Cross-sectional study to evaluate patients' medication management with a new model of care: incorporating a pharmacist into a community specialist palliative care telehealth service

BACKGROUND

Patients receiving palliative care are often on complex medication regimes to manage their symptoms and comorbidities and at high risk of medication-related problems. The aim of this cross-sectional study was to evaluate the involvement of a pharmacist to an existing community specialist palliative care telehealth service on patients' medication management.

METHOD

The specialist palliative care pharmacist attended two palliative care telehealth sessions per week over a six-month period (October 2020 to March 2021). Attendance was allocated based on funding received. Data collected from the medication management reviews included prevalence of polypharmacy, number of inappropriate medication according to the Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy criteria (STOPP/FRAIL) and recommendations on deprescribing, symptom control and medication management.

RESULTS

In total 95 patients participated in the pharmaceutical telehealth service with a mean age of 75.2 years (SD 10.67). Whilst 81 (85.3%) patients had a cancer diagnosis, 14 (14.7%) had a non-cancer diagnosis. At referral, 84 (88.4%, SD 4.57) patients were taking ≥ 5 medications with 51 (53.7%, SD 5.03) taking ≥ 10 medications. According to STOPP/FRAIL criteria, 142 potentially inappropriate medications were taken by 54 (56.8%) patients, with a mean of 2.6 (SD 1.16) inappropriate medications per person. Overall, 142 recommendations were accepted from the pharmaceutical medication management review including 49 (34.5%) related to deprescribing, 20 (14.0%) to medication-related problems, 35 (24.7%) to symptom management and 38 (26.8%) to medication administration.

CONCLUSION

This study provided evidence regarding the value of including a pharmacist in palliative care telehealth services. Input from the pharmacist resulted in improved symptom management of community palliative care patients and their overall medication management.

Are the deprescribing guidelines for proton pump inhibitors in palliative care applicable? A monocentric observational study

OBJECTIVES

Proton pump inhibitors (PPIs) are among the most commonly prescribed medications. The aim of this study was to assess the appropriateness of prescribing PPIs in the palliative care unit on admission and during hospitalisation to determine the applicability of deprescribing recommendations.

METHODS

A monocentric observational study was conducted over a 6-month period in 2020 in a university palliative care unit. Data on indication, starting date, dose and posology were collected at discharge from the medical record and by contacting the prescriber. A physician and a pharmacist evaluated PPI prescription appropriateness according to guidelines.

RESULTS

131 patients (mean age: 69.5 years; 82% with cancer) were included. Prior to admission, 41% (54/131) of patients were already prescribed PPIs. During hospitalisation, 50% of prescriptions were discontinued, while 12% were initiated. The indication was known for 50% of patients on admission and 59% during their stay. Among patients with PPI prescriptions, 56% had a relevant indication on admission, and 63% during their stay. The prevalence of potential drug interactions was low (<1/10).

CONCLUSIONS

While PPIs remain essential for specific indications, this study highlights their excessive prescription even during palliative care. Implementing deprescribing recommendations in this population is crucial to optimise treatment plans.

Palatability of Crushed Over-the-Counter Medications

CONTEXT

Dysphagia is a common concern, especially in the last several days of life. Medications are often crushed for ease of administration for individuals with swallowing difficulty.

OBJECTIVES

To assess palatability of commonly used crushed over-the-counter (OTC) medications. A secondary objective is to evaluate pharmacist knowledge and opinions of crushing medications.

METHODS

Pharmacist participants sampled crushed OTC medications and completed presampling and postsampling surveys about crushing medications. Participants were excluded for current smoking or tobacco use, pregnancy, allergy to any study medication or applesauce, or potential drug-drug interaction with study medications. Eight OTC medications were crushed and mixed in applesauce: naproxen, fexofenadine, phenazopyridine, multivitamin, loperamide, famotidine, sennosides, and sennosides-docusate. Participants were blinded to medication samples and control (plain applesauce). Samples were rated from one (least palatable) to five (most palatable). Investigators recorded participants' comments, behaviors, and facial expressions during sampling.

RESULTS

Nineteen volunteers completed the study. Most participants rated three samples as not palatable (score of two or less): fexofenadine, 16 (84%); loperamide, 13 (68%); and sennosides-docusate, 16 (84%). All participants rated famotidine and sennosides palatable. The percentage of participants who would consider palatability in recommendations for crushing medications increased from 47% prestudy to 79% poststudy.

CONCLUSION

Palatability should be considered when recommending crushed medications. Survey responses indicate that pharmacists' opinions of crushed medications changed after this palatability experiment. Clinicians should evaluate the appropriateness of all medications when dysphagia is a concern and deprescribe medications when appropriate to reduce burden for patients and caregivers.