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Harsanyi H, Yang L, Harper A, Jarada TN, Quan ML, Cheung WY, Lupichuk S, Cuthbert C, Xu Y. Improvement in patient-reported pain among patients with metastatic cancer and its association with opioid prescribing. Support Care Cancer 2023; 31:427. [PMID: 37369812 DOI: 10.1007/s00520-023-07893-2] [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: 03/01/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023]
Abstract
PURPOSE Opioids are a mainstay of cancer pain management; however, patients with metastatic cancer are often excluded from studies, leading to a lack of evidence on whether increased prescribing (dosage and/or duration) results in improved outcomes for this population. This study aimed to investigate whether increased opioid prescribing is associated with an improvement in patient-reported pain among patients with metastatic cancer. PATIENTS AND METHODS A retrospective cohort of all adult patients diagnosed with stage IV cancers, who completed at least two patient-reported outcomes (PROs) within 30 days of each other, was identified from administrative data. Opioid prescriptions were categorized by dosage level and number of prescription days. Multivariable logistic regression was used to investigate the association between opioid prescribing and clinically important improvement in pain score (≥ 1 point change on the Edmonton Symptom Assessment System). RESULTS A total of 2169 patients were included, 770 (35.5%) of whom had active opioid prescription between PROs, with an average daily dosage of 86.1 mg of oral morphine equivalent. Active prescription was associated with improvement in pain (OR = 2.17, P < 0.001). However, among patients with active prescription, neither dosage nor number of prescription days was significantly associated with pain improvement. CONCLUSION Opioid prescription is important for treating cancer-related pain; however, increased dosage or duration may not be leading to greater improvements in pain. Patients with metastatic cancer who are receiving increased opioid prescribing may have difficult-to-treat pain and may benefit from multidisciplinary pain management strategies to supplement opioid prescription and improve outcomes.
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Affiliation(s)
- Hannah Harsanyi
- Department of Community Health Sciences, Foothills Medical Centre, University of Calgary, HRIC 2AA18, 3230, Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada.
| | - Lin Yang
- Department of Community Health Sciences, Foothills Medical Centre, University of Calgary, HRIC 2AA18, 3230, Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
- Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, AB, Canada
| | - Andrew Harper
- Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, AB, Canada
| | - Tamer N Jarada
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - May Lynn Quan
- Department of Community Health Sciences, Foothills Medical Centre, University of Calgary, HRIC 2AA18, 3230, Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Winson Y Cheung
- Department of Community Health Sciences, Foothills Medical Centre, University of Calgary, HRIC 2AA18, 3230, Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Sasha Lupichuk
- Department of Community Health Sciences, Foothills Medical Centre, University of Calgary, HRIC 2AA18, 3230, Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Colleen Cuthbert
- Department of Community Health Sciences, Foothills Medical Centre, University of Calgary, HRIC 2AA18, 3230, Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Yuan Xu
- Department of Community Health Sciences, Foothills Medical Centre, University of Calgary, HRIC 2AA18, 3230, Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- The Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Murphy M, Bennett K, Wright M, O’Reilly M, Conroy M, Hughes C, McLean S, Cadogan CA. Potentially inappropriate prescribing in older adults with cancer receiving specialist palliative care: a retrospective observational study. Int J Clin Pharm 2023; 45:174-183. [PMID: 36378404 PMCID: PMC9664032 DOI: 10.1007/s11096-022-01506-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/14/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Older adults (≥ 65 years) with cancer receiving palliative care often have other health conditions requiring multiple medications. AIM To describe and assess the appropriateness of prescribing for older adults with cancer in the last seven days of life in an inpatient palliative care setting. METHOD Retrospective observational study of medical records for 180 patients (60.6% male; median age: 74 years; range 65-94 years) over a two-year period. Medication appropriateness was assessed using: STOPPFrail, OncPal deprescribing guideline and criteria for identifying Potentially Inappropriate Prescribing in older adults with Cancer receiving Palliative Care (PIP-CPC). RESULTS 94.5% of patients had at least one other health condition (median 3, IQR 2-5). The median number of medications increased from five (IQR 3-7) seven days before death, to 11 medications on the day of death (IQR 9-15). The prevalence of PIP varied depending on the tool used: STOPPFrail (version 1: 17.2%, version 2: 19.4%), OncPal (12.8%), PIP-CPC (30%). However, the retrospective nature of the study limited the applicability of the tools. Increasing number of medications had a statistically significant effect on risk of PIP across all tools (STOPPFrail (version 1: 1.29 (1.13-1.37), version 2: 1.30 (1.16-1.48)); OncPal 1.13 (1.01-1.27); PIP-CPC 0.70 (0.61-0.82)). CONCLUSION This study found that the number of medications prescribed to older adults with cancer increased as time to death approached, and the prevalence of PIP varied with the application of different tools. The study also highlights the difficulties of examining PIP in this patient cohort.
