Medicines With Bottle On Purple Background
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A new study suggests a new way for hematologic oncologists to protect older patients from the risks of medication interactions. As part of the Older Adult Hematologic Malignancies Program, investigators from Brigham and Women’s Hospital and the Dana-Farber Cancer Institute studied the association between older patients with blood cancers who were taking multiple medications and their corresponding frailty.

“To prevent dangerous interactions, we developed a scale for Potentially Inappropriate Medications, or PIMs, based on the National Comprehensive Cancer Network (NCCN) guidelines list of medications of concern in older adults with cancer and named it the GO-PIMs (Geriatric Oncology-Potentially Inappropriate Medications) Scale,” the authors wrote. “The GO-PIMs Scale carried the strongest association with frailty among other scales studied and can be used by oncology teams to help decrease inappropriate medication usage.”  A paper describing the research and details of the GO-PIMs scale are published in the Journal of the National Comprehensive Cancer Network.

This scale was created due to the fact that many older adults with blood cancer take multiple medications at the same time, along with their prescribed cancer treatments, raising their risk of experiencing adverse events. Most older adults with blood cancers take ≥5 medications, and studies in older adults with solid tumors showed that polypharmacy, defined as ≥8 medications, was highly related to impaired physical function.

“We were interested in the NCCN list of medications of concern because, in contrast to other lists, it was developed by geriatricians and oncologists to be specific for older adults with cancer,” explained co-lead author Tammy T. Hshieh, MD, MPH, of Dana-Farber Cancer Institute, Brigham and Women’s Hospital and Harvard Medical School. The GO-PIMs scale was designed to measure the total number of medications on the NCCN list, with each increase in number of individual medications representing higher risk. The team then applied this scale to all the chronic medications extracted from patient charts, measuring the total number of GO-PIMs for each patient in the study.

In this study, the researchers examined 785 transplant-ineligible blood cancer patients aged 75-and-older looking for measures of frailty. The researchers found that taking eight or more medications increases the odds of an older patient being frail; with each additional medication, their odds of being frail increases. That risk only increased with each additional PIM. Specifically, each additional ‘unspecified’ medication in general increased the relative odds of being pre-frail or frail by 8%, while each additional medication on the GO-PIMs scale increased the relative odds by 65%. Compared to robust patients, frail and pre-frail patients were more likely to be taking benzodiazepines, selective serotonin reuptake inhibitors (SSRIs), or corticosteroids. The team was surprised, however, that taking many medications, including PIMs, did not appear to impair patients ‘cognitive function.

The study could not determine whether the medications caused the frailty, but it is known from other studies in non-cancer populations that PIMs contribute to the development of frailty over time. “The health risks of these medications (e.g., falls associated with benzodiazepines and sedation associated with opioids) often outweigh their benefits, especially in older adults whose drug metabolism and ability to tolerate side effects are reduced,” the authors write.

“This is exciting work because it gives us a new and pretty easy-to-use tool to improve patient’s overall health,” said co-lead author Clark DuMontier, MD, MPH, also with Brigham and Women’s Hospital and Harvard Medical School. “And the GO-PIMs tool makes it easier for oncology teams to identify these medications and determine whether they are a net risk to increasing a patient’s frailty and thus merit consideration of deprescribing.” This scale can also be converted into an automated tool that identifies high-risk medications within an electronic health record.

Added Hshieh: “The scale also allows us to partner with patients — – who are increasingly proactive about their health — to set them up to be more successful on their cancer treatment journey.”

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