management Recommendations. J Pain Symptom Manage 2024; 67:e99-e104. [PMID: 37797677 DOI: 10.1016/j.jpainsymman.2023.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/22/2023] [Accepted: 09/28/2023] [Indexed: 10/07/2023]
Affiliation(s)
- Sonal Admane
- Division of Palliative, Integrative, and Rehabilitation Medicine - University of Texas MD Anderson Cancer Center, Houston Texas, USA.
| | - Matthew Clark
- Division of Palliative, Integrative, and Rehabilitation Medicine - University of Texas MD Anderson Cancer Center, Houston Texas, USA
| | - Akhila Reddy
- Division of Palliative, Integrative, and Rehabilitation Medicine - University of Texas MD Anderson Cancer Center, Houston Texas, USA
| | - Santhosshi Narayanan
- Division of Palliative, Integrative, and Rehabilitation Medicine - University of Texas MD Anderson Cancer Center, Houston Texas, USA
| | - Eduardo Bruera
- Division of Palliative, Integrative, and Rehabilitation Medicine - University of Texas MD Anderson Cancer Center, Houston Texas, USA
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Jeong E, Malin B, Nelson SD, Su Y, Li L, Chen Y. Revealing the dynamic landscape of drug-drug interactions through network analysis. Front Pharmacol 2023; 14:1211491. [PMID: 37860114 PMCID: PMC10583566 DOI: 10.3389/fphar.2023.1211491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 09/18/2023] [Indexed: 10/21/2023] Open
Abstract
Introduction: The landscape of drug-drug interactions (DDIs) has evolved significantly over the past 60 years, necessitating a retrospective analysis to identify research trends and under-explored areas. While methodologies like bibliometric analysis provide valuable quantitative perspectives on DDI research, they have not successfully delineated the complex interrelations between drugs. Understanding these intricate relationships is essential for deciphering the evolving architecture and progressive transformation of DDI research structures over time. We utilize network analysis to unearth the multifaceted relationships between drugs, offering a richer, more nuanced comprehension of shifts in research focus within the DDI landscape. Methods: This groundbreaking investigation employs natural language processing, techniques, specifically Named Entity Recognition (NER) via ScispaCy, and the information extraction model, SciFive, to extract pharmacokinetic (PK) and pharmacodynamic (PD) DDI evidence from PubMed articles spanning January 1962 to July 2023. It reveals key trends and patterns through an innovative network analysis approach. Static network analysis is deployed to discern structural patterns in DDI research, while evolving network analysis is employed to monitor changes in the DDI research trend structures over time. Results: Our compelling results shed light on the scale-free characteristics of pharmacokinetic, pharmacodynamic, and their combined networks, exhibiting power law exponent values of 2.5, 2.82, and 2.46, respectively. In these networks, a select few drugs serve as central hubs, engaging in extensive interactions with a multitude of other drugs. Interestingly, the networks conform to a densification power law, illustrating that the number of DDIs grows exponentially as new drugs are added to the DDI network. Notably, we discovered that drugs connected in PK and PD networks predominantly belong to the same categories defined by the Anatomical Therapeutic Chemical (ATC) classification system, with fewer interactions observed between drugs from different categories. Discussion: The finding suggests that PK and PD DDIs between drugs from different ATC categories have not been studied as extensively as those between drugs within the same categories. By unearthing these hidden patterns, our study paves the way for a deeper understanding of the DDI landscape, providing valuable information for future DDI research, clinical practice, and drug development focus areas.
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Affiliation(s)
- Eugene Jeong
- Department of Biomedical Informatics, School of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Bradley Malin
- Department of Biomedical Informatics, School of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Biostatistics, School of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Computer Science, School of Engineering, Vanderbilt University, Nashville, TN, United States
| | - Scott D. Nelson
- Department of Biomedical Informatics, School of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Yu Su
- Department of Computer Science and Engineering, College of Engineering, The Ohio State University, Columbus, OH, United States
| | - Lang Li
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - You Chen
- Department of Biomedical Informatics, School of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Computer Science, School of Engineering, Vanderbilt University, Nashville, TN, United States
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Page AJ, Mulvey MR, Bennett MI. Designing a clinical trial of non-steroidal anti-inflammatory drugs for cancer pain: a survey of UK palliative care physicians. BMJ Support Palliat Care 2023; 13:e55-e58. [PMID: 33268476 DOI: 10.1136/bmjspcare-2020-002792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Insufficient quality evidence exists to support or refute the use of non-steroidal anti-inflammatory drugs (NSAIDs) in the management of cancer pain. We aimed to determine the most clinically pragmatic design of a future randominsed controlled trial (RCT), based on how NSAIDs are currently used and perceived efficacy. METHODS An online survey was distributed to members of the Association for Palliative Medicine of Great Britain and Ireland examining NSAID use, indications and perceived efficacy, as well as duration of respondents' experience in palliative medicine. RESULTS 23% of 968 members responded. A placebo-controlled trial of NSAIDs as a strong opioid adjunct in cancer-related bone pain was considered the most clinically pragmatic design. Concerning current practice, oral administration was the preferential route (79.4%), dosed regularly (79.5%). Selective cyclooxygenase-2 (COX-2) inhibitors and non-selective COX-2 inhibitors were considered similarly effective by 45% in cancer pain; ibuprofen being the first line oral NSAID of choice (42.6%). Treatment efficacy is generally determined within 1 week (94.3%). On a Likert scale, most physicians consider NSAIDs improve cancer pain either 'sometimes' (57.7%) or 'often' (40%). Years of specialist palliative care experience did not affect perception of efficacy (p=0.353). CONCLUSIONS A randomised controlled trial of NSAIDs as opioid adjuncts for cancer-related bone pain would be the most pragmatic design supported by palliative care clinicians to benefit clinical practice.
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Affiliation(s)
- Andrew J Page
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Matthew R Mulvey
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Michael I Bennett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Huisman BAA, Geijteman ECT, Dees MK, van Zuylen L, van der Heide A, Perez RSGM. Better drug use in advanced disease: an international Delphi study. BMJ Support Palliat Care 2023; 13:e115-e121. [PMID: 30446489 PMCID: PMC10646859 DOI: 10.1136/bmjspcare-2018-001623] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 10/24/2018] [Accepted: 11/01/2018] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Bregje A A Huisman
- Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Eric C T Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marianne K Dees
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Roberto S G M Perez
- Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands
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Strassl I, Windhager A, Machherndl-Spandl S, Buxhofer-Ausch V, Stiefel O, Weltermann A. TOP-PIC: a new tool to optimize pharmacotherapy and reduce polypharmacy in patients with incurable cancer. J Cancer Res Clin Oncol 2023; 149:7113-7123. [PMID: 36877279 PMCID: PMC10374723 DOI: 10.1007/s00432-023-04671-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 02/26/2023] [Indexed: 03/07/2023]
Abstract
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.
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Affiliation(s)
- Irene Strassl
- Division of Hematology With Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz and Seilerstätte 4, 4010, Linz, Austria.
- Doctoral Programme MedUni Vienna, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria.
| | - Armin Windhager
- Department of Cardiology and Intensive Care Medicine, Kepler University Hospital Linz, Krankenhausstrasse 9, 4021, Linz, Austria
| | - Sigrid Machherndl-Spandl
- Division of Hematology With Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz and Seilerstätte 4, 4010, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Veronika Buxhofer-Ausch
- Division of Hematology With Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz and Seilerstätte 4, 4010, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Olga Stiefel
- Division of Hematology With Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz and Seilerstätte 4, 4010, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Ansgar Weltermann
- Division of Hematology With Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz and Seilerstätte 4, 4010, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
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12
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Tang M, Clark M, Reddy A, Bruera E. Fentanyl Toxicity Related to Concomitant Use of Ciprofloxacin and its Effects as a CYP3A4 Inhibitor. J Pain Symptom Manage 2023; 66:e307-e309. [PMID: 37150364 DOI: 10.1016/j.jpainsymman.2023.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 05/09/2023]
Affiliation(s)
- Michael Tang
- Department of Palliative (M.T., A.R., E.B.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| | - Matthew Clark
- Department of Pharmacy (M.C.), MD Anderson Cancer Center, Houston, Texas, USA
| | - Akhila Reddy
- Department of Palliative (M.T., A.R., E.B.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative (M.T., A.R., E.B.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Løhre ET, Svedahl A, Jakobsen G, Solheim TS, Klepstad P, Thronæs M. Emergency Palliative Cancer Care: Dexmedetomidine Treatment Experiences-A Retrospective Brief Report on Nine Consecutive Cases. Pain Ther 2023; 12:593-605. [PMID: 36807085 PMCID: PMC10036681 DOI: 10.1007/s40122-023-00485-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/06/2023] [Indexed: 02/23/2023] Open
Abstract
INTRODUCTION Dexmedetomidine, an alpha-2 adrenergic receptor agonist with potential opioid sparing properties, is utilized in palliative medicine, but the knowledge base for this practice is limited. We describe concomitant use of dexmedetomidine and opioids in an acute palliative care unit. METHODS We included all hospitalized palliative cancer care patients treated with dexmedetomidine from January 2019 to January 2021. Demographics, opioid doses, dexmedetomidine indications and dosing, reported effects and adverse responses, as well as treatment lengths were recorded. RESULTS Three women and six men aged 42-66 years with metastatic cancer and Eastern Cooperative Oncology Group (ECOG) performance status I-IV used dexmedetomidine and opioids concomitantly. Indications for dexmedetomidine were pain (n = 7) and anxiety (n = 2). Dexmedetomidine was administered intravenously in two patients and subcutaneously in seven. All administrations were continuous infusions; initial doses ranged from 240 to 1344 µg/24 h with later doses from 240 to 2440 µg/24 h. Physicians reported relief from pain and anxiety, but two patients required neuraxial pain management during admission. At day 2 of dexmedetomidine treatment, the opioid dose was reduced in six out of nine patients. For all patients with available data at day 7, mean opioid dose was reduced to 74% of the initial dose. When excluding the two patients requiring neuraxial pain management, the corresponding number was 80%. Two patients had transient hypotension, but dexmedetomidine was well tolerated and in no cases withdrawn due to adverse effects. Mean dexmedetomidine treatment length was 40 days. CONCLUSIONS Dexmedetomidine treatment decreased opioid consumption and was well tolerated in a retrospective study of nine palliative cancer care patients. It may represent a treatment option late in the disease trajectory.
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Affiliation(s)
- Erik Torbjørn Løhre
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Augstein Svedahl
- Department of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Gunnhild Jakobsen
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Tora Skeidsvoll Solheim
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Pål Klepstad
- Department of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Morten Thronæs
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
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Potentially inappropriate medication use based on two deprescribing criteria and related factors in patients with terminal cancer: A cross-sectional study. J Geriatr Oncol 2023; 14:101472. [PMID: 36931198 DOI: 10.1016/j.jgo.2023.101472] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 03/06/2023] [Indexed: 03/17/2023]
Abstract
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.
