Improving the prescribing of medicines for people living with cancer and receiving palliative care

Research Project Title

Medicines optimisation for patients living with cancer and receiving palliative care

Key Words

Advanced cancer, Comorbidities, Prescribing, Medication management, Palliative care, Symptom Management, Guideline development

Challenge

An important challenge in palliative care for older adults (≥65 years) with cancer is making sure that they are prescribed the most suitable medicines. Often older adults with cancer have existing comorbidities, necessitating the use of polypharmacy, which is commonly defined as the prescribing of five or more medicines [1-3]*. While older adults with cancer can benefit from taking multiple medicines, the cancer diagnosis, compounded with advancing age also makes them more vulnerable to potential side-effects and drug–drug interactions. As the disease progresses, the goal of prescribing for older adults with advanced incurable cancer moves from preventing and treating existing illnesses, to controlling symptoms such as pain and improving the person’s quality of life [4,5]*. Prescribers need guidance to help them review patients’ prescriptions and make sure the correct medicines are prescribed.

*References for the above
1.  Deliens C, Deliens G, Filleul O, Pepersack T, Awada A, Piccart M, et al. Drugs prescribed for patients hospitalized in a geriatric oncology unit: Potentially inappropriate medications and impact of a clinical pharmacist. Journal of Geriatric Oncology. 2016;7(6):463-70.
2.  Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017;17(1):230-.
3.  
Sharma M, Loh KP, Nightingale G, Mohile SG, Holmes HM. Polypharmacy and potentially inappropriate medication use in geriatric oncology. Journal of Geriatric Oncology. 2016;7(5):346-53.
4.  Turner JP, Shakib S, Bell JS. Is my older cancer patient on too many medications? Journal of Geriatric Oncology. 2017;8(2):77-81.
5.  Holmes HM. Rational prescribing for patients with a reduced life expectancy. Clinical pharmacology and therapeutics. 2009;85(1):103-7.

Research Project

This project aimed to develop guidance for identifying potentially inappropriate prescribing of medications for symptom relief in older adults (≥65 years) with cancer who are receiving palliative care and have an estimated life expectancy of less than one year.

The project comprised three distinct phases:
In Phase 1, we searched the literature to identify previous studies that looked at prescribing practices for adult patients (≥18 years) receiving palliative care for any life-limiting illness in any setting. The broad, scoping nature of this review was intended to overcome limitations of previous reviews, which only looked at preventative medicines among patients with any life-limiting illness and did not focus specifically on palliative care. In Phase 2, we used the literature review findings to help inform the development of guidance for identifying potentially inappropriate prescribing of medicines for the relief of symptoms commonly experienced by older adults with cancer who are receiving palliative care. In Phase 3, we looked at the types of medicines that have previously been prescribed to a sample of older adults with cancer using historical information from a palliative care centre. We tried to determine whether prescribing practices followed the recommendations that were developed in Phase 2.

Key Findings

Results of Phase 1  We searched four electronic databases to identify previous studies that looked at prescribing practices for adult patients (≥18 years) receiving palliative care for any life-limiting illness in any setting. Fifty-six studies met our inclusion criteria.

Prescription Trends: This review showed that the average number of prescribed medicines per patient ranged from 3 to 23. Typically, prescribing changes involved decreases in medicines for existing long-term condition and increases in medicines for symptom relief closer to the time of death. However, less than 50% of the studies assessed whether the medicines that patients received were appropriate. These studies reported that 15-92% of patients were receiving a medicine that may not have been appropriate.

Phase 1 – Conclusion: This review provided a broad overview of existing research and showed that many patients receiving palliative care receive multiple medicines closer to the time of death. The review includes recommendations for future research and the full-text review article [1] is freely available in Exploratory Research in Clinical and Social Pharmacy (link to paper).

Results of Phase 2  We used the literature review findings to help inform the development of draft guidance for identifying potentially inappropriate prescribing of medicines for the relief of symptoms commonly experienced by older adults with cancer who are receiving palliative care. This guidance focused on patients with an estimated life expectancy of less than one year.

Developing Prescribing Guidance: The developed guidance, containing a list of 28 recommendations was shared with a group of 18 experts in palliative care as part of a Delphi consensus exercise**.

PIP-CPC recommendations: The final prescribing guidance on identifying potentially inappropriate prescribing of medicines for the relief of symptoms commonly experienced by older adults with cancer who are receiving palliative care contains 24 recommendations. These relate to: anorexia-cachexia (n = 1); anxiety (n = 2); constipation (n = 5); delirium (n = 1); depression (n = 3); diarrhoea (n = 1); dyspnoea/breathlessness (n = 1); fatigue (n = 2); insomnia (n = 2); nausea and vomiting (n = 2); pain (n = 3); duplicate drug classes (n = 1).

