Polypharmacy in older cancer patients

Tuesday, July 23, 2019

Ginah Nightingale, PharmD, of the Jefferson College of Pharmacy at Thomas Jefferson University in Philadelphia chats with David H. Henry, MD, host of Blood & Cancer, about the definition of polypharmacy and the challenges it poses in treating older cancer patients.

Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about the waiting that cancer patients face.

Show notes

Older adults comprise about 15% of the total population but account for more than 33% of prescription drug use.
Polypharmacy can be defined as taking five or more medications (prescription and nonprescription), as well as being on medications that have adverse effects in older adults.
Older adults are at increased risk for adverse effects from polypharmacy for multiple reasons, including multiple comorbidities and altered drug metabolism.
In a study by Nightingale et al., 61% of patients already had a major drug-drug interaction on their medication list prior to initiation of cancer therapy.
In a study by Sharma et al., 22% of patients were taking proton pump inhibitors concurrently with tyrosine kinase inhibitors, an interaction that was associated with increased risk of death at 90 days and 1 year.
Patients who receive medications from multiple pharmacies, such as a specialty pharmacy for oncologic drugs, are at increased risk of polypharmacy errors.
Tools to screen for polypharmacy include:
- Beers criteria by American Geriatrics Society
- STOPP/START criteria (commonly used in Europe)
- Medication appropriateness index
Considerations such as patient’s life expectancy and quality-of-life goals should be taken into account when deciding which medications are necessary and what may be deprescribed.
Clinicians should encourage patients to bring in all medications to every doctor’s visit, and certainly at the time of initiation of cancer treatment.

Show notes by Sugandha Landy, MD, resident in the department of internal medicine, University of Pennsylvania, Philadelphia.

Additional reading

American Geriatrics Society 2019 Updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019 Apr;67(4):674-94.

O'Mahony Denis et al. STOPP/START criteria for potentially inappropriate prescribing in older people: Version 2. Age Ageing. 2015 Mar;44(2):213-8.

Nightingale G et al. Evaluation of a pharmacist-led medication assessment used to identify prevalence of and associations with polypharmacy and potentially inappropriate medication use among ambulatory senior adults with cancer. J Clin Oncol. 2015 May 1;33(13):1453-9.

Sharma M et al. The concomitant use of tyrosine kinase inhibitors and proton pump inhibitors: Prevalence, predictors, and impact on survival and discontinuation of therapy in older adults with cancer. Cancer. 2019 Apr 1;125(7):1155-62.

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^{David Henry, MD}

David Henry, MD, FACP, is a clinical professor of medicine at the University of Pennsylvania and vice chairman of the department of medicine at Pennsylvania Hospital in Philadelphia. He received his bachelor’s degree from Princeton University and his MD from the University of Pennsylvania, then completed his internship, residency, and fellowship at the Hospital of the University of Pennsylvania. After 2 years as an attending in the U.S. Air Force, he was drawn to practicing as a hem-onc because of the close patient contact and interaction, and his belief that, win or lose with each patient, one can always make a difference in their care and lives. Follow Dr. Henry on Twitter: @davidhenrymd. Dr. Henry reported being on the advisory board for Amgen, AMAG Pharmaceuticals, and Pharmacosmos. He reported institutional funding from the National Institutes of Health and FibroGen.