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International Journal of Clinical Pharmacy

, Volume 36, Issue 3, pp 535–543 | Cite as

Inappropriate prescribing in patients accessing specialist palliative day care services

  • A. ToddEmail author
  • H. Nazar
  • S. Pearson
  • I. Andrew
  • L. Baker
  • A. Husband
Research Article

Abstract

Background For patients accessing specialist palliative care day services, medication is prescribed routinely to manage acute symptoms, treat long-term conditions or prevent adverse events associated with these conditions. As such, the pharmacotherapeutic burden for these patients is high and polypharmacy is common. Consequently, the risk of these patients developing drug-related toxicities through drug–drug interactions is exacerbated. Medication use in this group should, therefore, be evaluated regularly to align with achievable therapeutic outcomes considering remaining life expectancy. Objective To (1) assess the prevalence of inappropriate medication use; (2) identify potential drug–drug interactions; and, (3) determine how many potential drug–drug interactions could be prevented by discontinuing inappropriate medication. Setting A specialist tertiary care palliative care centre in Northern England serving a population of 330,000. Main outcome measure Prescribing of inappropriate medication. Method Medication histories for patients accessing a specialist palliative day care centre were established and a modified Delphi method was used to reach consensus of medication appropriateness. The Delphi method utilized a framework considering the following factors: remaining life expectancy of the patient, time until benefit of the treatment, goals of care and treatment targets. Potential drug interactions were established using drug interaction recognition software and categorised by their ability to cause harm. Results A total number of 132 patients were assessed during the study period who were prescribed 1,532 (mean = 12/patient) medications; 238 (16 %) were considered inappropriate in the context of limited life expectancy. The most common class of medications considered inappropriate were the statins, observed in 35 (27 %) patients. A total of 267 potential drug–drug interactions were identified; 112 were clinically significant and 155 were not considered clinically significant. Discontinuation of inappropriate medication would reduce the total number of medications taken to 1,294 (mean = 10/patient) and prevent 31 clinically significant potential drug–drug interactions. Conclusion Patients accessing specialist palliative day care services take many inappropriate medications. These medications not only increase the pharmacotherapeutic burden for the patient but they also contribute to potential drug–drug interactions. These patients should have their medication reviewed in the context of life limiting illness aligned with achievable therapeutic outcomes.

Keywords

Drug interactions Inappropriate prescribing Life expectancy Medication review Palliative care 

Notes

Acknowledgments

We wish to thank Dr. Mark Lee and Dr. Peter Robson for their critical discussions around appropriate medication use in palliative care.

Funding

None.

Conflicts of interest

The author(s) declare that they have no competing interests.