Phase 2 – Conclusion: A consensus-agreed set of prescribing recommendations was developed for identifying potentially inappropriate prescribing of medications for symptomatic relief in older adults with cancer who are receiving palliative care and have an estimated life expectancy of less than one year. The full-text article [2] is freely available in the Journal of Geriatric Oncology (link to paper).

** The Delphi consensus exercise is a method used to arrive at a group opinion or decision. Experts respond to several rounds of questionnaires, and the responses are gathered and shared with the group after each round. The experts have an opportunity to adjust their answers after each round, based on how they interpret the "group response" provided to them. This approach allows for a true consensus of what the group thinks

Results of Phase 3  We looked at the types of medicines that have previously been prescribed to a sample of older adults with cancer using historical information from a palliative care centre. We tried to determine whether prescribing practices followed the recommendations that were developed in Phase 2.

Applying the guidelines: Of the 24 recommendations developed in Phase 2, only four could be applied. This was due to a lack of additional information available in patients’ notes, mainly in terms of why a medicine had been prescribed or the date of on which a medicine was first started. Based on these four criteria, the prevalence of potentially inappropriate prescriptions ranged from 0-30%. No patient received oral liquid paraffin as a laxative (recommendation 3.3) or a drug known as a monoamine oxidase inhibitor for depression (recommendation 5.3). Of the patients prescribed opioid painkillers (n=180), 30% (n=54) did not receive a laxative (recommendation 3.4). Of the patients using non-steroidal anti-inflammatory drugs (e.g., ibuprofen) together with corticosteroids (n=53), 15.1% did not receive a drug to protect the stomach such as a proton pump inhibitor (recommendation 11.3).

Phase 3 – Conclusion: This study reports on the first application of the PIC-CPC criteria to clinical records for older adults with cancer who were receiving palliative care prior to death. The study highlighted the challenges in retrospectively applying the criteria using historical data.

Overall Conclusion & Recommendations:

Criteria for identifying potentially inappropriate prescribing of medications for symptomatic relief in older adults with cancer have been developed and undergone consensus validation using the Delphi technique.

  • The scoping review (Phase 1) has provided a broad and comprehensive overview of observational studies examining prescribing in palliative care. The review shows that many patients with palliative care needs receive considerable numbers of medications, including preventative medications that may provide limited or no therapeutic benefit closer to death. A limited number of studies examined the appropriateness of prescribing or the potential for harm. The review has generated important recommendations for future research such as the inclusion of assessments of prescribing appropriateness using tools that have been developed specifically to guide prescribing in palliative care, as well as assessment of the appropriateness of medications to relieve common symptoms experienced by palliative care populations towards the end of life.
  • The Delphi study (Phase 2) enabled development and consensus validation of the PIP-CPC criteria using an expert panel of palliative care clinicians. The PIP-CPC criteria consist of 24 criteria for identifying potentially inappropriate prescribing of medications for symptomatic relief in older adults with cancer who are receiving palliative care and have an estimated life expectancy of less than one year.  
  • The retrospective cohort study (Phase 3) enabled the initial testing of the application of these criteria using clinical records for older adults with cancer who are receiving palliative care.

The study highlighted the challenges in retrospectively applying the criteria using historical data. Future research is needed to facilitate implementation of the PIP-CPC criteria into clinical practice and examine the impact on patient outcomes.

Timeline

Study carried out: September 2018 – June 2021

Research Team

Principal Investigator: Dr Cathal Cadogan, School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin

Research Team: Prof Carmel Hughes, School of Pharmacy, Queen’s University Belfast, Dr Sarah McLean, St Vincent’s Private Hospital, Dublin, Ireland, Ms Melanie Murphy, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Prof Kathleen Bennett, Division of Population Health Sciences, Royal College of Surgeons in Ireland

Funding & Support

This project was funded jointly by the Irish Cancer Society and All Ireland Institute of Hospice and Palliative Care

Research Project Outputs:

Guidance[PIP-CPC criteria]: for medicines for the relief of symptoms commonly experienced by older adults with cancer who are receiving palliative care.

Peer Reviewed Publications:

  1. Cadogan CA, Murphy M, Boland M, Bennett K, McLean S, Hughes C. Prescribing practices, patterns and potential harms in patients receiving palliative care: A systematic scoping review. Exploratory Research in Social and Clinical Pharmacy [in press] https://doi.org/10.1016/j.rcsop.2021.100050 [Accessed 8 Sept 2021]
  2. Cadogan CA, Murphy M, McLean S, Bennett K, Hughes C. Development of criteria for identifying potentially inappropriate prescribing in older cancer patients receiving palliative care. Journal of Geriatric Oncology [in press] https://doi.org/10.1016/j.jgo.2021.06.003 [Accessed 8 Sept 2021]

For Further Information Contact:

Email: info@aiihpc.org | Telephone: +353 (0)1 491 2948

 

Join Our Mailing List