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Affiliation(s)
- Melanie Murphy
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Kathleen Bennett
- Data Science Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | | | | | | - Carmel Hughes
- School of Pharmacy, Queen’s University Belfast, Belfast, UK
| | | | - Cathal A. Cadogan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, D02PN40 Ireland
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Prescribing practices, patterns, and potential harms in patients receiving palliative care: A systematic scoping review. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2021; 3:100050. [PMID: 35480601 PMCID: PMC9031741 DOI: 10.1016/j.rcsop.2021.100050] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 07/12/2021] [Accepted: 07/20/2021] [Indexed: 01/25/2023] Open
Abstract
Background Patients receiving palliative care often have existing comorbidities necessitating the prescribing of multiple medications. To maximize quality of life in this patient cohort, it is important to tailor prescribing of medication for preventing and treating existing illnesses and those for controlling symptoms, such as pain, according to individual specific needs. Objective(s) To provide an overview of peer-reviewed observational research on prescribing practices, patterns, and potential harms in patients receiving palliative care. Methods A systematic scoping review was conducted using four electronic databases (PubMed, EMBASE, CINAHL, Web of Science). Each database was searched from inception to May 2020. Search terms included ‘palliative care,’ ‘end of life,’ and ‘prescribing.’ Eligible studies had to examine prescribing for adults (≥18 years) receiving palliative care in any setting as a study aim or outcome. Studies focusing on single medication types (e.g., opioids), medication classes (e.g., chemotherapy), or clinical indications (e.g., pain) were excluded. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews, and the findings were described using narrative synthesis. Results Following deduplication, 16,565 unique citations were reviewed, and 56 studies met inclusion criteria. The average number of prescribed medications per patient ranged from 3 to 23. Typically, prescribing changes involved decreases in preventative medications and increases in symptom-specific medications closer to the time of death. Twenty-one studies assessed the appropriateness of prescribing using various tools. The prevalence of patients with ≥1 potentially inappropriate prescription ranged from 15 to 92%. Three studies reported on adverse drug events. Conclusions This scoping review provides a broad overview of existing research and shows that many patients receiving palliative care receive multiple medications closer to the time of death. Future research should focus in greater detail on prescribing appropriateness using tools specifically developed to guide prescribing in palliative care and the potential for harm.
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4
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Ham L, Geijteman ECT, Aarts MJ, Kuiper JG, Kunst PWA, Raijmakers NJH, Visser LE, van Zuylen L, Brokaar EJ, Fransen HP. Use of potentially inappropriate medication in older patients with lung cancer at the end of life. J Geriatr Oncol 2021; 13:53-59. [PMID: 34366274 DOI: 10.1016/j.jgo.2021.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 06/10/2021] [Accepted: 07/29/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Medications at the end of life should be used for symptom control. Medications which potential adverse effects outweigh their expected benefits are called 'potentially inappropriate medications' (PIMs). PIMs are related with adverse drug events and reduced quality of life. In this study, we investigated to what extent PIMs are dispensed to older patients with lung cancer in the last month of life. METHODS We selected patients with lung cancer, aged 65+, diagnosed between 2009 and 2014, and who died before April 1st 2015 from the population-based Netherlands Cancer Registry (NCR). The NCR is linked to the PHARMO Database Network, that includes medications dispensed by community pharmacies in the Netherlands. The eight PIM groups were based on the OncPal Deprescribing Guideline: aspirin, dyslipidaemia medications, antihypertensives, osteoporosis medications, peptic ulcer prophylaxis, oral hypoglycaemics, vitamins and minerals. RESULTS Data of 7864 patients with lung cancer were analyzed. Median age was 74 year (IQR = 70-79) and 67% was male. 45% of all patients received at least one PIM in their last month of life. Taking into account all dispensed medications, patients receiving PIMs received more different medications compared to those receiving no PIMs, respectively 10 (SD = 5) vs. 3 (SD = 4) different medications (P < 0.001). CONCLUSION Almost half of the older patients with lung cancer in the Netherlands received PIMs in their last month of life. Since PIM use is associated with reduced quality of life, it is important that health care professionals continue to critically assess which medication can be discontinued at the end of life.