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McCaffrey N, Cheah SL, Luckett T, Phillips JL, Agar M, Davidson PM, Boyle F, Shaw T, Currow DC, Lovell M. 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. PLoS One 2023; 18:e0282465. [PMID: 36854021 PMCID: PMC9974128 DOI: 10.1371/journal.pone.0282465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/16/2023] [Indexed: 03/02/2023] Open
Abstract
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.
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Affiliation(s)
- Nikki McCaffrey
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood Campus, Burwood, VIC, Australia
- * E-mail:
| | - Seong Leang Cheah
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - Tim Luckett
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - Jane L. Phillips
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
- Faculty of Health, School of Nursing, Queensland University of Technology, Kelvin Grove Brisbane, Queensland
| | - Meera Agar
- Faculty of Health, IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation Sydney), University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - Patricia M. Davidson
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Frances Boyle
- Patricia Ritchie Centre for Cancer Care and Research, Mater Hospital North Sydney, and University of Sydney, Sydney, NSW, Australia
| | - Tim Shaw
- Faculty of Medicine and Health, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - David C. Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Melanie Lovell
- Department of Palliative Care, HammondCare, Greenwich Hospital, Sydney, NSW, Australia
- Northern Clinical School, University of Sydney, Sydney, NSW, Australia
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Pharmacists' clinical roles and activities in inpatient hospice and palliative care: a scoping review. Int J Clin Pharm 2023:10.1007/s11096-023-01535-7. [PMID: 36773207 PMCID: PMC9918816 DOI: 10.1007/s11096-023-01535-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 01/03/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Pharmacists contribute to medication safety by providing their services in various settings. However, standardized definitions of the role of pharmacists in hospice and palliative care (HPC) are lacking. AIM The purpose of this scoping review was to provide an overview of the evidence on the role of pharmacists and to map clinical activities in inpatient HPC. METHOD We performed a scoping review according to the PRISMA-ScR extension in CINAHL, Embase, and PubMed. We used the American Society of Hospital Pharmacists (ASHP) Guidelines on the Pharmacist's Role in Palliative and Hospice Care as a framework for standardized categorization of the identified roles and clinical activities. RESULTS After screening 635 records (published after January 1st, 2000), the scoping review yielded 23 publications reporting various pharmacy services in HPC. The articles addressed the five main categories in the following descending order: 'Medication order review and reconciliation', 'Medication counseling, education and training', 'Administrative Roles', 'Direct patient care', and 'Education and scholarship'. A total of 172 entries were mapped to the subcategories that were added to the main categories. CONCLUSION This scoping review identified a variety of pharmacists' roles and clinical activities. The gathered evidence will help to establish and define the role of pharmacists in inpatient hospice and palliative care.
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Jakobsen G, Sjue K, Paulsen Ø, Kaasa S, Hjermstad MJ, Klepstad P. Zopiclone versus placebo for short-term treatment of insomnia in patients with advanced cancer-a double-blind, randomized placebo-controlled clinical multicenter phase IV trial. Support Care Cancer 2023; 31:60. [PMID: 36534165 PMCID: PMC9763131 DOI: 10.1007/s00520-022-07537-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Insomnia is frequent in patients with advanced cancer, and a variety of pharmacological agents is used to treat this condition. Still, few clinical trials have investigated the effectiveness of pharmacological sleep therapies in this patient group. We aimed to study the short-term effectiveness of zopiclone on sleep quality in patients with advanced cancer who report insomnia. METHODS A randomized, double-blind, placebo-controlled, parallel-group, multicenter, phase IV clinical trial in adult patients with metastatic malignant disease and insomnia. Patients were treated with zopiclone or placebo for six subsequent nights. Primary end point was patient-reported sleep quality during the final study night (NRS 0-10). Secondary end points were patient-reported sleep onset latency (SOL) and total sleep time (TST). RESULTS Forty-one patients were randomized, with 18 being analyzed in the zopiclone group and 21 in the placebo group. Median age was 66, median Karnofsky performance score was 80, and 56% were male. Mean sleep quality at end of study was 2.9 (CI 2.3 to 3.8) in the zopiclone group and 4.5 (CI 3.6 to 5.4) in the placebo group (p = 0.021). At end of study, SOL was significantly different between the treatment groups: zopiclone 29 min (CI 13 to 51) and placebo 62 min (CI 40 to 87) (p = 0.045). TST was not significantly different across groups: zopiclone 449 min (403 to 496) and placebo 411 min (CI 380 to 440) (p = 0.167). CONCLUSION Zopiclone improved short-term patient-reported sleep quality in this cohort of patients with advanced cancer. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02807922.
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Affiliation(s)
- Gunnhild Jakobsen
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), and Cancer Clinic, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Karin Sjue
- Department of Oncology, Vestfold Hospital Trust, Tønsberg, Norway
| | - Ørnulf Paulsen
- Institute of Clinical Medicine, European Palliative Care Research Centre, Department of Oncology, Oslo University Hospital, Oslo, Norway, University of Oslo, Oslo, Norway, and Palliative Care Unit, Telemark Hospital Trust, Skien, Norway
| | - Stein Kaasa
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Marianne Jensen Hjermstad
- Regional Advisory Unit in Palliative Care, Department of Oncology, Oslo University Hospital, Oslo, Norway, and European Palliative Care Research Centre, Department of Oncology, Oslo University Hospital, Oslo, Norway, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Pål Klepstad
- Department of Anaesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway, and Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology NTNU, Trondheim, Norway
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Matthews S, Moriarty F, Ward M, Nolan A, Normand C, Kenny RA, May P. Overprescribing among older people near end of life in Ireland: Evidence of prevalence and determinants from The Irish Longitudinal Study on Ageing (TILDA). PLoS One 2022; 17:e0278127. [PMID: 36449504 PMCID: PMC9710761 DOI: 10.1371/journal.pone.0278127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/09/2022] [Indexed: 12/05/2022] Open
Abstract
International evidence shows that people approaching end of life (EOL) have high prevalence of polypharmacy, including overprescribing. Overprescribing may have adverse side effects for mental and physical health and represents wasteful spending. Little is known about prescribing near EOL in Ireland. We aimed to describe the prevalence of two undesirable outcomes, and to identify factors associated with these outcomes: potentially questionable prescribing, and potentially inadequate prescribing, in the last year of life (LYOL). We used The Irish Longitudinal Study on Ageing, a biennial nationally representative dataset on people aged 50+ in Ireland. We analysed a sub-sample of participants with high mortality risk and categorised their self-reported medication use as potentially questionable or potentially inadequate based on previous research. We identified mortality through the national death registry (died in <365 days versus not). We used descriptive statistics to quantify prevalence of our outcomes, and we used multivariable logistic regression to identify factors associated with these outcomes. Of 525 observations, 401 (76%) had potentially inadequate and 294 (56%) potentially questionable medications. Of the 401 participants with potentially inadequate medications, 42 were in their LYOL. OF the 294 participants with potentially questionable medications, 26 were in their LYOL. One factor was significantly associated with potentially inadequate medications in LYOL: male (odds ratio (OR) 4.40, p = .004) Three factors were associated with potentially questionable medications in LYOL: male (OR 3.37, p = .002); three or more activities of daily living (ADLs) (OR 3.97, p = .003); and outpatient hospital visits (OR 1.03, p = .02). Thousands of older people die annually in Ireland with potentially inappropriate or questionable prescribing patterns. Gender differences for these outcomes are very large. Further work is needed to identify and reduce overprescribing near EOL in Ireland, particularly among men.
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Affiliation(s)
- Soraya Matthews
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Frank Moriarty
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
| | - Mark Ward
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
| | - Anne Nolan
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
- Economic and Social Research Institute (ESRI), Dublin, Ireland
| | - Charles Normand
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, London, United Kingdom
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
| | - Peter May
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
- * E-mail:
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19
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Wernli U, Hischier D, Meier CR, Jean-Petit-Matile S, Panchaud A, Kobleder A, Meyer-Massetti C. Prescription Trends in Hospice Care: A Longitudinal Retrospective and Descriptive Medication Analysis. Am J Hosp Palliat Care 2022:10499091221130758. [PMID: 36168963 DOI: 10.1177/10499091221130758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Ursina Wernli
- Clinical Pharmacology and Toxicology, 27252Inselspital University Hospital Bern, Bern, Switzerland.,Graduate School for Health Sciences, 27210University of Bern, Bern, Switzerland
| | - Désirée Hischier
- Clinical Pharmacy and Pharmacoepidemiology, 27209University of Basel, Basel, Switzerland
| | - Christoph R Meier
- Clinical Pharmacy and Pharmacoepidemiology, 27209University of Basel, Basel, Switzerland
| | | | - Alice Panchaud
- Institute of Primary Health Care (BIHAM), 27210University of Bern, Bern, Switzerland
| | - Andrea Kobleder
- Institute of Applied Nursing Science, 112888Eastern Switzerland University of Applied SciencesOST, St Gallen, Switzerland
| | - Carla Meyer-Massetti
- Clinical Pharmacology and Toxicology, 27252Inselspital University Hospital Bern, Bern, Switzerland.,Clinical Pharmacy and Pharmacoepidemiology, 27209University of Basel, Basel, Switzerland
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20
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Novak J, Goldberg A, Dharmarajan K, Amini A, Maggiore RJ, Presley CJ, Nightingale G. Polypharmacy in older adults with cancer undergoing radiotherapy: A review. J Geriatr Oncol 2022; 13:778-783. [PMID: 35227626 PMCID: PMC9283217 DOI: 10.1016/j.jgo.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 12/09/2021] [Accepted: 02/10/2022] [Indexed: 01/09/2023]
Abstract
Polypharmacy is characterized by the simultaneous use of multiple medications, including prescription drugs, over-the-counter drugs, and nutritional supplements. Polypharmacy is known to increase the risk of adverse drugs reactions, drug-drug interactions, and medication errors, and to negatively impact quality of life. The prevalence of polypharmacy varies by population, but has been reported to exceed 90% among older adults with cancer. Polypharmacy may be exacerbated among older adults with cancer receiving radiation therapy due to the resulting acute or chronic side effects that need to be managed with additional medications. The medications prescribed to manage radiation-related side effects increase the risk of adverse drug events, as do changes in nutritional status related to the secondary side effects of radiation treatment. Side effects from treatment may result in the need for breaks in cancer therapy or treatment delays, which ultimately can lead to worse oncologic outcomes. Few studies have examined polypharmacy in the context of older adults undergoing radiation therapy. We sought to review the literature pertaining to polypharmacy among older adults with cancer and discuss implications specifically for those individuals undergoing radiation therapy. This paper presents a narrative review of studies published in the past decade that provided detailed information on polypharmacy in older adults undergoing radiation therapy for cancer. The review elucidated good practices to avoid adverse drug events from polypharmacy, but more studies are warranted to develop standard guidelines.
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Affiliation(s)
- Jennifer Novak
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Annette Goldberg
- Department of Nutrition Services, Dana Farber Cancer Institute, Boston, MA, USA
| | - Kavita Dharmarajan
- Department of Geriatrics and Palliative Medicine, Mount Sinai Health System, New York, NY, USA; Department of Radiation Oncology, Mount Sinai Health System, New York, NY, USA
| | - Arya Amini
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Ronald J Maggiore
- Department of Medical Oncology, University of Rochester, Rochester, NY, USA
| | - Carolyn J Presley
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Ginah Nightingale
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA.