References

  1. 1.
    Potter J, Hami F, Bryan T, Quigley C. Symptoms in 400 patients referred to palliative care services: prevalence and patterns. Palliat Med. 2003;17:310–4.PubMedCrossRefGoogle Scholar
  2. 2.
    Sera L, McPherson ML, Holmes HM. Commonly prescribed medications in a population of hospice patients. Am J Hosp Palliat Care. 2013; Feb 12 (Epub ahead of print).Google Scholar
  3. 3.
    Koh NY, Koo WH. Polypharmacy in palliative care: can it be reduced? Singap Med J. 2002;43(6):279–83.Google Scholar
  4. 4.
    Rottlaender D, Scherner M, Schneider T, Erdmann E. Polypharmacy, compliance and non-prescription medication in patients with cardiovascular disease in Germany. Dtsch Med Wochenschr. 2007;132(4):139–44.PubMedCrossRefGoogle Scholar
  5. 5.
    Riechelmann RP, Zimmermann C, Chin SN, Wang L, O’Carroll A, Zarinehbaf S, et al. Potential drug interactions in cancer patients receiving supportive care exclusively. J Pain Symptom Manag. 2008;35:535–43.CrossRefGoogle Scholar
  6. 6.
    Girre V, Arkoub H, Puts MT, Vantelon C, Blanchard F, Droz JP, et al. Potential drug interactions in elderly cancer patients. Crit Rev Oncol Hematol. 2011;78:220–6.PubMedCrossRefGoogle Scholar
  7. 7.
    Currow DC, Abernethy AP. Frameworks for approaching prescribing at the end of life. Arch Intern Med. 2006;166(21):2404.PubMedGoogle Scholar
  8. 8.
    Hall PS, Lord SR, El-Laboudi A, Seymour MT. Non-cancer medications for patients with incurable cancer: time to stop and think? Br J Gen Pract. 2010;60(573):243–4.PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Maddison AR, Fisher J, Johnston G. Preventive medication use among persons with limited life expectancy. Prog Palliat Care. 2011;19(1):15–21.PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Nicholson A, Andrew I, Etherington R, Gamlin R, Lovel T, Lloyd J. Futile and inappropriate prescribing: an assessment of the issue in a series of patients admitted to a specialist palliative care unit. Int J Pharm Pract. 2001;9(S1):72.CrossRefGoogle Scholar
  11. 11.
    The end of life care. The national audit office, 2008. http://www.nao.org.uk/wp-content/uploads/2008/11/07081043.pdf. Accessed 10 Oct 2013.
  12. 12.
    Boulkedid R, Abdoul H, Loustau M, Sibony O, Alberti C. Using and reporting the Delphi method for selecting healthcare quality indicators: a systematic review. PLoS ONE. 2011;6(6):e20476.PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    Holmes HM, Hayley DC, Alexander GC, Sachs GA. Reconsidering medication appropriateness for patients late in life. Arch Intern Med. 2006;166(6):605–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Hsu CC, Sandford BA. The Delphi technique: making sense of consensus. Pract Assess Res Eval. 2007;12(10):1–8.Google Scholar
  15. 15.
    Rx systems. Proscript. http://rxsystems.co.uk/products. Accessed 10 Oct 2013.
  16. 16.
    Riechelmann RP, Tannock IF, Wang L, Saad ED, Taback NA, et al. Potential drug interactions and duplicate prescriptions among cancer patients. J Natl Cancer Inst. 2007;99(8):592–600.PubMedCrossRefGoogle Scholar
  17. 17.
    Baxter K, Preston CL. Stockley’s drug interactions. 10th ed. UK: Pharmaceutical Press; 2013. ISBN 978 0 85711 061 9.Google Scholar
  18. 18.
    Electronic Medicines Compendium. http://www.medicines.org.uk/emc/. Last accessed 10 Oct 2013.
  19. 19.
    Todd A, Williamson S, Husband A, Baqir W, Mahony M. Patients with advanced lung cancer: is there scope to discontinue inappropriate medication? Int J Clin Pharm. 2013;35:181–4.PubMedCrossRefGoogle Scholar
  20. 20.
    Riechelmann RP, Krzyzanowska MK, Zimmermann C. Futile medication use in terminally ill cancer patients. Support Care Cancer. 2009;17(6):745–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Fede A, Miranda M, Antonangelo D, Trevizan L, Schaffhausser H, Hamermesz B, et al. Use of unnecessary medications by patients with advanced cancer: cross-sectional survey. Support Care Cancer. 2011;19:1313–8.PubMedCrossRefGoogle Scholar
  22. 22.
    van Leeuwen RW, Swart EL, Boven E, Boom FA, Schuitenmaker MG, Hugtenburg JG. Potential drug interactions in cancer therapy: a prevalence study using an advanced screening method. Ann Oncol. 2011;22(10):2334–41.PubMedCrossRefGoogle Scholar
  23. 23.
