Pharmacist-led medication review cuts inappropriate prescribing in older adults with cancer

A pharmacist-led medication review sharply reduced inappropriate prescribing, unnecessary drugs and missed treatments among older adults with cancer who take five or more medications, according to a randomized controlled trial published in the Journal of Internal Medicine.

By the end of the three-week rehabilitation stay, 29.9% of patients in the intervention group were taking a potentially inappropriate medication. In the usual care group, the figure was 70.8%. Medication overuse was 34.2% versus 64.1%, and medication underuse was 44.9% versus 73.2%.

The researchers said evidence from randomized trials of medication reviews in geriatric oncology has been sparse. Earlier trials in older cancer patients have been small, with 60 to 147 participants each.

"The pharmacist-led intervention … substantially improved the medication quality of older cancer patients with polypharmacy in clinical practice," the authors wrote.

How the trial worked

The OPTIMAL trial was coordinated by the German Cancer Research Center and run in 10 inpatient rehabilitation clinics across Germany. In Germany, a three-week rehabilitation stay is part of usual care shortly after primary cancer treatment ends.

Patients were eligible if they were 65 or older, regularly took at least five drugs and had been diagnosed with one of 22 common cancers within the previous five years. The analysis included 443 patients. Their average age was 73, about two-thirds were women and roughly half had breast cancer.

For patients randomized to the intervention, a study pharmacist reviewed diagnoses and medication lists using the Fit fOR The Aged (FORTA) list. FORTA is a free, validated tool that rates drugs for older adults from "indispensable" to "avoid" across 30 indications. The pharmacist then sent the rehabilitation physician an advisory letter recommending specific changes: switching inappropriate drugs to better alternatives, stopping drugs with no clear indication, starting treatment for untreated conditions and catching up on missed vaccinations. Physicians decided which recommendations to accept. Patients in the control group were covered by a sham letter.

At admission, medication problems were nearly universal. About two-thirds of patients were taking at least one potentially inappropriate medication, and 58.9% were taking a drug with no appropriate indication. Once missed vaccinations were counted, nearly 95% had some form of underuse.

What physicians accepted

Physicians accepted about 77% of recommendations to switch inappropriate drugs and 77% of recommendations to stop overused drugs. For underuse, they accepted 52.4% of recommendations to start new medications and 89.9% of recommendations for vaccinations.

Analgesics and beta blockers were the most frequently flagged inappropriate drugs. Nonsteroidal anti-inflammatory drugs made up nearly two-thirds of the pain-related flags. For beta blockers, the authors recommended checking whether patients had an indication beyond hypertension, such as atrial fibrillation or heart failure. Antidepressants, antipsychotics and sedatives were also commonly flagged. The authors noted their links to falls and cognitive impairment.

Proton pump inhibitors were the drugs most often classified as overuse, and physicians agreed to stop them in 85.4% of cases. The authors described PPIs and antithrombotics as frequent "leftovers" from hospital stays that were never meant to continue after discharge. They also said deprescribing PPIs matters especially for cancer patients, because PPIs can interact with some antineoplastic agents.

The most common untreated conditions were chronic pain, incontinence and insomnia. The researchers said many of these problems surfaced only through patient questionnaires, which suggests physicians may not have known about them. They urged clinicians to ask about these symptoms proactively.

Vaccination gaps were widespread. On average, patients were missing two of the four vaccines recommended in Germany for adults 65 and older: COVID-19, shingles, pneumococcal and influenza. The authors encouraged oncologists to ask about vaccination status rather than leaving it to primary care.

Implications for practice

The researchers said a centralized review delivered by advisory letter is a practical model when clinics lack pharmacy staff. Most of the process was automated with software, and a typical review took less than 15 minutes. They added that software-based tools could let clinicians run such reviews without a pharmacist in most cases.

The authors noted that the FORTA list is not meant to replace clinical judgment. They also acknowledged that physicians could not be fully blinded, because they could often guess which patients received the sham letter.

The findings add to a growing body of research on the risks of potentially inappropriate drugs in older patients, and on structured deprescribing efforts to address them.

The trial's primary endpoint, quality of life at eight months, will be reported separately. That report will also cover whether primary care physicians kept the medication changes in place after discharge.