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21
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Check DK, Avecilla RAV, Mills C, Dinan MA, Kamal AH, Murphy B, Rezk S, Winn A, Oeffinger KC. Opioid Prescribing and Use Among Cancer Survivors: A Mapping Review of Observational and Intervention Studies. J Pain Symptom Manage 2022; 63:e397-e417. [PMID: 34748896 DOI: 10.1016/j.jpainsymman.2021.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/22/2021] [Accepted: 10/23/2021] [Indexed: 12/12/2022]
Abstract
CONTEXT Recent years show a sharp increase in research on opioid use among cancer survivors, but evidence syntheses are lacking, leaving knowledge gaps. Corresponding research needs are unclear. OBJECTIVES To provide an evidence synthesis. METHODS We searched PubMed and Embase, identifying articles related to cancer, and opioid prescribing/use published through September 2020. We screened resulting titles/abstracts. Relevant studies underwent full-text review. Inclusion criteria were quantitative examination of and primary focus on opioid prescribing or use, and explicit inclusion of cancer survivors. Exclusion criteria included end-of-life opioid use and opioid use as a secondary or downstream outcome (for intervention studies). We extracted information on the opioid-related outcome(s) examined (including definitions and terminology used), study design, and methods. RESULTS Research returned 16,591 articles; 296 were included. Only 22 of 296 studies evaluated an intervention. There were 105 studies evaluating outcomes indicative of potentially high-risk, nonrecommended, or avoidable opioid use, e.g., continuous use-described as chronic use, prolonged use, and persistent use (n = 17); use after completion of curative-intent treatment-described as chronic opioid use, long-term opioid use, persistent opioid use, prolonged opioid use, continued opioid use, late opioid use, post-treatment opioid use (n = 27); use of opioids concurrent with other potentially high-risk medications (n = 13), and opioid misuse (n = 14). CONCLUSIONS We found lack of consistency in the measurement of and terms used to describe similar opioid use outcomes, and a lack of interventional research targeting well-documented patterns of potentially nonrecommended, potentially avoidable, or potentially high-risk opioid prescribing or use.
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Affiliation(s)
- Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine (D.K.C.), Durham, North Carolina; Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina.
| | - Renee A V Avecilla
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina
| | - Coleman Mills
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina
| | - Michaela A Dinan
- Department of Chronic Disease Epidemiology, Yale School of Public Health (M.A.D.), New Haven, Connecticut; Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center (M.A.D.), New Haven, Connecticut
| | - Arif H Kamal
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina; Department of Medicine, Duke University Medical Center (A.H.K.), Durham, North Carolina
| | - Beverly Murphy
- Duke University Medical Center Library & Archives, Duke University School of Medicine (B.M.), Durham, North Carolina
| | - Salma Rezk
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy (S.R.), Chapel Hill, North Carolina
| | - Aaron Winn
- School of Pharmacy, Medical College of Wisconsin (A.W.), Milwaukee, Wisconsin
| | - Kevin C Oeffinger
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina; Department of Medicine, Duke University School of Medicine (K.C.O.), Durham, North Carolina
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Sohi G, Lao N, Caraceni A, Moulin DE, Zimmermann C, Herx L, Gilron I. Nonopioid drug combinations for cancer pain: a systematic review. Pain Rep 2022; 7:e995. [PMID: 35261931 PMCID: PMC8893303 DOI: 10.1097/pr9.0000000000000995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 12/29/2021] [Accepted: 02/03/2022] [Indexed: 11/25/2022] Open
Abstract
Pain is highly prevalent in patients with cancer-nearly 40% report moderate-severe pain, which is commonly treated with opioids. Increasing cancer survivorship, opioid epidemics in some regions of the world, and limited opioid access in other regions have focused attention on nonopioid treatments. Given the limitations of monotherapy, combining nonopioids-such as antiepileptics and antidepressants-have shown promise in noncancer pain. This review seeks to evaluate efficacy of nonopioid combinations for cancer-related pain. Systematic searches of PubMed, EMBASE, and Cochrane CENTRAL were conducted for double-blind, randomized, controlled trials comparing a nonopioid combination with at least one of its components and/or placebo. This search yielded 4 randomized controlled trials, published between 1998 and 2019 involving studies of (1) imipramine + diclofenac; (2) mitoxantrone + prednisone + clodronate; (3) pentoxifylline + tocopherol + clodronate; and (4) duloxetine + pregabalin + opioid. In the first 3 of these trials, trends favouring combination efficacy failed to reach statistical significance. However, in the fourth trial, duloxetine + pregabalin + opioid was superior to pregabalin + opioid. This review illustrates recognition for the need to evaluate nonopioid drug combinations in cancer pain, although few trials have been published to date. Given the growing practice of prescribing more than 1 nonopioid for cancer pain and the need to expand the evidence base for rational combination therapy, more high-quality trials in this area are needed.
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Affiliation(s)
- Gursharan Sohi
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Nicholas Lao
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Augusto Caraceni
- Pain Therapy and Palliative Care Unit, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
- Department of Clinical and Community SciencesUniversità degli Studi di Milano, Milan, Italy
| | - Dwight E. Moulin
- Departments of Clinical Neurological Sciences and Oncology, Western University, London, Canada
| | - Camilla Zimmermann
- Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Leonie Herx
- Division of Palliative Medicine, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Ian Gilron
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
- School of Policy Studies, Queen's University, Kingston, ON, Canada
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23
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Graça J, Vasconcelos de Matos L, Baleiras AM, Ferreira F, Costa R, Pinto MM, Martins A. Therapeutic Futility in Terminal Cancer Patients: A Retrospective and Observational Study. Cureus 2021; 13:e14073. [PMID: 33777589 PMCID: PMC7988361 DOI: 10.7759/cureus.14073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Advanced cancer patients often need therapy for symptomatic control, in addition to cancer and other disease treatments. As the cancer disease progresses and life expectancy decreases, there should be a change in the goal of care. If this change is not accompanied by therapeutic adjustments, there is a risk of maintaining useless and ineffective treatments, as well as potential harmful drug interactions. This study analyzed the prevalence of therapeutic futility in patients with advanced cancer disease. Materials and methods This was a retrospective and observational single-center study, that included advanced cancer patients who died during the hospital stay, at a University Hospital in Lisbon, Portugal. Demographic and clinical data were collected. A Palliative Prognostic Score (PaP) was used to stratify patients according to their prognosis group. An analysis of the prescribed therapy was performed to quantify the "potentially inappropriate medications" (PIMs) and "inappropriate medications" (IMs), at admission and 24 hours prior to the patient's death. Results Over 140 patients were included. On the first day of hospitalization, 119 patients (85%) were exposed to at least one IM or PIM and 100 patients (71%) were still exposed to at least one IM or PIM in the last 24 hours of life. Regarding chemotherapy, 66 patients (47%) had treatment in the last two months of life, 38 (27%) in the last month, and 17 (12%) in the last two weeks prior to death. Therapeutic simplification (suspension of IMs and reduction of at least 50% of PIMs during hospitalization) was performed in 43% of the overall population and was higher in PaP score group C, but not statistically significant (p=0.09). The patient's inclusion in PaP score group C and inpatient consultation by the palliative care team were independent predictors of therapeutic simplification. Discussion There is an effort to achieve greater therapeutic suitability in palliative patients. However, many patients maintain futile and disproportionate therapy at the end of life (EoL). In many cases, systemic cancer treatment is performed until quite late in the course of the disease. The prescription of PIMs was significantly higher than that of IMs, which could be expected given their definition. A shorter life expectancy at admission led to a greater therapeutic simplification, as well as an intervention by the Palliative Care Team, which can be explained by the more focused approach towards quality-of-life improvement and symptomatic control. Different than expected the prescription of supportive therapies at hospital admission was not a predictor of therapeutic simplification. Although there was a reduction in IMs and PIMs in the studied population, and therapeutic simplification occurred in one fraction of the patients, the fact is that more than half of the patients evaluated did not undergo therapeutic simplification as defined in this work. Conclusion It appears that there is an effort to achieve greater therapeutic suitability in palliative patients, however, many patients maintain futile therapy at the EoL. It is of paramount importance to change the standard of care in this setting, to privilege a more patient-focused approach and tailored therapy, and to prioritize symptomatic control and quality-of-life improvement.
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Affiliation(s)
- Joana Graça
- Medical Oncology, Centro Hospitalar Lisboa Ocidental - Hospital São Francisco Xavier, Lisbon, PRT
| | | | - Ana Mafalda Baleiras
- Medical Oncology, Centro Hospitalar Lisboa Ocidental - Hospital São Francisco Xavier, Lisbon, PRT
| | - Filipa Ferreira
- Medical Oncology, Centro Hospitalar Lisboa Ocidental - Hospital São Francisco Xavier, Lisbon, PRT
| | - Rui Costa
- Internal Medicine, Hospital da Luz, Lisboa, PRT
| | - Marta M Pinto
- Medical Oncology, Centro Hospitalar Lisboa Ocidental - Hospital São Francisco Xavier, Lisbon, PRT
| | - Ana Martins
- Medical Oncology, Centro Hospitalar Lisboa Ocidental - Hospital São Francisco Xavier, Lisbon, PRT
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24
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Drug-related problems and risk factors related to unplanned hospital readmission among cancer patients in Belgium. Support Care Cancer 2021; 29:3911-3919. [PMID: 33389085 DOI: 10.1007/s00520-020-05916-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 11/25/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION There are about 60,000 diagnoses of cancer per year in Belgium. After hospital care, about 12-13% of cancer patients are readmitted within 30 days after discharge. These readmissions are partly related to drug-related problems (DRP), such as interactions or adverse drug effects (ADE). OBJECTIVES The aim of this study is to quantify and to classify DRP readmissions within 30 days for cancer patients and to highlight risk factors potentially correlated to readmissions. METHODS This study is a 6-month observational retrospective study in two care facilities in Brussels: an academic general hospital and an academic oncology center. Patients readmitted within 30 days after their last hospital care for a potential DRP were included. Patient files were evaluated with an intermediate medication review that included interactions analysis (Lexicomp®). The probability of DRP readmission was assessed using the World Health Organization's Uppsala Monitoring Centre (WHO-UMC) system. RESULTS The final population included 299 patients; among them, 123 (41.1%) were readmitted due to DRP (certain DRP (4.9%), probable DRP (49.6%), and possible DRP (45.5%)). Risks factors linked to these DRP were a low Charlson Comorbidity Index, polypharmacy, the kind of hospital, and some chemotherapies (platinum preparations). Among all readmitted patients, the D-type interactions were the most common (44.8%), which suggest a possible therapy modification. However, around 10% of interactions were X-type (drug combination to avoid). CONCLUSION Almost 10% of patient readmitted within 30 days were potentially related to a DRP, most of them from adverse drug effects. Four risk factors (low Charlson Comorbidity Index, polypharmacy, the hospital, and some chemotherapies) were highlighted to prevent these readmissions.