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Affiliation(s)
- Laurien Ham
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands; Netherlands Association for Palliative Care (PZNL), PO box 19079, Utrecht 3501 DB, the Netherlands.
| | - Eric C T Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, PO box 2040, Rotterdam 3000 CA, the Netherlands
| | - Mieke J Aarts
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands
| | - Josephina G Kuiper
- PHARMO Institute for Drug Outcomes Research, Van Deventerlaan 30-40, Utrecht 3528 AE, the Netherlands
| | - Peter W A Kunst
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands; Onze Lieve Vrouwe Gasthuis, PO box 9243, Amsterdam 1006 AE, the Netherlands
| | - Natasja J H Raijmakers
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands; Netherlands Association for Palliative Care (PZNL), PO box 19079, Utrecht 3501 DB, the Netherlands
| | - Loes E Visser
- Department of Hospital Pharmacy, Haga Teaching Hospital, PO box 40551, The Hague 2504 LN, the Netherlands; Department of Epidemiology, Erasmus Medical Centre, PO box 2040, Rotterdam 3000 CA, the Netherlands; Department of Hospital Pharmacy, Erasmus Medical Centre, PO box 2040, Rotterdam 3000 CA, the Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Amsterdam University Medical Centre, De Boelelaan 1117, Amsterdam 1081 HV, the Netherlands
| | - Edwin J Brokaar
- Department of Hospital Pharmacy, Haga Teaching Hospital, PO box 40551, The Hague 2504 LN, the Netherlands
| | - Heidi P Fransen
- Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), PO box 19079, Utrecht 3501 DB, the Netherlands; Netherlands Association for Palliative Care (PZNL), PO box 19079, Utrecht 3501 DB, the Netherlands
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5
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Honinx E, Van den Block L, Piers R, Van Kuijk SMJ, Onwuteaka-Philipsen BD, Payne SA, Szczerbińska K, Gambassi GG, Finne-Soveri H, Deliens L, Smets T. Potentially Inappropriate Treatments at the End of Life in Nursing Home Residents: Findings From the PACE Cross-Sectional Study in Six European Countries. J Pain Symptom Manage 2021; 61:732-742.e1. [PMID: 32916262 DOI: 10.1016/j.jpainsymman.2020.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/28/2020] [Accepted: 09/01/2020] [Indexed: 12/15/2022]
Abstract
CONTEXT Certain treatments are potentially inappropriate when administered to nursing homes residents at the end of life and should be carefully considered. An international comparison of potentially inappropriate treatments allows insight into common issues and country-specific challenges of end-of-life care in nursing homes and helps direct health-care policy in this area. OBJECTIVES To estimate the prevalence of potentially inappropriate treatments in the last week of life in nursing home residents and analyze the differences in prevalence between countries. METHODS A cross-sectional study of deceased residents in nursing homes (2015) in six European countries: Belgium (Flanders), England, Finland, Italy, The Netherlands, and Poland. Potentially inappropriate treatments included enteral administration of nutrition, parental administration of nutrition, artificial fluids, resuscitation, artificial ventilation, blood transfusion, chemotherapy/radiotherapy, dialysis, surgery, antibiotics, statins, antidiabetics, new oral anticoagulants. Nurses were questioned about whether these treatments were administered in the last week of life. RESULTS We included 1384 deceased residents from 322 nursing homes. In most countries, potentially inappropriate treatments were rarely used, with a maximum of 18.3% of residents receiving at least one treatment in Poland. Exceptions were antibiotics in all countries (between 11.3% in Belgium and 45% in Poland), artificial nutrition and hydration in Poland (54.3%) and Italy (41%) and antidiabetics in Poland (19.7%). CONCLUSION Although the prevalence of potentially inappropriate treatments in the last week of life was generally low, antibiotics were frequently prescribed in all countries. In Poland and Italy, the prevalence of artificial administration of food/fluids in the last week of life was high, possibly reflecting country differences in legislation, care organization and culture, and the palliative care competences of staff.
