Polypharmacy linked to risk for adverse treatment outcomes among older adults with cancer
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Key takeaways:
- The polypharmacy group had a higher mean number of grade 2 or higher toxicities (9.8 vs. 7.7).
- Patients with major drug-drug interactions had 59% higher odds of treatment discontinuation.
Polypharmacy and potential drug-drug interactions appeared associated with increased risk for adverse treatment outcomes among older adults with advanced cancer, according to a secondary analysis of the GAP70+ trial published in Cancer.
Researchers recommended use of meaningful screening and interventional tools to optimize medication use and improve treatment-associated outcomes in this patient population.
Rationale and methodology
Polypharmacy is common among older patients with cancer, and managing medications for older adults with multiple health problems, including cancer, can be tough for patients, caregivers and the oncology care team, Erika E. Ramsdale, MD, associate professor in the department of medicine at University of Rochester Medical Center, told Healio.
“This study is a continuation of our group’s prior research examining polypharmacy and how it might impact a patient with cancer, especially those who are starting treatment,” Ramsdale said. “There is still little written in the medical literature focused on the problem of polypharmacy in our patients, its consequences and how we might intervene to improve outcomes.”
As Healio previously reported, the GAP70+ trial included 718 patients (mean age, 77 years; 57% men) with advanced lung or gastrointestinal cancers who received care across 40 U.S. community oncology practice clusters and planned to initiate a new treatment regimen. Researchers randomly assigned patients to either an intervention group in which oncologists received a tailored geriatric assessment summary and management recommendations or to a usual care group with no geriatric assessment summary or management recommendations provided to oncologists.
For the current secondary analysis, researchers assessed polypharmacy — defined as the concurrent use of eight or more medications — before initiation of treatment. They examined outcomes within 3 months of treatment, including the number of grade 2 or higher and grade 3 or higher toxicities as per NCI Common Toxicity Criteria, treatment-associated unplanned hospitalizations and early treatment discontinuation. They used multivariable regression models to examine the association of medication measures with outcomes.
Findings
Overall, patients received a median five medications. Less than a third (28%) received eight or more medications, two thirds (67%) received one or more potentially inappropriate medications and 25% had potential drug-drug interactions.
Results showed a mean number of grade 2 or higher toxicities of 9.8 among those with polypharmacy compared with 7.7 among those without polypharmacy (P < .01), and 2.9 vs. 2.2 (P = .04) for grade 3 or higher toxicities.
Patients with one or more major potential drug-drug interactions had 59% higher odds of early treatment discontinuation (OR = 1.59; 95% CI, 1.03-2.46).
“We don’t believe it is simply because people who take more medications were sicker — we tried to control for how many medical conditions they had and how physically fit they were as part of our model,” Ramsdale said. “This study adds to the evidence that the number and types of medications that an older adult with cancer takes can impact their experience of chemotherapy and possibly the effectiveness of that therapy, as well.”
Implications
The findings of this analysis could impact any older adult initiating cancer treatment, especially those on many medications, Ramsdale told Healio.
“Paying attention to medications is an important thing to do in the oncology clinic, and there may be an opportunity to intervene and reduce risk,” she said. “Perhaps some part of the toxicity of cancer treatment is not inevitable, and we might have opportunities to improve patients’ quality of life and their outcomes from treatment through relatively simple interventions that we already know how to do, such as careful medication review and streamlining what patients are taking.”
However, a significant issue is the oncologist’s time, she continued.
“There is a lot to do already in the oncology clinic, and carefully sorting through medication lists and thinking through each medication takes time,” Ramsdale said. “Another implication of our work for patients, in particular, is that we found a lot of over-the-counter medications had risk higher than benefit and/or were involved in drug interactions. Patients may assume that these medications are safe for them, but this is not necessarily true, and they should tell their oncology care team everything they are taking, including over-the-counter and complementary medications.”
Next steps
Further research is needed in this area, Ramsdale added.
“Our team is studying what we should do about the problem of polypharmacy, and I am leading a randomized clinical trial at our institution comparing two different approaches to address this,” she said. “One approach is very personalized and is led by a pharmacist who develops and communicates a medication plan just for that patient. The pharmacist meets with the patient using a telemedicine approach, which can happen anywhere, including the patient’s home. The pharmacist spends some time to understand their situation and how medications fit into that.”
Often, the pharmacist recommends that medications be discontinued or reduced as they no longer have benefit higher than risk, Ramsdale continued.
“The other approach is a very simple one — providing a brochure about polypharmacy to patients, which is obviously less personalized and involved but may still be helpful,” she said. “We are studying how these interventions impact conversations between patients and their oncology care team, how feasible they might be to implement more broadly, and how they might impact chemotherapy and physical function outcomes for these patients. We are not quite sure what the best approach is to do this in a busy oncology clinic, so we need to study it.”
For more information:
Erika E. Ramsdale, MD, can be reached at erika_ramsdale@urmc.rochester.edu.
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