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25
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Quirk K, Smith MA. Acetaminophen in Patients Receiving Strong Opioids for Cancer Pain. J Pain Palliat Care Pharmacother 2020; 34:197-202. [PMID: 32744914 DOI: 10.1080/15360288.2020.1784355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The mainstay of treatment in advanced cancer pain is opioids; however, non-opioid medications such as acetaminophen continue to be included in guidelines despite a lack of clear, convincing evidence for their use. The aim of our study was to determine if acetaminophen improves pain control or reduces opioid utilization in hospitalized patients receiving strong opioids for cancer pain managed by the palliative care consult service (PCCS). We carried out at single-center retrospective cohort study of 194 adult cancer patients seen by the PCCS and who received strong opioids. Patients who received acetaminophen during their admission were compared to those who did not. The primary outcome was a 30% reduction in average daily pain score from admission to discharge using a numeric rating scale. There was no difference between groups in achieving a 30% reduction in pain (35.8% vs. 35.4%, adjusted odds ratio 0.87, 95% confidence interval [CI] 0.46 to 1.63). Acetaminophen was associated with a longer LOS (8 days vs. 6 days, adjusted relative risk 1.67, 95% CI 1.30 to 2.15). In this study of cancer patients receiving strong opioids, acetaminophen use was not associated with improved pain control or reduced opioid utilization, but was associated with a greater LOS.
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26
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Use of Non-Cancer Medications in New Zealand Women at the Diagnosis of Primary Invasive Breast Cancer: Prevalence, Associated Factors and Effects on Survival. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17217962. [PMID: 33138255 PMCID: PMC7663632 DOI: 10.3390/ijerph17217962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/20/2020] [Accepted: 10/26/2020] [Indexed: 11/17/2022]
Abstract
Background: Assessing the use of multiple medications in cancer patients is crucial as such use may affect cancer outcomes. This study reports the prevalence of non-cancer medication use at breast cancer diagnosis, its associated factors, and its effect on survival. Methods: We identified all women diagnosed with primary invasive breast cancer between 1 January 2007 and 31 December 2016, from four population-based breast cancer registries, in Auckland, Waikato, Wellington, and Christchurch, New Zealand. Through linkage to the pharmaceutical records, we obtained information on non-cancer medications that were dispensed for a minimum of 90 days’ supply between one year before cancer diagnosis and first cancer treatment. We performed ordered logistic regressions to identify associated factors and Cox regressions to investigate its effect on patient survival. Results: Of 14,485 patients, 52% were dispensed at least one drug (mean—1.3 drugs; maximum—13 drugs), with a higher prevalence observed in patients who were older, treated at a public facility, more economically deprived, and screen-detected. The use of 2–3 drugs showed a reduced non-breast cancer mortality (HR = 0.75, 95%CI = 0.60–0.92) in previously hospitalised patients, with other groups showing non-significant associations when adjusted for confounding factors. Drug use was not associated with changes in breast cancer-specific mortality. Conclusions: Non-cancer medication use at breast cancer diagnosis was common in New Zealand, more prevalent in older and disadvantaged women, and showed no effect on breast cancer-specific mortality, but a reduction in other cause mortality with the use of 2–3 drugs.
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McNeill R, Hanger HC, Chieng J, Chin P. Polypharmacy in Palliative Care: Two Deprescribing Tools Compared with a Clinical Review. J Palliat Med 2020; 24:661-667. [PMID: 32991250 DOI: 10.1089/jpm.2020.0225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background: Lack of guidance is highlighted as a barrier to deprescribing in palliative care. Two deprescribing tools exist, but with inclusion and exclusion criteria that limit utility. The tools have not previously been compared directly or used in an unselected palliative population. Objective: To compare the OncPal and STOPPFrail deprescribing tools to an expert review in an unselected palliative population. Secondary aims included a description of medicines incorrectly classified by both tools. Design: Fifty palliative inpatients were retrospectively reviewed by an expert panel, and both tools were independently applied to the patients. Positive and negative predictive values (PPV and NPV) were calculated per patient using the expert review as the gold standard. Results: The median number of medicines per patient was 11, with 19% of medicines deemed inappropriate. The PPV and NPV were 75% (interquartile range 50-100) and 91% (interquartile range 84-100), respectively, for OncPal, and 100% (interquartile range 50-100) and 90% (interquartile range 78-100), respectively, for STOPPFrail. There was no statistically significant difference between the tools (PPV p = 0.42 and NPV p = 0.07). The main medicines incorrectly ceased by OncPal were antianginals for stable coronary artery disease, and haloperidol for nausea by STOPPFrail. Conclusion: There was no significant difference between the tools. Both tools performed well in an unselected population. Some minor amendments could improve the PPV of both tools.
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Affiliation(s)
- Richard McNeill
- Department of Palliative Care, Christchurch Hospital, Christchurch, New Zealand.,Department of Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand
| | - Hugh Carl Hanger
- Department of Older Persons' Health, Burwood Hospital, Christchurch, New Zealand.,Department of Medicine, University of Otago, Otago, New Zealand
| | - Jenny Chieng
- Department of Older Persons' Health, Burwood Hospital, Christchurch, New Zealand.,Department of General Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Paul Chin
- Department of Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand.,Department of Medicine, University of Otago, Otago, New Zealand
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Hakozaki T, Matsuo T, Shimizu A, Ishihara Y, Hosomi Y. Polypharmacy among older advanced lung cancer patients taking EGFR tyrosine kinase inhibitors. J Geriatr Oncol 2020; 12:64-71. [PMID: 32952094 DOI: 10.1016/j.jgo.2020.09.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/07/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Polypharmacy (PP) is a common problem among the older adults and has a potential effect on health-related problems. However, the significance of PP in older advanced non-small cell lung cancer (NSCLC) patients and those on oral molecular-targeted anticancer agents is unclear. MATERIALS AND METHODS This retrospective, nonrandomized study reviewed the records of 334 advanced NSCLC patients who underwent epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) treatment. PP was defined as ≥ 5 concomitant medications. Potentially inappropriate medication (PIM) use was measured using the updated screening tool of older people's prescriptions (STOPP) ver. 2 criteria. We also estimated survival distributions using the Kaplan-Meier method, compared between-group differences using the log-rank test, explored potential predictors of survival using Cox regression, and performed cluster analysis to identify factors affecting multiple-medication use. RESULTS The PP and PIM use prevalence was 38.4% and 31.9%, respectively. The median overall survival (OS) for PP(+) and PP(-) patients was 19.4 and 27.3 months, respectively. Multivariate analysis revealed a significant correlation between PP and OS. The frequency of unexpected hospitalization during EGFR-TKI treatment was higher in PP(+) patients compared to PP(-) patients (49.4% vs. 29.4%; odds ratio = 2.34). CONCLUSION PP is an independent prognostic factor in older advanced NSCLC patients taking EGFR-TKIs. PP can be used as a simple indicator of such patients' comorbidities and symptoms or as a predictive marker of unexpected hospitalization during treatment.
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Affiliation(s)
- Taiki Hakozaki
- Department of Thoracic Oncology and Respiratory Medicine, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo, Tokyo 113-0021, Japan.
| | - Takuma Matsuo
- Department of Pharmacy, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo, Tokyo 113-0021, Japan
| | - Akihiro Shimizu
- Department of Pharmacy, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo, Tokyo 113-0021, Japan
| | - Yoko Ishihara
- Department of Pharmacy, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo, Tokyo 113-0021, Japan
| | - Yukio Hosomi
- Department of Thoracic Oncology and Respiratory Medicine, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo, Tokyo 113-0021, Japan
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29
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The short-term impact of methylprednisolone on patient-reported sleep in patients with advanced cancer in a randomized, placebo-controlled, double-blind trial. Support Care Cancer 2020; 29:2047-2055. [PMID: 32856209 PMCID: PMC7892512 DOI: 10.1007/s00520-020-05693-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 08/19/2020] [Indexed: 11/13/2022]
Abstract
Purpose Although corticosteroids are frequently used in patients with advanced cancer, few studies have examined the impact of these drugs on patient-reported sleep. We aimed to examine the short-term impact of methylprednisolone on patient-reported sleep in patients with advanced cancer. Methods Patient-reported sleep was a predefined secondary outcome in a prospective, randomized, placebo-controlled, double-blind trial that evaluated the analgesic efficacy of corticosteroids in advanced cancer patients (18+), using opioids, and having pain ≥ 4 past 24 h (NRS 0–10). Patients were randomized to the methylprednisolone group with methylprednisolone 16 mg × 2/day or placebo for 7 days. The EORTC QLQ-C30 (0–100) and the Pittsburgh Sleep Quality Index questionnaire (PSQI) (0–21) were used to assess the impact of corticosteroids on sleep at baseline and at day 7. Results Fifty patients were randomized of which 25 were analyzed in the intervention group and 22 in the control group. Mean age was 64 years, mean Karnofsky performance status was 67 (SD 13.3), 51% were female, and the mean oral daily morphine equivalent dose was 223 mg (SD 222.77). Mean QLQ-C30 sleep score at baseline was 29.0 (SD 36.7) in the methylprednisolone group and 24.2 (SD 27.6) in the placebo group. At day 7, there was no difference between the groups on QLQ-C30 sleep score (methylprednisolone 20.3 (SD 32.9); placebo 28.8 (SD 33.0), p = 0.173). PSQI showed similar results. Conclusions Methylprednisolone 16 mg twice daily for 7 days had no impact on patient-reported sleep in this cohort of patients with advanced cancer. Trial registration Clinical trial information NCT00676936 (13.05.2008)
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30
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Polypharmacy as a prognostic factor in older patients with advanced non-small-cell lung cancer treated with anti-PD-1/PD-L1 antibody-based immunotherapy. J Cancer Res Clin Oncol 2020; 146:2659-2668. [PMID: 32462298 DOI: 10.1007/s00432-020-03252-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/08/2020] [Indexed: 01/25/2023]
Abstract
PURPOSE Polypharmacy is a common problem among older adults. However, its prevalence and impact on the clinical outcomes of anticancer treatment, such as survival and adverse events, in older patients with advanced cancer have not been well investigated. METHODS We retrospectively reviewed data from Japanese patients treated with an immune checkpoint inhibitor (ICI) for advanced or recurrent non-small-cell lung cancer (NSCLC) between 2016 and 2019. RESULTS Among 157 older (aged ≥ 65 years) patients, the prevalence of polypharmacy, defined as ≥ 5 medications, was 59.9% (94/157). The prevalence of potentially inappropriate medication use, according to the screening tool of older people's prescription (STOPP) criteria version 2, was 38.2% (60/157). The median progression-free survival (PFS) in patients with and without polypharmacy was 3.7 and 5.5 months, respectively (P = 0.0017). The median overall survival (OS) in patients with and without polypharmacy was 9.5 and 28.1 months, respectively (P < 0.001). Multivariate analysis revealed marked associations between polypharmacy and OS, but no significant associations between polypharmacy and PFS. Polypharmacy was not associated with immune-related adverse events but was associated with higher rate of unexpected hospitalizations during ICI treatment (59.6% vs. 31.7%, P < 0.001). CONCLUSION Polypharmacy is an independent prognostic factor in older patients with advanced NSCLC treated with ICI. Also, polypharmacy could be utilized as a simple indicator of patients' comorbidities and symptoms or as a predictive marker of unexpected hospitalizations during ICI treatment.
