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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 404-405

Polypharmacy and inappropriate medication use in older patients with cancer: An unaddressed and ubiquitous problem

Department of Clinical Hematology and Stem Cell Transplantation, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

Date of Submission08-Apr-2021
Date of Decision14-Apr-2021
Date of Acceptance16-Apr-2021
Date of Web Publication30-Jun-2021

Correspondence Address:
Suvir Singh
Department of Clinical Hematology and Stem Cell Transplantation, Dayanand Medical College and Hospital, Ludhiana, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/crst.crst_69_21

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How to cite this article:
Singh S, Sharma R. Polypharmacy and inappropriate medication use in older patients with cancer: An unaddressed and ubiquitous problem. Cancer Res Stat Treat 2021;4:404-5

How to cite this URL:
Singh S, Sharma R. Polypharmacy and inappropriate medication use in older patients with cancer: An unaddressed and ubiquitous problem. Cancer Res Stat Treat [serial online] 2021 [cited 2021 Oct 22];4:404-5. Available from: https://www.crstonline.com/text.asp?2021/4/2/404/320244

We read with interest the recent study by Noronha et al.[1] that elegantly described the patterns of polypharmacy in older adults receiving cancer therapy and the accompanying editorial.[2] Strikingly, over 55% of the patients were noted to receive more than five drugs, with over 80% of the patients receiving a prescription for at least one potentially inappropriate drug. These findings are illustrative of the larger patterns of prescribing drugs for patients with cancer, in general, and offer several pragmatic inferences. Extending the discussion from Noronha et al.'s study, we would like to highlight two more important conclusions that can be drawn from it.

First, the financial toxicity associated with low-value medications is significantly underestimated, with no systematic data to support the same. Cancer treatment is increasingly associated with high rates of financial toxicity, especially in the era of molecular and targeted therapies.[3] Approximately 40%–50% of the patients in several studies from high-income countries have reported a significant financial burden from cancer-related expenses, a number expected to be much higher in India.[4] Occurrence of financial toxicity in older patients is associated with poor health-related quality of life and a compensatory reduction in spending on other necessities.[5] Despite the cost of therapy in India being considerably lower than that in high-income countries, significant out-of-pocket expenditures make it imperative to adopt a parsimonious approach before recommending any addition to therapy.[6],[7] Analysis of data from the Social Consumption: Health Survey (71st round) of India revealed that over 60% of the patients treated in the private setting incur out-of-pocket expenses in excess of 20% of the annual per capita household expenditure.[8] In this setting, adding unindicated medications is a low-value practice that could potentially add up to substantial financial toxicity over a period of time.

Second, it is also important to highlight the active harm caused by low-value or inappropriate medication use, which may not be readily apparent due to the innocuous nature or over-the-counter availability of many medications. For instance, the commonly used supplements containing Vitamins A, E, and C have been shown to alter the pharmacokinetics of imatinib by altering its bioavailability.[9] Similar caveats apply to the usage of oral medications containing antioxidants, multivitamins, and other supplements. Various datasets have revealed conflicting evidence on the effects of antioxidants,[10] multivitamins, and other dietary supplements[11] on patients receiving cancer therapy, with several studies demonstrating potential for clinical harm. The exact effects of several compounds, including Vitamin D3 and Vitamin C on leukemic cells, are still not known, and hence, the decision to prescribe these supplements should not be taken lightly.[12],[13] The use of innocuous drugs such as proton pump inhibitors (most common drugs involved in polypharmacy in the above study) has also been noted to have significant effects on the pharmacokinetics of several drugs such as methotrexate,[14] dasatinib,[15] and ibrutinib.[16]

Noronha et al.'s study highlights an important, ubiquitous, but unaddressed problem with potential for significant harm. It is essential to review or study de novo the effects of several commonly used drugs, which are added to core cancer therapy, so that informed and mindful decisions can be made before prescribing seemingly harmless drugs to patients with cancer.

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  References Top

Noronha V, Ramaswamy A, Gattani S, Castelino R, Krishnamurthy M, Menon N, et al. Polypharmacy and potentially inappropriate medication use in older Indian patients with cancer: A prospective observational study. Cancer Res Stat Treat 2021;4:67-73.  Back to cited text no. 1
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Rajesh V, Rao M. Conundrum of polypharmacy in geriatrics: Less is better than more. Cancer Res Stat Treat 2021;4:127-9.  Back to cited text no. 2
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Kalra D, Menon N, Singh GK, Dale O, Adak S, Das S, et al. Financial toxicities in patients receiving systemic therapy for brain tumors: A cross-sectional study. Cancer Res Stat Treat 2020;3:724-9.  Back to cited text no. 3
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Carrera PM, Kantarjian HM, Blinder VS. The financial burden and distress of patients with cancer: Understanding and stepping-up action on the financial toxicity of cancer treatment. CA Cancer J Clin 2018;68:153-65.  Back to cited text no. 4
Arastu A, Patel A, Mohile SG, Ciminelli J, Kaushik R, Wells M, et al. Assessment of financial toxicity among older adults with advanced cancer. JAMA Netw Open 2020;3:e2025810.  Back to cited text no. 5
Singh MP, Chauhan AS, Rai B, Ghoshal S, Prinja S. Cost of treatment for cervical cancer in India. Asian Pac J Cancer Prev 2020;21:2639-46.  Back to cited text no. 6
Rajpal S, Kumar A, Joe W. Economic burden of cancer in India: Evidence from cross-sectional nationally representative household survey, 2014. PLoS One 2018;13:e0193320.  Back to cited text no. 7
Goyanka R. Economic and non-economic burden of cancer: A propensity score matched analysis using household health survey data of India. Cancer Res Stat Treat 2021;4:29-36.  Back to cited text no. 8
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Maher HM, Alzoman NZ, Shehata SM. Ultra-performance LC-MS/MS study of the pharmacokinetic interaction of imatinib with selected vitamin preparations in rats. Bioanalysis 2018;10:1099-113.  Back to cited text no. 9
Ozben T. Antioxidant supplementation on cancer risk and during cancer therapy: An update. Curr Top Med Chem 2015;15:170-8.  Back to cited text no. 10
Harvie M. Nutritional supplements and cancer: Potential benefits and proven harms. Am Soc Clin Oncol Educ Book 2014:e478-86.  Back to cited text no. 11
Zhao H, Zhu H, Huang J, Zhu Y, Hong M, Zhu H, et al. The synergy of Vitamin C with decitabine activates TET2 in leukemic cells and significantly improves overall survival in elderly patients with acute myeloid leukemia. Leuk Res 2018;66:1-7.  Back to cited text no. 12
Wang J, Lian H, Zhao Y, Kauss MA, Spindel S. Vitamin D3 induces autophagy of human myeloid leukemia cells. J Biol Chem 2008;283:25596-605.  Back to cited text no. 13
Bezabeh S, Mackey AC, Kluetz P, Jappar D, Korvick J. Accumulating evidence for a drug-drug interaction between methotrexate and proton pump inhibitors. Oncologist 2012;17:550-4.  Back to cited text no. 14
Egorin MJ, Shah DD, Christner SM, Yerk MA, Komazec KA, Appleman LR, et al. Effect of a proton pump inhibitor on the pharmacokinetics of imatinib. Br J Clin Pharmacol 2009;68:370-4.  Back to cited text no. 15
Hussaarts KG, Veerman GD, Jansman FG, van Gelder T, Mathijssen RH, van Leeuwen RW. Clinically relevant drug interactions with multikinase inhibitors: A review. Ther Adv Med Oncol 2019;11:1758835918818347.  Back to cited text no. 16


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