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Affiliation(s)
- Elisabeth Honinx
- End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.
| | - Lieve Van den Block
- End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Ruth Piers
- Clinic of Geriatric Medicine, Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | - Sander M J Van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), MUMC, Maastricht, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Vrije Universiteit Amsterdam Medisch Centrum, Amsterdam, The Netherlands
| | - Sheila A Payne
- Faculty of Health And Medicine, Lancaster University, Lancaster, UK
| | - Katarzyna Szczerbińska
- Laboratory for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine, Medical Faculty, Jagiellonian University Medical College, Kraków, Poland
| | - Giovanni G Gambassi
- Department of Internal Medicine, Istituto di Medicina Interna e Geriatria, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Harriet Finne-Soveri
- Geriatric Medicine, Department of Welfare, Ageing Disability and Functioning Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Luc Deliens
- End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Tinne Smets
- End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
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6
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Roydhouse JK, Suzman DL, Menapace LA, Mishra-Kalyani PS, Sridhara R, Blumenthal GM, Beaver JA, Pazdur R, Kluetz PG. Global Variation in Opioid Use in Prostate Cancer Trials. JAMA Oncol 2019; 5:e192971. [PMID: 31513232 DOI: 10.1001/jamaoncol.2019.2971] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance Regional variation in opioid use may be attenuated when pharmaceutical-sponsored trials include care that is often standardized by protocols. Understanding such variation is important for global trials that sometimes include time to opioid use as an end point. Objective To identify whether regional and country-level variation in opioid use exists among prostate cancer clinical trials across the world. Design, Setting, and Participants International phase 3 randomized clinical trials with patients with metastatic prostate cancer and initiation from January 1, 2008, or later were identified through internal databases of the US Food and Drug Administration. Data of patients in the intention-to-treat population from each trial were pooled. Descriptive and regression analyses of the collected data were conducted from September 2018 to February 2019. Exposures Cancer therapy. Main Outcomes and Measures Opioid use data were from concomitant medications reported in the database for each trial. Logistic regression models, descriptive statistics, and χ2 tests were used to compare opioid use across world regions while adjusting for patient age, presence of visceral disease, bony disease, and baseline Eastern Cooperative Oncology Group Performance Status score and pain score. Results In total, 9670 patients (mean [SD] age of 69.2 [8.3] years) from 8 prostate cancer clinical trials in 46 countries were included. Patients in Eastern Europe (adjusted odds ratio [AOR], 0.19; 95% CI, 0.16-0.22) and Asia (AOR, 0.31; 95% CI, 0.25-0.38) were less likely to use opioids compared with patients in North America. These findings held even when the analysis was restricted to patients who reported moderate to high pain levels at baseline (Eastern Europe: AOR, 0.16 [95% CI, 0.12-0.22]; Asia: AOR, 0.47 [95% CI, 0.29-0.79]). Within North America, rates of opioid use were similar between the United States and Canada (AOR, 1.13; 95% CI, 0.93-1.37). Conclusions and Relevance This study found that, despite the clinical trial setting, opioid use appeared to vary by world regions, suggesting that this variability should be considered in international clinical trials.