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Huisman BAA, Geijteman ECT, Dees MK, Schonewille NN, Wieles M, van Zuylen L, Szadek KM, van der Heide A. Role of nurses in medication management at the end of life: a qualitative interview study. BMC Palliat Care 2020; 19:68. [PMID: 32404166 PMCID: PMC7222510 DOI: 10.1186/s12904-020-00574-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 05/07/2020] [Indexed: 11/13/2022] Open
Abstract
Background Patients in the last phase of their lives often use many medications. Physicians tend to lack awareness that reviewing the usefulness of medication at the end of patients’ lives is important. The aim of this study is to gain insight into the perspectives of patients, informal caregivers, nurses and physicians on the role of nurses in medication management at the end of life. Methods Semi-structured interviews were conducted with patients in the last phase of their lives, in hospitals, hospices and at home; and with their informal caregivers, nurses and physicians. Data were qualitatively analyzed using the constant comparative method. Results Seventy-six interviews were conducted, with 17 patients, 12 informal caregivers, 15 nurses, 20 (trainee) medical specialists and 12 family physicians. Participants agreed that the role of the nurse in medication management includes: 1) informing, 2) supporting, 3) representing and 4) involving the patient, their informal caregivers and physicians in medication management. Nurses have a particular role in continuity of care and proximity to the patient. They are expected to contribute to a multidimensional assessment and approach, which is important for promoting patients’ interest in medication management at the end of life. Conclusions We found that nurses can and should play an important role in medication management at the end of life by informing, supporting, representing and involving all relevant parties. Physicians should appreciate nurses’ input to optimize medication management in patients at the end of life. Health care professionals should recognize the role the nurses can have in promoting patients’ interest in medication management at the end of life. Nurses should be reinforced by education and training to take up this role.
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Affiliation(s)
- Bregje A A Huisman
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, Netherlands. .,Hospice Kuria, Amsterdam, Netherlands.
| | - Eric C T Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, Netherlands.,Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Marianne K Dees
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
| | - Noralie N Schonewille
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, Netherlands.,Department of Gynaecology, OLVG West, Amsterdam, the Netherlands
| | | | - Lia van Zuylen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Karolina M Szadek
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
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32
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Laurent V, Saillard J, Thierry M, Lepelletier A, Fronteau C, Huon JF. Anticancer agents and phytotherapy: Interactions that are often unrecognized. J Oncol Pharm Pract 2020; 27:322-328. [PMID: 32356688 DOI: 10.1177/1078155220920363] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Phytotherapy is the main complementary medicine for which patients afflicted with cancer have recourse but the associated consumption of phytotherapy products gives rise to a risk of interaction with anticancer agents. The aim of this prospective study was to measure the prevalence of the consumption of phytotherapy products as well as their interactions with anticancer agents in a cohort of patients from January 2018 to August 2019. Patients hospitalized in the conventional hematology unit and outpatients who had their prescriptions for oral anticancer agents filled at the hospital pharmacy were questioned about consumption of phytotherapy products by pharmacy externs trained in pharmaceutical interviews. Among the 110 hospitalized patients who answered the questionnaire, 40% (n = 44) used phytotherapy and 5 of them continued to consume it during the cycles of injectable chemotherapy. As a result, 10 interactions were found between the plants and the anticancer agents (prevalence of 27%). Among the 59 outpatients, 17% (n = 10) consumed phytotherapy. Eight interactions were identified (prevalence of 80%). The potential consequences were an increase or a decrease in the concentration of the anticancer agents and an increase in the risk of bleeding, hepatoxicity, and hypokalemia. The consumption of phytotherapy was unknown by a health professional for 44% of hospitalized patients and 60% of the outpatients. The risk of interactions between plants and anticancer agents is not negligible and professionals should be cognizant of this in their daily practice. The availability of tools for training and detection of interactions is indispensable for managing patients undergoing onco-hematology treatments.
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Affiliation(s)
- Vanille Laurent
- 26922CHU Nantes, Nantes, France *Vanille Laurent and Justine Saillard are co-first authors
| | - Justine Saillard
- 26922CHU Nantes, Nantes, France *Vanille Laurent and Justine Saillard are co-first authors
| | - Margot Thierry
- 26922CHU Nantes, Nantes, France *Vanille Laurent and Justine Saillard are co-first authors
| | - Aline Lepelletier
- 26922CHU Nantes, Nantes, France *Vanille Laurent and Justine Saillard are co-first authors
| | - Clémentine Fronteau
- 26922CHU Nantes, Nantes, France *Vanille Laurent and Justine Saillard are co-first authors
| | - Jean-François Huon
- 26922CHU Nantes, Nantes, France *Vanille Laurent and Justine Saillard are co-first authors
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Herledan C, Baudouin A, Larbre V, Gahbiche A, Dufay E, Alquier I, Ranchon F, Rioufol C. Clinical and economic impact of medication reconciliation in cancer patients: a systematic review. Support Care Cancer 2020; 28:3557-3569. [PMID: 32189099 DOI: 10.1007/s00520-020-05400-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 03/04/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Medication reconciliation can reduce drug-related iatrogenesis by facilitating exhaustive information transmission at care transition points. Given the vulnerability of cancer patients to adverse drug events, medication reconciliation could provide a significant clinical benefit in cancer care. This review aims to synthesize existing evidence on medication reconciliation in cancer patients. METHODS A comprehensive search was performed in the PubMed/Medline, Scopus, and Web of Science databases, associating the keywords "medication reconciliation" and "cancer" or "oncology." RESULTS Fourteen studies met the selection criteria. Various medication reconciliation practices were reported: performed at admission or discharge, for hospitalized or ambulatory patients treated with oral or parenteral anticancer drugs. In one randomized controlled trial, medication reconciliation decreased clinically significant medication errors by 26%. Although most studies were non-comparative, they highlighted that medication reconciliation led to identification of discrepancies and other drug-related problems in up to 88% and 94.7% of patients, respectively. The impact on post-discharge healthcare utilization remains under-evaluated and mostly inconclusive, despite a trend toward reduction. No comparative economic evaluations were available but one study estimated the benefit:cost ratio of medication reconciliation to be 2.31:1, suggesting its benefits largely outweigh its costs. Several studies also underlined the extended pharmacist time required for the intervention, highlighting the need for further cost analysis. CONCLUSION Medication reconciliation can reduce adverse drug events in cancer patients. More robust and economic evaluations are still required to support its development in everyday practice.
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Affiliation(s)
- Chloé Herledan
- Unité de Pharmacie Clinique Oncologique, Groupement Hospitalier Sud, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, Pierre-Bénite, France
- EMR3738, Université de Lyon, Lyon, France
| | - Amandine Baudouin
- Unité de Pharmacie Clinique Oncologique, Groupement Hospitalier Sud, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, Pierre-Bénite, France
| | - Virginie Larbre
- Unité de Pharmacie Clinique Oncologique, Groupement Hospitalier Sud, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, Pierre-Bénite, France
- EMR3738, Université de Lyon, Lyon, France
| | - Anas Gahbiche
- Unité de Pharmacie Clinique Oncologique, Groupement Hospitalier Sud, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, Pierre-Bénite, France
| | - Edith Dufay
- Service Pharmacie, Centre Hospitalier de Lunéville, 6 Rue Jean Girardet, Lunéville, France
| | - Isabelle Alquier
- Direction de l'Amélioration de la Qualité et de la Sécurité des Soins, Service Evaluation et Outils pour la Qualité et la Sécurité des Soins, Haute Autorité de Santé, 5 avenue du Stade de France, Saint-Denis la Plaine, France
| | - Florence Ranchon
- Unité de Pharmacie Clinique Oncologique, Groupement Hospitalier Sud, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, Pierre-Bénite, France
- EMR3738, Université de Lyon, Lyon, France
| | - Catherine Rioufol
- Unité de Pharmacie Clinique Oncologique, Groupement Hospitalier Sud, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, Pierre-Bénite, France.
- EMR3738, Université de Lyon, Lyon, France.
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Haider A, Azhar A, Nguyen K, Dev R, Naqvi SMA, Naqvi SMA, Edwards T, Reddy A, Dalal S, Tanco KC, Arthur J, Williams JL, Park M, Liu DD, Dibaj SS, Bruera E. Concurrent use of opioids with benzodiazepines or nonbenzodiazepine sedatives among patients with cancer referred to an outpatient palliative care clinic. Cancer 2019; 125:4525-4531. [PMID: 31460669 DOI: 10.1002/cncr.32484] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 07/10/2019] [Accepted: 08/02/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND The concurrent use of opioids with benzodiazepines (BZD) or nonbenzodiazepine sedatives (S) recently was found to be associated with an increased risk of overdose death compared with the use of opioids alone. In the current study, the authors examined the frequency and trend of concurrent opioid/BZD-S use and its associated risk factors among patients with cancer. METHODS Data regarding the frequency and trend of concurrent opioid/BZD-S use were extracted for 1500 randomly selected patients referred to the outpatient palliative care clinic at The University of Texas MD Anderson Cancer Center between the calendar years of 2011 and 2016. To explore associated risk factors, the authors compared the demographic and clinical predictors of 418 patients each in the concurrent opioid/BZD-S group and opioids-only group. RESULTS In 2011, at the time of referral to the palliative care clinic, 96 of 221 patients with cancer (43%) were prescribed concurrent opioids/BZD-S. This rate progressively declined to 67 of 217 patients (31%) by 2016 (P = .0008). Patients in the concurrent opioid/BZD-S group had a higher percentage of females (233 individuals; 55% [P = .007]) and whites (323 individuals; 77% [P = .002]), and patients reported higher scores regarding depression (P = .0001), anxiety (P ≤ .0001), drowsiness (P = .048), and worst feeling of well-being (P = .001). The morphine equivalent daily dose was significantly higher in concurrent opioid/BZD-S group (median of 67.5 mg/day [interquartile range (IQR), 30-135 mg/day] vs 60 mg/day [IQR, 30-105 mg/day]; P = .034). Multivariate analysis demonstrated that anxiety (P ≤ .0001), white race (P = .0092), and poor Eastern Cooperative Oncology Group performance status (P = .0017) were significantly associated with concurrent use. CONCLUSIONS The concurrent use of opioids with BZD-S has declined but continues to be frequent among patients with cancer. Anxiety, white race, and poor Eastern Cooperative Oncology Group performance status were associated with its use. More research is needed to explore which medications can replace these agents.
