Indian Journal of Palliative Care
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 »  Abstract
 » Introduction
 » Methods
 » Results
 » Discussion
 » Conclusion
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Table of Contents 
ORIGINAL ARTICLE
Year : 2019  |  Volume : 25  |  Issue : 1  |  Page : 124-126

The use of antidiabetic, antihypertensive, and lipid-lowering medications in the elderly dying with advanced cancer


1 King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
2 King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; Kasr Alaini Center of Clinical Oncology, Faculty of Medicine, Cairo University, Cairo, Egypt
3 Kasr Alaini Center of Clinical Oncology, Faculty of Medicine, Cairo University, Cairo, Egypt

Date of Web Publication31-Jan-2019

Correspondence Address:
Dr. Mohammad Zafir Al-Shahri
King Faisal Specialist Hospital and Research Center, MBC #64, P.O. Box 3354, Riyadh 11211
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPC.IJPC_96_18

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 » Abstract 

Background: Maintenance of medications that are unconducive to the quality of life is difficult to justify in dying terminally-ill cancer patients. Objective: We aimed at determining the prevalence of administering antidiabetic, antihypertensive, and lipid-lowering medications to elderly patients dying with cancer. Methods: We reviewed the medical records of patients above 60 years of age with advanced cancer who died in a palliative care unit. The collected data included the use of antidiabetic, antihypertensive, and lipid-lowering medications during the last week of life. Results: Of 103 patients, 51.5% were female and the median age was 69 years. The most common cancers included gastrointestinal (40.8%), gynecological (13.6%), and head and neck (12.6%). All patients had advanced cancer and 59.2% had hypertension, 52.4% had diabetes mellitus, and 19.4% had dyslipidemia. During their last week of life, 38.8% received antidiabetic, 23.3% received antihypertensive, and 3.9% received lipid-lowering agents. The data showed that 68.5% of people with diabetes received antidiabetic medications, 37.7% of hypertensive patients received antihypertensive medications, and 20% of dyslipidemics received lipid-lowering agents. Hypoglycemia was reported in 7.5% of patients receiving antidiabetic drugs, while hypotension was reported in 66.7% of patients receiving antihypertensive agents. Conclusion: Many elderly patients dying with advanced cancer in a palliative care unit were maintained on medications for chronic conditions until the very late stages of their lives. For such imminently dying patients, benefits of such medications are unlikely and burdens are possible. Further research is needed to explore physicians' justifications, if any, for maintaining such patients on apparently futile medications.


Keywords: Cancer, dying, futile medications, palliative care, Saudi Arabia


How to cite this article:
Al-Shahri MZ, Sroor MY, Ghareeb WA, Aboulela EN, Edesa W. The use of antidiabetic, antihypertensive, and lipid-lowering medications in the elderly dying with advanced cancer. Indian J Palliat Care 2019;25:124-6

How to cite this URL:
Al-Shahri MZ, Sroor MY, Ghareeb WA, Aboulela EN, Edesa W. The use of antidiabetic, antihypertensive, and lipid-lowering medications in the elderly dying with advanced cancer. Indian J Palliat Care [serial online] 2019 [cited 2019 Feb 20];25:124-6. Available from: http://www.jpalliativecare.com/text.asp?2019/25/1/124/251089



 » Introduction Top


Patients with advanced cancer are often unnecessarily maintained on medications that do not meaningfully add to their quality of life but may rather increase the risk for adverse reactions and drug interactions in addition to the unjustified financial burden.[1],[2] Such practice is even more difficult to justify when such patients are in their last days of life.

Metabolic syndrome is nowadays a global problem, with high prevalence in Saudi Arabia exceeding 28%.[3] Hence, the high prevalence of diabetes mellitus, hypertension, and dyslipidemia is seen in Saudi Arabia.[4],[5],[6] These chronic conditions are more common among older adults as is the case with cancer. Therefore, many adults diagnosed with cancer may also be on treatments for one or more of these comorbidities. The aim of this study is to determine the prevalence of administering antidiabetic, antihypertensive, and lipid-lowering medications to elderly patients dying with advanced cancer.