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Affiliation(s)
- Jessica K Roydhouse
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Daniel L Suzman
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Laurel A Menapace
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Pallavi S Mishra-Kalyani
- Office of Biostatistics, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Rajeshwari Sridhara
- Office of Biostatistics, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Gideon M Blumenthal
- Oncology Center of Excellence, Food and Drug Administration, Silver Spring, Maryland
| | - Julia A Beaver
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Richard Pazdur
- Oncology Center of Excellence, Food and Drug Administration, Silver Spring, Maryland
| | - Paul G Kluetz
- Oncology Center of Excellence, Food and Drug Administration, Silver Spring, Maryland
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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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9
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Paque K, De Schreye R, Elseviers M, Vander Stichele R, Pardon K, Dilles T, Christiaens T, Deliens L, Cohen J. Discontinuation of medications at the end of life: A population study in Belgium, based on linked administrative databases. Br J Clin Pharmacol 2019; 85:827-837. [PMID: 30667540 DOI: 10.1111/bcp.13874] [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: 09/25/2018] [Revised: 01/11/2019] [Accepted: 01/15/2019] [Indexed: 12/17/2022] Open
Abstract
AIMS The aim of this study was to examine the use of potentially inappropriate medication (PIM) in relation to time before death, to explore whether PIMs are discontinued at the end of life, and the factors associated with this discontinuation. METHODS We conducted a retrospective register-based mortality cohort study of all deceased in 2012 in Belgium, aged at least 75 years at time of death (n = 74 368), using linked administrative databases. We used STOPPFrail to identify PIMs received during the period from 12 to 6 months before death (P1) and the last 4 months (P2) of life. RESULTS Median age was 86 (IQR 81-90) at time of death, 57% were female, 38% were living in a nursing home, and 16% were admitted to hospital between 2 years and 4 months before death. Overall, PIM use was high, and increased towards death for all PIMs. At least one PIM was discontinued during P2 for one in five (20%) of the population, and 49% had no discontinuation. Being hospitalized in the period before the last 4 months of life, living in a nursing home, female gender and a higher number of medications used during P1 were associated with discontinuation of PIMs (respective aOR [95% CI]: 2.89 [2.73-3.06], 1.29 [1.23-1.36], 1.26 [1.20-1.32], 1.17 [1.16-1.17]). CONCLUSION Initial PIM use was high and increased towards death. Discontinuation was observed in only one in five PIM users. More guidance for discontinuation of PIMs is needed: practical, evidence-based deprescribing guidelines and implementation plans, training for prescribers and a better consensus on what inappropriate medication is.
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Affiliation(s)
- Kristel Paque
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium.,Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Robrecht De Schreye
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Monique Elseviers
- Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium.,Faculty of Medicine and Health Sciences, Department of Nursing Science, Centre for Research and Innovation in Care (NuPhaC), University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
| | - Robert Vander Stichele
- Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Koen Pardon
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Tinne Dilles
- Faculty of Medicine and Health Sciences, Department of Nursing Science, Centre for Research and Innovation in Care (NuPhaC), University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
| | - Thierry Christiaens
- Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
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10
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Paque K, Ivanova I, Elseviers M, Stichele RV, Dilles T, Pardon K, Deliens L, Christiaens T. Initiation of advance care planning in newly admitted nursing home residents in Flanders, Belgium: A prospective cohort study. Geriatr Gerontol Int 2018; 19:141-146. [PMID: 30523667 DOI: 10.1111/ggi.13576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 08/27/2018] [Accepted: 10/22/2018] [Indexed: 12/28/2022]
Abstract
AIM To describe (i) the timing of initiation of advance care planning (ACP) after nursing home admission; (ii) the association of dementia and physical health with ACP initiation; and (iii) if and how analgesic use and use of lipid modifying agents is related to ACP, in a cohort of newly admitted residents. METHODS A prospective, observational cohort study of nursing home residents was carried out. Data were collected 3 months, 15 months (year 1) and 27 months (year 2) after admission, using a structured questionnaire and validated measuring tools. RESULTS ACP was never initiated during the 2-year stay for 38% of the residents, for 22% ACP was initiated at admission, for 21% during year 1 and for 19% during year 2 (n = 323). ACP initiation was strongly associated with dementia, but not with physical health. Residents without dementia were more likely to have ACP initiation at admission or not at all, whereas ACP initiation was postponed for residents with dementia. Between admission and year 2, analgesic use increased (from 34% to 42%), and the use of lipid-modifying agents decreased (from 28% to 21%). Analgesic use increased more in residents with ACP initiation during year 1 and year 2. The use of lipid-modifying agents was not associated with ACP. CONCLUSIONS The timing of ACP initiation differed significantly for residents with and without dementia, which highlights the importance of an early onset of ACP before residents lose their decision-making capacity. ACP conversations might create opportunities to discuss adequate pain and other symptom treatment, and deprescribing at the end of life. Geriatr Gerontol Int 2019; 19: 141-146.