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Affiliation(s)
- Ali Haider
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ahsan Azhar
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kristy Nguyen
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rony Dev
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Syed Mujtaba Ali Naqvi
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Syed Mussadiq Ali Naqvi
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tonya Edwards
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Akhila Reddy
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shalini Dalal
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kimberson C Tanco
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joseph Arthur
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Janet L Williams
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Minjeong Park
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Diane D Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Seyedeh S Dibaj
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Wenedy A, Lim YQ, Lin Ronggui CK, Koh GCH, Chong PH, Chew LST. A Study of Medication Use of Cancer and Non-Cancer Patients in Home Hospice Care in Singapore: A Retrospective Study from 2011 to 2015. J Palliat Med 2019; 22:1243-1251. [DOI: 10.1089/jpm.2018.0559] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Aldo Wenedy
- Department of Pharmacy, National Cancer Center Singapore, Singapore
| | - Yong Quan Lim
- Department of Pharmacy, National University of Singapore, Singapore
| | | | - Gerald Choon Huat Koh
- Saw Swee Hock School of Public Health and Yong Loo Lin School of Medicine, National University of Singapore/National University Health System, Singapore
| | | | - Lita Sui Tjien Chew
- Department of Pharmacy, National Cancer Center Singapore, Singapore
- Department of Pharmacy, National University of Singapore, Singapore
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Oldak S, Ioannou S, Kamath P, Huang M, George S, Slomovitz B, Schlumbrecht M. Polypharmacy in Patients with Ovarian Cancer. Oncologist 2019; 24:1201-1208. [PMID: 30952819 PMCID: PMC6738286 DOI: 10.1634/theoncologist.2018-0807] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/12/2019] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Polypharmacy has been associated with morbidity and mortality in patients with cancer. Data about polypharmacy among patients with ovarian cancer are limited. The primary objective of this study was to evaluate polypharmacy in a cohort of patients with ovarian cancer and to assess the evolution of polypharmacy from initial presentation to 2 years posttreatment. A secondary objective was to evaluate differences in polypharmacy between a subset of patients primarily treated in our comprehensive cancer center (CCC) and our safety net hospital (SNH). METHODS Women treated for ovarian cancer between January 1, 2011, and December 31, 2016, were included. Data were abstracted from the electronic medical record. Medication safety was assessed using the established Anticholinergic Burden (ACB) scale and the Beers criteria. Statistical analyses were performed using paired t tests and Cox proportional hazards models, with significance set at p < .05. RESULTS The study included 152 patients. The majority of patients had high-grade serous carcinoma. Hypertension was the most common medical problem. The mean number of medications at the time of diagnosis was 3.72. Paired testing demonstrated significant patient-level increases in the number medications at 2 years following initial diagnosis (4.16 vs. 7.01, p < .001). At the CCC, 47.4% of patients met criteria for polypharmacy at diagnosis compared with 19.4% at the SNH (p < .001). By 2 years postdiagnosis, 77.6% of patients at the CCC met criteria for polypharmacy compared with 43.3% at the SNH (p = .001). The use of any medications on the ACB scale (p < .001) increased significantly between initial diagnosis and 2 years for the entire population. Polypharmacy was not a significant predictor of overall survival. CONCLUSION Polypharmacy worsens as women go through ovarian cancer treatment. Both at initial presentation and at 2 years postdiagnosis, rates of polypharmacy were higher at the CCC. Polypharmacy did not have an effect on survival in this cohort. IMPLICATIONS FOR PRACTICE Awareness of escalating numbers of medications and potentially adverse interactions is crucial among women with ovarian cancer, who are at high risk for polypharmacy.
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Affiliation(s)
- Sean Oldak
- Miller School of Medicine, University of Miami, Miami, Florida, USA
| | | | - Priyanka Kamath
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
| | - Marilyn Huang
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
| | - Sophia George
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
| | - Brian Slomovitz
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
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Sleep quality in hospitalized patients with advanced cancer: an observational study using self-reports of sleep and actigraphy. Support Care Cancer 2019; 28:2015-2023. [PMID: 31392550 DOI: 10.1007/s00520-019-04998-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Although patients with advanced cancer report poor sleep quality, few studies have assessed sleep quality with a combination of subjective and objective measures. We aimed to examine sleep quality in hospitalized patients with advanced cancer by combining patient-reported outcome-measures (PROMs) and polysomnography (PSG) or actigraphy. METHODS A one-night prospective observational study of sleep in hospitalized patients with metastatic cancer using WHO step III opioids was conducted. Total sleep time, sleep onset latency, number of awakenings, and wake after sleep onset were assessed by PROMs and actigraphy. Sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI) (range; 0-21), where higher scores indicate worse sleep quality. RESULTS Forty patients were monitored. Median age was 70, median oral morphine equivalent dose was 80 mg/24 h (10-1725), median Karnofsky Performance Score was 50 (20-90), and median time to death from inclusion was 38 days (4-319). Mean PSQI score was 6.5 (SD ± 3.4). PROMs and actigraphy of mean (SD) sleep onset latency were 46 (± 64) and 35 min (± 61), respectively, while mean time awake at night was 37 (± 35) and 40 min (± 21). PROMs and actigraphy differed on number of awakenings (mean 2 (± 1) vs. 24 (± 15), p ˂ 0.001). Bland-Altman plots showed large individual differences between PROMs and actigraphy. PSG was not feasible. CONCLUSIONS PROMs and actigraphy documented poor sleep quality, but a lack of agreement across methods. The study demonstrates a need to improve assessment of sleep quality and treatment of sleep disturbance in hospitalized patients with advanced cancer near end of life.
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Magee DJ, Jhanji S, Poulogiannis G, Farquhar-Smith P, Brown MRD. Nonsteroidal anti-inflammatory drugs and pain in cancer patients: a systematic review and reappraisal of the evidence. Br J Anaesth 2019; 123:e412-e423. [PMID: 31122736 PMCID: PMC6676054 DOI: 10.1016/j.bja.2019.02.028] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/28/2019] [Accepted: 02/28/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Emerging data highlights the potential role of cyclooxygenase (COX) inhibitors in the primary prevention of malignancy, reducing metastatic spread and improving overall mortality. Despite nonsteroidal anti-inflammatory drugs (NSAIDs) forming a key component of the WHO analgesic ladder, their use in cancer pain management remains relatively low. This review re-appraises the current evidence regarding the efficacy of COX inhibitors as analgesics in cancer pain, providing a succinct resource to aid clinicians' decision making when determining treatment strategies. METHODS Medline® and Embase® databases were searched for publications up to November 2018. Randomised controlled trials (RCTs) and double-blind controlled studies considering the use of NSAIDs for management of cancer-related pain in adults were included. Animal studies, case reports, and retrospective observational data were excluded. RESULTS Thirty studies investigating the use of NSAIDs in cancer pain management were identified. There is a lack of high-quality evidence regarding the analgesic efficacy of NSAIDs in cancer pain, with short study durations and heterogeneity in outcome measures limiting the ability to draw meaningful conclusions. CONCLUSIONS Despite the renewed interest in these cost-effective, well-established medications in cancer treatment outcomes, there is a paucity of data from the past 15 yr regarding their efficacy in cancer pain management. However, when analgesic strategies in the cancer population are being formulated, it is important that the potential benefits of this class of drug are considered. Further work investigating the role of NSAIDs in cancer pain management is undoubtedly warranted.
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Affiliation(s)
- D J Magee
- Pain Medicine Department, The Royal Marsden Hospital, London, UK; Signalling and Cancer Metabolism, Division of Cancer Biology, The Institute of Cancer Research, London, UK.
| | - S Jhanji
- Anaesthesia and Perioperative Medicine, The Royal Marsden Hospital, London, UK; Perioperative and Critical Care Outcomes Group, Division of Cancer Biology, The Institute of Cancer Research, London, UK
| | - G Poulogiannis
- Signalling and Cancer Metabolism, Division of Cancer Biology, The Institute of Cancer Research, London, UK
| | - P Farquhar-Smith
- Pain Medicine Department, The Royal Marsden Hospital, London, UK
| | - M R D Brown
- Pain Medicine Department, The Royal Marsden Hospital, London, UK; Targeted Approaches to Cancer Pain Group, The Institute of Cancer Research, Sutton, Surrey, UK
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Uchida M, Suzuki S, Sugawara H, Suga Y, Kokubun H, Uesawa Y, Nakagawa T, Takase H. A nationwide survey of hospital pharmacist interventions to improve polypharmacy for patients with cancer in palliative care in Japan. J Pharm Health Care Sci 2019; 5:14. [PMID: 31308953 PMCID: PMC6607579 DOI: 10.1186/s40780-019-0143-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/21/2019] [Indexed: 12/29/2022] Open
Abstract
Background There is no nationwide data on polypharmacy in palliative care in Japan. In this study, the research committee of the Japanese Society for Pharmaceutical Palliative Care and Sciences conducted an online survey on polypharmacy and inappropriate prescriptions involving its members who worked as hospital pharmacists. Methods The online questionnaire included questions about hospital pharmacist interventions for cancer patients who regularly used six or more drugs during a two-month period from October to November 2017. Results Of 2618 hospital pharmacists, 359 responded (13.7%). With regard to cancer patients receiving opioids, 40.9 and 22.3% of the respondents replied that percentages of patients prescribed six or more regular medications were “40–69%” and “70–99%,” respectively. Regarding patients on polypharmacy, 73.0% of the respondents reported a low or moderate rate of inappropriate prescriptions, with responses such as “long-term administration of irresponsible or aimless medications”, “adverse drug reactions,” and “duplication of the pharmacological effect”. Furthermore, 24.2, 46.8, and 23.4% of respondents replied that the rates of drug reduction due to pharmacist recommendations were “0”, “1–39%”, and “more than 40%,” respectively. Pharmacist interventions decreased the use of inappropriate medications, including antiemetics, gastrointestinal medications, and hypnotic sedatives, and reduced or prevented adverse drug reactions such as extrapyramidal symptoms, delirium, and sleepiness. Similar results were obtained for cancer patients who did not use opioids. However, the rates of cancer patients on polypharmacy and with reduction of inappropriate medications by pharmacist interventions were significantly higher in cancer patients receiving opioids. Finally, recommendations of board-certified pharmacists in palliative pharmacy contributed to a decrease in the use of inappropriate medications in cancer patients on polypharmacy (p = 0.06). Conclusion This nationwide survey clarified pharmacist interventions for polypharmacy in palliative care in Japan. Our data showed frequent polypharmacy in cancer patients receiving opioids, and benefits of pharmacist interventions, especially by board-certified pharmacists in palliative pharmacy, for reducing inappropriate medications and improving adverse drug reactions. Trial registration The study approval numbers in the institution; 0046. Registered November 6, 2017. Electronic supplementary material The online version of this article (10.1186/s40780-019-0143-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mayako Uchida
- 1Education and Research Center for Clinical Pharmacy, Osaka University of Pharmaceutical Sciences, 4-20-1 Nasahara, Takatsuki, Osaka, 569-1094 Japan.,Research Promotion Committee, Japanese Society for Pharmaceutical Palliative Care and Sciences (JSPPCS), Osaka, Japan
| | - Shinya Suzuki