 » Methods Top


This is a retrospective chart review for patients above 60 years of age who died with cancer in the Palliative Care Unit at King Faisal Specialist Hospital and Research Center, Riyadh. The collected data covered 23 months, from February 2010 to December 2011, inclusive. The project was approved by the respective Institutional Review Board before the commencement of data collection. In addition to patients' demographics, we collected data on the use of antidiabetic, antihypertensive, and lipid-lowering medications during the last week of life.

For patients on antidiabetic medications, we reviewed the medical records for the occurrence of hypoglycemic episodes, defined as a blood sugar of <3.9 mmol/L.[7] Similarly, for patients on antihypertensive medications, we reviewed the medical record for the occurrence of the hypotensive episodes, defined as a systolic blood pressure of <90 mmHg and/or a diastolic blood pressure of <60 mmHg.[8]

The statistical procedures included simple frequencies as well as Chi-square tests as appropriate. P < 0.05 was considered statistically significant. The Statistical Package for the Social Sciences (SPSS) version 20 (IBM Corp., Armonk, NY, USA) was used for analyzing the data.


 » Results Top


Of the 103 patients included, 51.5% were female and the median age was 69 years. The most common cancer categories included gastrointestinal (40.8%), gynecological (13.6%), and head and neck (12.6%). All patients had advanced stages of cancer manifested as metastatic (92.2%) or locally extensive (7.8%) disease. Of the studied patients, 59.2% had hypertension, 52.4% had diabetes mellitus, and 19.4% had dyslipidemia. [Table 1] shows further patients' characteristics. During their last week of life, the proportions of patients who were still receiving antidiabetic, antihypertensive, and (or) lipid-lowering medications were 38.8%, 23.3%, and 3.9%, respectively. The disease-specific analysis showed that 68.5% of diabetic patients received antidiabetic medications, 37.7% of hypertensive patients received antihypertensive medications, and 20% of dyslipidemic patients received lipid-lowering agents during the last week of life. During the last week of their life, 66.7% of patients on antihypertensive medications were reported to experience a minimum of one episode of hypotension. On the other hand, 7.5% of patients who received antidiabetic medications during their last week of life had the experience of at least one episode of hypoglycemia during that period. The maintenance of patients on the studied medications during the last week of their life was not significantly associated with their gender or age group.
Table 1: Patients' demographics

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 » Discussion Top


Maintaining terminally ill patients on unnecessary medications had previously been reported and critiqued by several reports.[9],[10],[11],[12] However, to the best of our knowledge, our data are the first of its kind in the Arab countries to describe the pattern of prescribing antidiabetic, antihypertensive, and lipid-lowering agents among advanced cancer patients in their final week of life.

Various research groups have suggested different definitions to define the futility of a medication in the terminally ill patient.[13],[14] In our study, we focused on a specific subgroup of the terminally ill cancer patients, namely, those in the final week of life who died in a palliative care unit. In such a group of patients, we believe that almost all antidiabetic, antihypertensive, and lipid-lowering medications could be considered futile and should ideally be discontinued. This belief is further supported by the fact that a considerable proportion of the studied patients was found to develop potentially drug-related complications such as hypotension or hypoglycemia.

In our palliative care unit, routine review and reordering of all medications for all patients are mandatory once a week. If a drug was not reordered, it will be automatically discontinued by the hospital pharmacy. This is a hospital-wide procedure aiming at reviewing the list of medications at least once weekly for potential dose modification and drug deletion or replacement as appropriate. Our data suggest that this method is probably insufficient to ensure the discontinuation of futile medications for dying patients and also that there is need for more training of staff involved.

One potential cause of failure to discontinue some futile medications for dying patients might be the hesitancy of physicians to discuss this sensitive matter with the patient and/or the family. Physicians might be worried that patients and families may perceive an offer to discontinue such chronically used medications as a sign of hopelessness and despair. Another possible reason for maintaining dying patients on such futile medications could be the worry among physicians that families may think of the discontinuation of futile medications as being contributory to the patient's death, when the latter occurs.

