The development and evaluation of an oncological palliative care deprescribing guideline: the ‘OncPal deprescribing guideline’

Abstract

Purpose

Current data suggests that potentially inappropriate medicines (PIMs) are common in palliative cancer patients; however, there is a lack of criteria to assist clinicians in identifying PIMs in these patients. The aims of this study were to design and validate a deprescribing guideline for palliative cancer patients and to undertake a descriptive analysis of the identified PIMs.

Methods

This prospective, non-interventional cohort study consisted of four major stages: developing an ‘OncPal Deprescribing Guideline’ from current evidence, the prospective recruitment of consecutive palliative cancer inpatients with an estimated <6-month prognosis, the assessment of all medications to identify PIMs using both a panel of medical experts without access to the guideline as well as a Clinical Pharmacist independently using the OncPal Deprescribing Guideline and the evaluation of the guideline by testing concordance. Descriptive data on the incidence of PIMs identified were also assessed.

Results

A total of 61 patients were recruited. The OncPal Deprescribing Guideline matched 94 % of 617 medicines to the expert panel with a Kappa value of 0.83 [95 % CI (0.76, 0.89)] demonstrating an ‘outstanding’ concordance. Forty-three (70 %) patients were taking at least one PIM, with 21.4 % of the total medicines assessed identified as PIMs. The medication-associated cost per patient/month was AUD$26.71.

Conclusion

A guideline to assist in the de-escalation of inappropriate medications in palliative cancer patients was developed from current literature. The OncPal Deprescribing Guideline was successfully validated, demonstrating statistically significant concordance with an expert panel. We found that the incidence of PIMs was high in our patient group, demonstrating the potential benefits for the OncPal Deprescribing Guideline in clinical practice.

Appendix 1 OncPal De-prescribing guideline

This guideline has been developed to assist in highlighting medications with a limited benefit that are suitable targets for discontinuation in palliative cancer patients. Medication classes not listed below have demonstrated benefits in this population or the literature is lacking to guide a decision-making process. If the foreseeable benefits of any medications do NOT outweigh the adverse effects and/or associated risks, it is recommended to consider appropriate de-escalation

Medication class	Medication	Considerations for limited benefit	Explanation
Blood and blood-forming organs	Aspirin	For primary prevention only.	Long-term benefits at population level. Little short or intermediate term risk of stopping (1). Drugs for primary prevention have, in general, no place in the treatment of end-of-life patients since the time-to-benefit usually exceeds life expectancy (2).
Cardiovascular system	Dyslipidaemia medications  Statins  Fibrates  Ezetimibe	All indications.	Long-term benefits at population level. Little short or intermediate term risk of stopping (1).
	Antihypertensives  ACE inhibitors  Sartans  Beta blockers  Calcium channel blockers  Thiazide  Diuretics	If sole use is to reduce mild to moderate hypertension for secondary prevention of cardiovascular events or as management of stable coronary artery disease.ab	Long-term benefits at population level. Ongoing therapy unnecessary in most shortened life expectancy (1).
Musculo-skeletal system	Osteoporosis medications  Bisphosphonates  Raloxifene  Strontium  Denosumab	Except if used for the treatment of hypercalcaemia secondary to bone metastases.	Except if used for the treatment of hypercalcaemia secondary to bone metastases. Long-term benefits at population level. Little short or intermediate term risk of stopping (1).
Alimentary tract and metabolism	Peptic ulcer prophylaxis  Proton pump inhibitors  H2 antagonists	Lack of any medical history of gastrointestinal bleeding, peptic ulcer, gastritis, GORD or the concomitant use of anti-inflammatory agents including NSAIDs and steroids (3).	Ongoing therapy unnecessary in most shortened life expectancy (1).
	Oral Hypoglycaemics  Metformin  Sulfonylureas  Thiazolidinediones  DPP-4 inhibitors  GLP-1 analogues  Acarbose	If sole use is to reduce mild hyperglycaemia for secondary prevention of diabetic associated events.c	Potential short-term complications outweigh benefit (1).
	Vitamins Minerals Complementary—alternative medicines	If not indicated to treat a low blood plasma concentration.	No evidence for effectiveness (4, 5).d

^aSome short-term benefits need consideration—recommended to monitor blood pressure after discontinuation for symptomatic hypertension

^bThe use of these agents in symptom management for an underlying disease should be continued. For example, antihypertensives in heart failure or rate control in irregular heart rhythm (6)

^cSome short-term benefits need consideration—recommended to monitor blood sugar levels infrequently after discontinuation for symptomatic hyperglycaemia. Aim for blood sugar levels below 20mmols/L (7)

^dSome topical preparations may provide some benefits (5)

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