- 2Department of Pharmacy, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577 Japan.,Research Promotion Committee, Japanese Society for Pharmaceutical Palliative Care and Sciences (JSPPCS), Osaka, Japan
| | - Hideki Sugawara
- 3Department of Pharmacy, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima 890-8520 Japan.,Research Promotion Committee, Japanese Society for Pharmaceutical Palliative Care and Sciences (JSPPCS), Osaka, Japan
| | - Yukio Suga
- 4Department of Clinical Drug Informatics, Faculty of Pharmacy, Institute of Medical, Pharmaceutical & Health Science, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa 920-8641 Japan.,Research Promotion Committee, Japanese Society for Pharmaceutical Palliative Care and Sciences (JSPPCS), Osaka, Japan
| | - Hideya Kokubun
- 5Tokyo University of Pharmacy and Life Sciences, 1432-1, Horinouchi, Hachioji, Tokyo, 192-0392 Japan.,Research Promotion Committee, Japanese Society for Pharmaceutical Palliative Care and Sciences (JSPPCS), Osaka, Japan
| | - Yoshihiro Uesawa
- 6Department of Medical Molecular Informatics, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo, 204-8588 Japan.,Research Promotion Committee, Japanese Society for Pharmaceutical Palliative Care and Sciences (JSPPCS), Osaka, Japan
| | - Takayuki Nakagawa
- 7Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507 Japan.,Research Promotion Committee, Japanese Society for Pharmaceutical Palliative Care and Sciences (JSPPCS), Osaka, Japan
| | - Hisamitsu Takase
- 8Nippon Medical School Tama-Nagayama Hospital, 1-7-1, Nagayama, Tama-shi, Tokyo, 206-8512 Japan.,Research Promotion Committee, Japanese Society for Pharmaceutical Palliative Care and Sciences (JSPPCS), Osaka, Japan
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Azhar A, Haider A, Ali Naqvi SM, Wong AN, Dibaj SS, Liu DD, Williams JL, Bruera E. Frequency of Concomitant Use of Opioids and Psychoactive Medications Among Cancer Patients Referred to Outpatient Palliative Care. J Pain Symptom Manage 2019; 57:e7-e10. [PMID: 30878298 DOI: 10.1016/j.jpainsymman.2019.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 03/05/2019] [Accepted: 03/06/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Ahsan Azhar
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| | - Ali Haider
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Syed M Ali Naqvi
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Angelique N Wong
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Seyedeh S Dibaj
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane D Liu
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Janet L Williams
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Kotlinska-Lemieszek A, Klepstad P, Haugen DF. Clinically Significant Drug-Drug Interactions Involving Medications Used for Symptom Control in Patients With Advanced Malignant Disease: A Systematic Review. J Pain Symptom Manage 2019; 57:989-998.e1. [PMID: 30776538 DOI: 10.1016/j.jpainsymman.2019.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 11/23/2022]
Abstract
CONTEXT Most patients with advanced malignant disease need to take several drugs to control symptoms. This treatment raises risks of serious adverse effects and drug-drug interactions (DDIs). OBJECTIVES To identify studies reporting clinically significant DDIs involving medications used for symptom control, other than opioids used for pain management, in adult patients with advanced malignant disease. METHODS Systematic review with searches in Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials, from the start of the databases (Embase from 1980) through June 21, 2018. In addition, reference lists of relevant full-text articles were hand-searched. RESULTS Of 9699 retrieved citations, 462 were considered potentially eligible. After full-text reading, 29 were included in the final analysis, together with 13 articles from reference lists. The 42 included publications were case reports, letters to the Editor, and one retrospective study. Drugs most often involved were antiepileptics, antidepressants, corticosteroids, and nonopioid analgesics. Clinical manifestations of identified DDIs included sedation, respiratory depression, serotonin syndrome, neuroleptic malignant syndrome, delirium, seizures, ataxia, liver and kidney failure, bleeding, cardiac arrhythmias, rhabdomyolysis, and others. The most common mechanisms eliciting DDIs were alteration of CYP450-dependent metabolism and overstimulation of serotonin receptors in the central nervous system. CONCLUSION Drugs used for symptom control in patients with advanced cancer may cause serious DDIs. Although there is limited evidence for the risk of clinically significant DDIs, physicians treating patients with cancer should try to limit polypharmacy, avoid drug combinations with a high risk of DDIs, and closely monitor patients for adverse drug reactions.
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Affiliation(s)
- Aleksandra Kotlinska-Lemieszek
- Palliative Medicine Chair and Department, Karol Marcinkowski University of Medical Sciences, Poznan, Poland; Hospice Palium, University Hospital of the Lord's Transfiguration, Poznan, Poland.
| | - Pål Klepstad
- Department of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim, Norway; Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Dagny Faksvåg Haugen
- Regional Centre of Excellence for Palliative Care Western Norway, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine K1, University of Bergen, Bergen, Norway
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Morin L, Todd A, Barclay S, Wastesson JW, Fastbom J, Johnell K. Preventive drugs in the last year of life of older adults with cancer: Is there room for deprescribing? Cancer 2019; 125:2309-2317. [PMID: 30906987 DOI: 10.1002/cncr.32044] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/06/2019] [Accepted: 02/11/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND The continuation of preventive drugs among older patients with advanced cancer has come under scrutiny because these drugs are unlikely to achieve their clinical benefit during the patients' remaining lifespan. METHODS A nationwide cohort study of older adults (those aged ≥65 years) with solid tumors who died between 2007 and 2013 was performed in Sweden, using routinely collected data with record linkage. The authors calculated the monthly use and cost of preventive drugs throughout the last year before the patients' death. RESULTS Among 151,201 older persons who died with cancer (mean age, 81.3 years [standard deviation, 8.1 years]), the average number of drugs increased from 6.9 to 10.1 over the course of the last year before death. Preventive drugs frequently were continued until the final month of life, including antihypertensives, platelet aggregation inhibitors, anticoagulants, statins, and oral antidiabetics. Median drug costs amounted to $1482 (interquartile range [IQR], $700-$2896]) per person, including $213 (IQR, $77-$490) for preventive therapies. Compared with older adults who died with lung cancer (median drug cost, $205; IQR, $61-$523), costs for preventive drugs were higher among older adults who died with pancreatic cancer (adjusted median difference, $13; 95% confidence interval, $5-$22) or gynecological cancers (adjusted median difference, $27; 95% confidence interval, $18-$36). There was no decrease noted with regard to the cost of preventive drugs throughout the last year of life. CONCLUSIONS Preventive drugs commonly are prescribed during the last year of life among older adults with cancer, and often are continued until the final weeks before death. Adequate deprescribing strategies are warranted to reduce the burden of drugs with limited clinical benefit near the end of life.
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Affiliation(s)
- Lucas Morin
- Aging Research Center, Karolinska Institutet, Stockholm, Sweden
| | - Adam Todd
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, Newcastle, United Kingdom
| | - Stephen Barclay
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | | | - Johan Fastbom
- Aging Research Center, Karolinska Institutet, Stockholm, Sweden
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Paque K, Elseviers M, Vander Stichele R, Pardon K, Vinkeroye C, Deliens L, Christiaens T, Dilles T. Balancing medication use in nursing home residents with life-limiting disease. Eur J Clin Pharmacol 2019; 75:969-977. [DOI: 10.1007/s00228-019-02649-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 02/11/2019] [Indexed: 12/13/2022]
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Al-Shahri MZ, Sroor MY, Ghareeb WA, Aboulela EN, Edesa W. The Use of Antidiabetic, Antihypertensive, and Lipid-lowering Medications in the Elderly Dying with Advanced Cancer. Indian J Palliat Care 2019; 25:124-126. [PMID: 30820114 PMCID: PMC6388588 DOI: 10.4103/ijpc.ijpc_96_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Maintenance of medications that are unconducive to the quality of life is difficult to justify in dying terminally-ill cancer patients. Objective We aimed at determining the prevalence of administering antidiabetic, antihypertensive, and lipid-lowering medications to elderly patients dying with cancer. Methods We reviewed the medical records of patients above 60 years of age with advanced cancer who died in a palliative care unit. The collected data included the use of antidiabetic, antihypertensive, and lipid-lowering medications during the last week of life. Results Of 103 patients, 51.5% were female and the median age was 69 years. The most common cancers included gastrointestinal (40.8%), gynecological (13.6%), and head and neck (12.6%). All patients had advanced cancer and 59.2% had hypertension, 52.4% had diabetes mellitus, and 19.4% had dyslipidemia. During their last week of life, 38.8% received antidiabetic, 23.3% received antihypertensive, and 3.9% received lipid-lowering agents. The data showed that 68.5% of people with diabetes received antidiabetic medications, 37.7% of hypertensive patients received antihypertensive medications, and 20% of dyslipidemics received lipid-lowering agents. Hypoglycemia was reported in 7.5% of patients receiving antidiabetic drugs, while hypotension was reported in 66.7% of patients receiving antihypertensive agents. Conclusion Many elderly patients dying with advanced cancer in a palliative care unit were maintained on medications for chronic conditions until the very late stages of their lives. For such imminently dying patients, benefits of such medications are unlikely and burdens are possible. Further research is needed to explore physicians' justifications, if any, for maintaining such patients on apparently futile medications.
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Affiliation(s)
| | - Mahmoud Yassein Sroor
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,Kasr Alaini Center of Clinical Oncology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Wael Ali Ghareeb
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,Kasr Alaini Center of Clinical Oncology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Enas Noshy Aboulela
- Kasr Alaini Center of Clinical Oncology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Wael Edesa
- Kasr Alaini Center of Clinical Oncology, Faculty of Medicine, Cairo University, Cairo, Egypt
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Hertz DL, Siden R, Modlin J, Gabel LL, Wong SF. Drug interaction screening in SWOG clinical trials. Am J Health Syst Pharm 2019; 75:607-612. [PMID: 29748299 DOI: 10.2146/ajhp170449] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
PURPOSE The frequency and process for drug interaction (DI) screening at sites enrolling patients into SWOG clinical trials were studied. METHODS Survey invitations were e-mailed to 180 SWOG head clinical research associates to determine the frequency of and personnel involved in DI assessment in subjects who were screened for and enrolled in clinical trials at their sites. Descriptive statistics were performed to evaluate the data. RESULTS A total of 83 surveys recorded a response to at least 1 question, yielding an overall response rate of 46.1%. At least 72 completed surveys were submitted, for a completion rate of 40.0%. The majority of sites (51%) reported that DI screening only occurred during eligibility assessment when a DI was included in the protocol exclusion criteria. The pharmacist was "always" involved in DI screening during eligibility assessment at 17% of sites. Clinical research coordinators (56%) and research nurses (45%) were the predominant personnel who performed DI screening to assess eligibility for trial enrollment. A subset of sites (3-6%) reported not having access to a pharmacist. Fewer than 10% of sites reported that they "always" use drug information services, websites, resources, or literature searches, though many tools were used "often" or "sometimes" by more than 20% of sites. CONCLUSION A survey revealed that DI screening was not being systematically conducted within SWOG clinical trials. When DI screening did occur, it was primarily conducted by clinical research coordinators or study nurses. Pharmacist-led DI screening was not the current practice within SWOG sites surveyed and was precluded by a lack of pharmacists' availability or involvement.