Irrespective of the real causes of the clinical practice reflected by our data, we believe that in the foreseeable future, there will likely be a shift toward more rational prescribing practices in Saudi Arabia for all patients, including the terminally ill and the dying. This belief is based on the fact that the country is rapidly moving in the direction of privatizing health services and expanding the health insurance system to fully replace the previous system in which the government used to pay for all the health services delivered to Saudi citizens.

Limitations of our study include the fact that it did not investigate the views of the palliative care physicians to explain the rationale of keeping dying cancer patients on the medications under study. It would have also been interesting to explore the views of patients and families about discontinuing chronically used medications based on the physicians' decision on its futility in view of the patients' very limited life expectancy. Although our hospital had the first palliative care program in Saudi Arabia, our findings are single institutional and cannot be generalized to reflect the practice of other palliative care programs in the country.


 » Conclusion Top


The results of this study have shown that many of the elderly patients dying with advanced cancer in a palliative care unit are maintained on medications for chronic conditions until the very late stages of their lives. For these frail and imminently dying patients, the benefits of such medications are unlikely and the various burdens are possible. Further research is needed to explore the justifications, if any, expressed by health-care professionals maintaining dying patients on antidiabetic, antihypertensive, and lipid-lowering medications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 » References Top

1.
Kotlinska-Lemieszek A, Paulsen O, Kaasa S, Klepstad P. Polypharmacy in patients with advanced cancer and pain: A European cross-sectional study of 2282 patients. J Pain Symptom Manage 2014;48:1145-59.  Back to cited text no. 1
    
2.
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 palliative care unit. Int J Pharm Pract 2001;9:R72.  Back to cited text no. 2
    
3.
Aljohani NJ. Metabolic syndrome: Risk factors among adults in Kingdom of Saudi Arabia. J Family Community Med 2014;21:170-5.  Back to cited text no. 3
    
4.
Al-Nozha MM, Al-Maatouq MA, Al-Mazrou YY, Al-Harthi SS, Arafah MR, Khalil MZ, et al. Diabetes mellitus in Saudi Arabia. Saudi Med J 2004;25:1603-10.  Back to cited text no. 4
    
5.
Al-Nozha MM, Abdullah M, Arafah MR, Khalil MZ, Khan NB, Al-Mazrou YY, et al. Hypertension in Saudi Arabia. Saudi Med J 2007;28:77-84.  Back to cited text no. 5
    
6.
Al-Nozha MM, Arafah MR, Al-Maatouq MA, Khalil MZ, Khan NB, Al-Marzouki K, et al. Hyperlipidemia in Saudi Arabia. Saudi Med J 2008;29:282-7.  Back to cited text no. 6
    
7.
Workgroup on Hypoglycemia, American Diabetes Association. Defining and reporting hypoglycemia in diabetes: A report from the American Diabetes Association Workgroup on Hypoglycemia. Diabetes Care 2005;28:1245-9.  Back to cited text no. 7
    
8.
Oyetunji TA, Chang DC, Crompton JG, Greene WR, Efron DT, Haut ER, et al. Redefining hypotension in the elderly: Normotension is not reassuring. Arch Surg 2011;146:865-9.  Back to cited text no. 8
    
9.
Cruikshank RP, Stafford B, Jones L. Polypharmacy in the terminally ill. Med J Aust 2013;199:29.  Back to cited text no. 9
    
10.
Oliveira L, Ferreira MO, Rola A, Magalhães M, Ferraz Gonçalves J. Deprescription in advanced cancer patients referred to palliative care. J Pain Palliat Care Pharmacother 2016;30:201-5.  Back to cited text no. 10
    
11.
Lee HR, Yi SY, Kim DY. Evaluation of prescribing medications for terminal cancer patients near death: Essential or futile. Cancer Res Treat 2013;45:220-5.  Back to cited text no. 11
    
12.
Holmes HM, Hayley DC, Alexander GC, Sachs GA. Reconsidering medication appropriateness for patients late in life. Arch Intern Med 2006;166:605-9.  Back to cited text no. 12
    
13.
Riechelmann RP, Krzyzanowska MK, Zimmermann C. Futile medication use in terminally ill cancer patients. Support Care Cancer 2009;17:745-8.  Back to cited text no. 13
    
14.
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.  Back to cited text no. 14
    



 
 
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