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Affiliation(s)
- Kristel Paque
- Department of Pharmacology, Faculty of Medicine and Health Sciences, Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.,Faculty of Medicine and Pharmacy, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Ivana Ivanova
- Department of Pharmacology, Faculty of Medicine and Health Sciences, Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Monique Elseviers
- Department of Pharmacology, Faculty of Medicine and Health Sciences, Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.,Faculty of Medicine and Health Sciences, Department of Nursing Science, Center for Research and Innovation in Care (NuPhaC), University of Antwerp, Wilrijk, Belgium
| | - Robert Vander Stichele
- Department of Pharmacology, Faculty of Medicine and Health Sciences, Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Tinne Dilles
- Faculty of Medicine and Health Sciences, Department of Nursing Science, Center for Research and Innovation in Care (NuPhaC), University of Antwerp, Wilrijk, Belgium.,Department of Nursing and Midwifery, Thomas More University College, Lier, Belgium
| | - Koen Pardon
- Faculty of Medicine and Pharmacy, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Luc Deliens
- Faculty of Medicine and Pharmacy, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Thierry Christiaens
- Department of Pharmacology, Faculty of Medicine and Health Sciences, Clinical Pharmacology Research Unit, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
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Kadam UT, Roberts I, White S, Bednall R, Khunti K, Nilsson PM, Lawson CA. Conceptualizing multiple drug use in patients with comorbidity and multimorbidity: proposal for standard definitions beyond the term polypharmacy. J Clin Epidemiol 2018; 106:98-107. [PMID: 30385327 DOI: 10.1016/j.jclinepi.2018.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 09/28/2018] [Accepted: 10/24/2018] [Indexed: 12/22/2022]
Abstract
With older and aging populations, patients experience multiple chronic diseases at the same time. Individual chronic disease guidelines often recommend pharmacological therapies as a key intervention, resulting in patients being prescribed multiple regular medications for their different diseases. Although the term "polypharmacy" has been applied to the use of multiple medications, there is no consistent definition, and this term is now being used all inclusively. To improve both scientific rigor and optimal patient care, it is crucial that a standard terminology is used, which reclassifies the term "polypharmacy" into distinct phenotypes relating to the index chronic disease, additional conditions to the index (comorbidity), or the experience of multiple chronic conditions at the same time (multimorbidity). Using three exemplar index conditions; heart failure, type 2 diabetes, and breast cancer, we propose the reclassification of the term "polypharmacy" into three distinct phenotypes. First, index drug or multi-index drug therapy, where each index condition creates multiple drug use for that condition; second, codrug therapy, where addition of other comorbid conditions increases the multiple drug use and may influence the management of the index disease and third, multidrug therapy, where adult population with multimorbidity may be on many drugs. This article reviews guidelines for the individual exemplars to develop the basis for the new terms and then develops the pharmacoepidemiology of multiple drug use further by reviewing the evidence on the relationship between the phenotypic classification and important outcomes. The importance of standardizing "polypharmacy" terminology for the scientific agenda and clinical practice is that it relates to an index condition or disease safety outcomes including drug interactions, adverse side effects in hospital admissions, and related "polypill" concept.
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Affiliation(s)
- Umesh T Kadam
- Department of Health Sciences, University of Leicester, Leicester LE1 7RH, UK; Diabetes Research Centre, University of Leicester, Leicester LE5 4PW, UK.
| | - Isobel Roberts
- Pharmacy Directorate, University Hospitals of North Staffordshire, Stoke-on-Trent ST4 6QG, UK
| | - Simon White
- School of Pharmacy, Keele University, Keele ST5 5BG, UK
| | - Ruth Bednall
- Pharmacy Directorate, University Hospitals of North Staffordshire, Stoke-on-Trent ST4 6QG, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester LE5 4PW, UK
| | - Peter M Nilsson
- Department of Clinical Sciences, Lund University, Malmö S-205 02, Sweden
| | - Claire A Lawson
- Diabetes Research Centre, University of Leicester, Leicester LE5 4PW, UK
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