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Affiliation(s)
- Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI
| | - Rivka Siden
- Oncology Clinical Trials Support Unit, University of Michigan, Ann Arbor, MI
| | - Jessie Modlin
- St. Luke's Mountain States Tumor Institute, Boise, ID
| | | | - Siu Fun Wong
- Chapman University School of Pharmacy, Irvine, CA
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46
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Morio K, Maeda I, Yokota I, Niki K, Murata T, Matsumura Y, Uejima E. Risk Factors for Polypharmacy in Elderly Patients With Cancer Pain. Am J Hosp Palliat Care 2019; 36:598-602. [DOI: 10.1177/1049909118824031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Kayoko Morio
- Unit of Clinical Pharmacy Education, Graduate School of Pharmaceutical Sciences, Osaka University, Osaka, Japan
| | | | - Isao Yokota
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kazuyuki Niki
- Unit of Clinical Pharmacy Education, Graduate School of Pharmaceutical Sciences, Osaka University, Osaka, Japan
| | - Taizo Murata
- Department of Medical Information, Osaka University Medical Hospital, Osaka, Japan
| | - Yasushi Matsumura
- Department of Medical Information, Osaka University Medical Hospital, Osaka, Japan
| | - Etsuko Uejima
- Unit of Clinical Pharmacy Education, Graduate School of Pharmaceutical Sciences, Osaka University, Osaka, Japan
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47
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Paque K, Vander Stichele R, Elseviers M, Pardon K, Dilles T, Deliens L, Christiaens T. Barriers and enablers to deprescribing in people with a life-limiting disease: A systematic review. Palliat Med 2019; 33:37-48. [PMID: 30229704 DOI: 10.1177/0269216318801124] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND: Knowing the barriers/enablers to deprescribing in people with a life-limiting disease is crucial for the development of successful deprescribing interventions. These barriers/enablers have been studied, but the available evidence has not been summarized in a systematic review. AIM: To identify the barriers/enablers to deprescribing of medications in people with a life-limiting disease. DESIGN: Systematic review, registered in PROSPERO (CRD42017073693). DATA SOURCES: A systematic search of MEDLINE, Embase, Web of Science and CENTRAL was conducted and extended with a hand search. Peer-reviewed, primary studies reporting on barriers/enablers to deprescribing in the context of explicit life-limiting disease were included in this review. RESULTS: A total of 1026 references were checked. Five studies met the criteria and were included in this review. Three types of barriers/enablers were found: organizational, professional and patient (family)-related barriers/enablers. The most prominent enablers were organizational support (e.g. for standardized medication review), involvement of multidisciplinary teams in medication review and the perception of the importance of coming to a joint decision regarding deprescribing, which highlighted the need for interdisciplinary collaboration and involving the patient and his family in the decision-making process. The most important barriers were shortages in staff and the perceived difficulty or resistance of the nursing home resident's family - or the resident himself. CONCLUSION AND IMPLICATIONS OF KEY FINDINGS: The scarcity of findings in the literature highlights the importance of filling this gap. Further research should focus on deepening the knowledge on these barriers/enablers in order to develop sustainable multifaceted deprescribing interventions in palliative care.
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Affiliation(s)
- Kristel Paque
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.,2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Robert Vander Stichele
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Monique Elseviers
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.,3 Faculty of Medicine and Health Sciences, Department of Nursing Science, Centre for Research and Innovation in Care (CRIC), University of Antwerp, Antwerp, Belgium
| | - Koen Pardon
- 2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Tinne Dilles
- 3 Faculty of Medicine and Health Sciences, Department of Nursing Science, Centre for Research and Innovation in Care (CRIC), University of Antwerp, Antwerp, Belgium.,4 Department of Nursing and Midwifery, Thomas More University College, Lier, Belgium
| | - Luc Deliens
- 2 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,5 Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Thierry Christiaens
- 1 Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
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48
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Jakobsen G, Engstrøm M, Paulsen Ø, Sjue K, Raj SX, Thronæs M, Hjermstad MJ, Kaasa S, Fayers P, Klepstad P. Zopiclone versus placebo for short-term treatment of insomnia in patients with advanced cancer: study protocol for a double-blind, randomized, placebo-controlled, clinical multicenter trial. Trials 2018; 19:707. [PMID: 30591073 PMCID: PMC6307135 DOI: 10.1186/s13063-018-3088-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 11/30/2018] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Despite the high prevalence of insomnia in patients with advanced cancer, there are no randomized controlled trials on pharmacological interventions for insomnia in this group of patients. A variety of pharmacological agents is recommended to manage sleep disturbance for insomnia in the general population, but their efficacy and safety in adults with advanced cancer are not established. Thus, there is a need to evaluate the effectiveness of medications for insomnia in order to improve the evidence in patients with advanced cancer. One of the most used sleep medications at present in patients with cancer is zopiclone. METHODS This is a randomized, double-blind, placebo-controlled, parallel-group, multicenter trial. A total of 100 patients with metastatic cancer who report insomnia will be randomly allocated to zopiclone or placebo. The treatment duration with zopiclone/placebo is 6 consecutive nights. The primary endpoint is patient-reported sleep quality during the final study night (night 6) assessed on a numerical rating scale of 0-10, where 0 = Best sleep and 10 = Worst possible sleep. Secondary endpoints include the mean patient-reported total sleep time and sleep onset latency during the final study night (night 6). DISCUSSION Results from this study on treatment of insomnia in advanced cancer will contribute to clinical decision-making and improve the treatment of sleep disturbance in this patient cohort. TRIAL REGISTRATION ClinicalTrials.gov, NCT02807922 . Registered on 21 June 2016.
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Affiliation(s)
- Gunnhild Jakobsen
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology and St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway. .,Cancer Clinic, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Morten Engstrøm
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Neurology and Clinical Neurophysiology, St. Olavs hospital, Trondheim, Norway
| | - Ørnulf Paulsen
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology and St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway.,Palliative Care Unit, Telemark Hospital Trust, Skien, Norway
| | - Karin Sjue
- Department of Oncology, Vestfold Hospital Trust, Tønsberg, Norway
| | - Sunil X Raj
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology and St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway.,Cancer Clinic, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Morten Thronæs
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology and St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway.,Cancer Clinic, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Marianne Jensen Hjermstad
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Stein Kaasa
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Peter Fayers
- Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Pål Klepstad
- Department of Anaesthesiology and Intensive Care Medicine, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology NTNU, Trondheim, Norway
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49
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Ersoy S, Engin VS. Risk factors for polypharmacy in older adults in a primary care setting: a cross-sectional study. Clin Interv Aging 2018; 13:2003-2011. [PMID: 30410317 PMCID: PMC6197244 DOI: 10.2147/cia.s176329] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Purpose Polypharmacy (PP) is a clinical challenge in older adults. Therefore, assessment of daily drug consumption (DDC) and its relationships is important. First-line health services have a crucial role in monitoring and preventing PP. In this study, we aimed to assess DDC and investigate the risk factors for higher DDC among older adults in a primary care setting. Patients and methods A total of 1,000 patients aged ≥65 years who visited Melek Hatun Family Practice Center between December 1, 2014, and August 1, 2017, were enrolled in the study. All patients were seen either at the center or in their homes, and informed consent was obtained. Comprehensive geriatric assessment was performed for each subject. Data were analyzed using SPSS software (version 17). The daily number of medicines that each patient used (DDC) regardless of whether they were prescribed was the dependent variable. Relationships between DDC and other continuous variables were examined using Pearson's correlation. For between-group comparisons of DDC, Student's t-tests were performed. Results Univariate tests showed relationships between DDC and various demographic and clinical parameters. The variables that remained significant at the last step of a stepwise linear regression analysis were metabolic syndrome, chronic pain, incontinence, increased serum creatinine level, increased Geriatric Depression Scale scores, reported gastric disturbances, and neutrophil/lymphocyte ratio. Conclusion Along with certain chronic conditions, depressive symptoms and an inflammatory marker (neutrophil/lymphocyte ratio) were significantly and independently related to higher DDC. Longitudinal and larger studies are needed to further explore the multifaceted relationships of PP.
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Affiliation(s)
- Suleyman Ersoy
- Department of Family Medicine, Faculty of Medicine, Karabuk University, Karabuk, Turkey,
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50
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Bernatchez MS, Savard J, Aubin M, Ivers H. Correlates of disrupted sleep-wake variables in patients with advanced cancer. BMJ Support Palliat Care 2018; 10:55-63. [PMID: 29960955 DOI: 10.1136/bmjspcare-2018-001505] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 05/21/2018] [Accepted: 06/13/2018] [Indexed: 01/20/2023]
Abstract
OBJECTIVES High rates of sleep difficulties have been found in patients with advanced cancer. However, not much is known about factors that are associated with sleep impairments in this population and that could constitute their potential risk factors or consequences. This study conducted in patients with cancer receiving palliative care aimed to evaluate the relationships of subjective (sleep diary; Insomnia Severity Index, ISI) and objective (actigraphy) sleep-wake variables with several physical and psychological symptoms, maladaptive sleep behaviours, erroneous beliefs about sleep, quality of life, time to death and environmental factors. METHODS The sample was composed of 57 community-dwelling patients with cancer receiving palliative care and with an Eastern Cooperative Oncology Group Scale score of 2 or 3. Actigraphic, light and sound recording and a daily sleep and pain diary were completed for seven consecutive days. A battery of self-report scales was also administered. RESULTS Greater disruptions of subjective and objective sleep-wake variables were more consistently associated with worse physical symptoms than with psychological variables. Disrupted objective sleep-wake parameters were also associated with a greater frequency of maladaptive sleep behaviours. Finally, a greater nocturnal noise in the bedroom was correlated with more impairments in subjective and objective sleep-wake variables while a lower 24-hour light exposure was associated with more disruption of subjectively assessed sleep only. CONCLUSIONS Although longitudinal studies are needed to establish the etiology of sleep-wake difficulties in patients with advanced cancer, our findings suggest that physical symptoms, maladaptive sleep behaviours and environmental factors can contribute to their development or their persistence and need to be adequately addressed.
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Affiliation(s)
- Marie Solange Bernatchez
- School of Psychology, Université Laval, Quebec City, Quebec, Canada.,CHU de Québec-Université Laval Research Center, Quebec City, Quebec, Canada.,Université Laval Cancer Research Center, Quebec City, Quebec, Canada
| | - Josée Savard
- School of Psychology, Université Laval, Quebec City, Quebec, Canada.,CHU de Québec-Université Laval Research Center, Quebec City, Quebec, Canada.,Université Laval Cancer Research Center, Quebec City, Quebec, Canada
| | - Michèle Aubin
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Hans Ivers
- School of Psychology, Université Laval, Quebec City, Quebec, Canada.,CHU de Québec-Université Laval Research Center, Quebec City, Quebec, Canada.,Université Laval Cancer Research Center, Quebec City, Quebec, Canada
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