A new study from Sweden is suggesting that many older adults with cancer are being prescribed preventive medications at the end of their lives that may harm their quality of life while providing questionable clinical benefits. The problem may stem from inadequate deprescribing.
The study, published March 25, 2019, online in Cancer, found that deprescribing strategies need to be more widely adopted to help reduce the burden of drugs that have limited clinical benefit near the end of life.
There is little published research on how much overprescribing occurs in patients with advanced cancer during the final months and weeks of their lives. Lucas Morin, and his colleagues at the Karolinska Institute in Sweden evaluated a nationwide Swedish cohort study of older adults (age 65 years or older) who died due to solid tumors between 2007 and 2013.
They examined monthly drug use and the costs of preventive drugs throughout the year before the patients’ deaths.
The researchers identified 151,201 patients (mean age of 81.3 years) and found the average number of drugs prescribed to them increased from 6.9 to 10.1 during the last year of life. The percentage of patients taking 10 or more drugs doubled from 26% to 52%.
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Preventive agents, including antihypertensives, platelet aggregation inhibitors, anticoagulants, statins, and oral antidiabetics were frequently continued until the final month of life.
The Costs of Not Deprescribing
The study showed that the median drug costs during the last year of life were $1,482 per individual, including $213 for preventive therapies. Approximately one-fifth of the total costs of prescribed drugs were for preventive medicines. This proportion only decreased slightly as death approached.
Costs for preventive drugs were especially high in older adults who died from specific tumor types. These costs were higher among older adults who died of pancreatic cancer (adjusted median difference, $13; 95% confidence interval, interquartile range [IQR] $5 to $22) compared with older adults who died of lung cancer (median drug cost, $205; IQR, $61 to $523). The same was true for gynecologic cancers (adjusted median difference, $27; 95% confidence interval, IQR $18 to $36). The study showed no decreases in the costs of preventive drugs during the last year of life.
This large study suggests that a substantial number of older adults who die with solid tumors are receiving preventive drugs until their final four weeks of life, accounting for approximately 20% of total drug costs.
The authors of the study note that drug prices in general are much higher in the United States, with total U.S. pharmaceutical expenditures almost triple compared to expenditures seen in Sweden.
Geoffrey W. Brown, PharmD, with the University of Buffalo and the State University of New York, Buffalo, says the pharmacist’s role in deprescribing is to help weigh risks versus benefits of medications. While this is done throughout the patient’s lifetime, it requires a different approach at the end of life.
“Pharmacists are experts on side effects, monitoring parameters, drug interactions, dose-response, and routes of administration of medicines. All these details about a medication can affect a patient’s quality of life. A complex medication regimen should be reviewed by a pharmacist and each medication scrutinized,” Brown tells Drug Topics.
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