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Studies indicate a lack of deprescribing is causing physical and fiscal pain to patients.
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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Reduce Meds, Reduce Side Effects
The findings suggest that reducing the use of preventive medications in patients with cancer near the end of life may reduce unnecessary side effects, improve patient quality of life, and reduce financial burdens for patients.
Mark Ratain, MD, professor of medicine and the director of the Center for Personalized Therapeutics at the Comprehensive Cancer Center at the University of Chicago, says polypharmacy is the problem: patients age 65 and older in the United States are on too many medications.
“The oncologists are not paying attention to non-oncology drugs,” Ratain tells Drug Topics. “It is the tip of iceberg that nobody is paying attention to medications. Most U.S. Medical schools don’t even have a department of pharmacology anymore.”
Tanya M. Wildes, MD, associate professor of medicine in the Division of Medical Oncology at Washington University School of Medicine, St Louis, says deprescribing involves intentional, thoughtful discontinuation of specific medications, including those that likely will not benefit the patient or those that may increase the risk of adverse effects.
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“Deprescribing is difficult, particularly when patients have been on medications for a long period of time and no one stops to question whether it continues to provide benefit, especially when that risk/benefit ratio may have shifted in the setting of a cancer diagnosis,” Wildes tells Drug Topics.
She cites a trial published by Kutner et al. in 2015 in JAMA Internal Medicine that randomized patients with life-limiting diagnoses to either continuation or discontinuation of a current statin. The study highlighted how quality of life can be improved.
“Patients who stopped their statin lived just as long as patients who continued it, but they reported better quality of life. In addition, the group who stopped their statin tended to discontinue other medications as well. Presumably, in the process of stopping their statin, they became more intentional about each of the medications that they were taking, carefully considering its benefits,” says Wildes.
A Failure to Communicate?
Patricia A. Ganz, MD, professor of health policy and management and medicine at UCLA Fielding School of Public Health and director of the Center for Cancer Prevention and Control Research at the Jonsson Comprehensive Cancer Center, Los Angeles, CA, says the findings in the Swedish study are intriguing, but not surprising.
“It is particularly interesting because it comes from one of the Nordic countries where they have very good medical record data and other information, along with the ability to link cancer cases to that data. What is more interesting is that, generally, patients in these health care settings have good access to primary care physicians, who would be the doctors prescribing most of the preventive care medications,” Ganz tells Drug Topics.
Physicians and patients may be afraid to “rock the boat,” Ganz says. If a patient has been on one of these medications for many years, the medications often are not stopped even though the patient is failing.
“It is really an oversight. Stopping some of these medications could make life a lot simpler for patients and their families as there would be fewer pills to take,” says Ganz. “I think this speaks to the need for cancer doctors and primary care physicians to communicate with each other and to stop medications that clearly have no benefit when a patient is dying.”
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Pharmacists need to review each medication and ask if it is providing true benefit or just making life more difficult for the patient, Brown says. “Doctors and providers are pretty well versed on the benefits of medications, but pharmacists bring a different perspective. We’re more attuned to the details of medications and the hidden drawbacks they may have.”
The goal of palliative care is to reduce symptoms and maximize the quality of life, but sometimes what is used as palliative treatment decreases quality of life and that’s troubling, Brown says.