    Nishio S, Watanabe H, Kosuge K, Uchida S, Hayashi H, Ohashi K. Interaction between amlodipine and simvastatin in patients with hypercholesterolemia and hypertension. Hypertens Res. 2005;28(3):223–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Drug Safety Update. Simvastatin: evidence supporting recent advice on dose limitations with concomitant amlodipine or diltiazem. Med Healthc Regul Agency. http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON199561. Accessed 10 Oct 2013.
  25. 25.
    Steiness E. Diuretics, digitalis and arrhythmias. Acta Med Scand Suppl. 1981;647:75–8.PubMedGoogle Scholar
  26. 26.
    British National Formulary 64, September 2012. UK: Pharmaceutical Press. ISBN 978-0857110657.Google Scholar
  27. 27.
    Launay-Vacher V, Oudard S, Janus N, Gligorov J, Pourrat X, Rixe O, et al. Renal Insufficiency and Cancer Medications (IRMA) Study Group: prevalence of Renal Insufficiency in cancer patients and implications for anticancer drug management: the renal insufficiency and anticancer medications (IRMA) study. Cancer. 2007;110(6):1376–84.PubMedCrossRefGoogle Scholar
  28. 28.
    Gokula M, Holmes HM. Tools to reduce polypharmacy. Clin Geriatr Med. 2012;28(2):323–41.PubMedCrossRefGoogle Scholar
  29. 29.
    Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163:2716–24.PubMedCrossRefGoogle Scholar
  30. 30.
    Hanlon JT, Schmader KE, Samsa GP. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45:1045–51.PubMedCrossRefGoogle Scholar
  31. 31.
    Gallagher P, Ryan C, Byrne S. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert Doctors To Right Treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46:72–83.PubMedCrossRefGoogle Scholar
  32. 32.
    Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet. 1994;344(8934):1383–9.Google Scholar
  33. 33.
    Shepherd J, Blauw GJ, Murphy MB, Bollen EL, Buckley BM, Cobbe SM. PROSPER study group. PROspective Study of Pravastatin in the Elderly at Risk: pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet. 2002;360:1623.PubMedCrossRefGoogle Scholar
  34. 34.
    Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet. 2002;360(9326):7–22.CrossRefGoogle Scholar
  35. 35.
    Callahan AS. Vascular pleiotropy of statins: clinical evidence and biochemical mechanisms. Curr Atheroscler Rep. 2003;5(1):33–7.PubMedCrossRefGoogle Scholar
  36. 36.
    Weisman SM, Graham DY. Evaluation of the benefits and risks of low-dose aspirin in the secondary prevention of cardiovascular and cerebrovascular events. Arch Intern Med. 2002;162(19):2197–202.PubMedCrossRefGoogle Scholar
  37. 37.
    Nordin BEC. Calcium and osteoporosis. Nutrition. 1997;13(7/8):664–86.PubMedCrossRefGoogle Scholar
  38. 38.
    Bayliss EA, Bronsert MR, Reifler LM, Ellis JL, Steiner JF, McQuillen DB, et al. Statin prescribing patterns in a cohort of cancer patients with poor prognosis. J Palliat Med. 2013;16(4):412–8.PubMedCentralPubMedCrossRefGoogle Scholar
  39. 39.
    Tanvetyanon T, Choudhury AM. Physician practice in the discontinuation of statins among patients with advanced lung cancer. J Palliat Care. 2006;22(4):281–5.PubMedGoogle Scholar
  40. 40.
    Stavrou EP, Buckley N, Olivier J, Pearson SA. Discontinuation of statin therapy in older people: does a cancer diagnosis make a difference? An observational cohort study using data linkage. BMJ Open. 2012;2:e000880.PubMedCentralPubMedCrossRefGoogle Scholar
  41. 41.
    Schuling J, Gebben H, Veehof LJ, Haaijer-Ruskamp FM. Deprescribing medication in very elderly patients with multimorbidity: the view of Dutch GPs. A qualitative study. BMC Fam Pract. 2012;13:56.PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2014

Authors and Affiliations

  • A. Todd
    • 1
    Email author
  • H. Nazar
    • 2
  • S. Pearson
    • 3
  • I. Andrew
    • 4
  • L. Baker
    • 4
  • A. Husband
    • 1
  1. 1.Division of Pharmacy, School of Medicine, Pharmacy and HealthDurham UniversityStockon-on-TeesUK
  2. 2.Department of Pharmacy, Health and Well-being, Faculty of Applied ScienceUniversity of SunderlandSunderlandUK
  3. 3.Faculty of Pharmacy and School of Public HealthThe University of SydneySydneyAustralia
  4. 4.St Benedict’s Hospice and Centre for Specialist Palliative CareRyhope, SunderlandUK

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