Adherence to oral cancer therapies

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Marcia Lester
7 years ago
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1 Adherence to oral cancer therapies Just take your medicine Linda Nielsen, MS, DNPc, AOCNP Hematology Oncology of Indiana, PC

2 Importance of Adherence Study of breast cancer patients, adherence dropped from 77% to 50% between first and fourth year of treatment One study found that actual adherence was less than half of that indicated by patient selfreports Skipping doses of cancer medications have higher risks

3 Factors affecting adherence to prescribed oral medication regimens: -Patient-specific factors: Patient-perceived benefit of treatment (patient satisfaction) Patient health literacy Patient understanding of treatment plan and need for treatment interventions History of non-adherence History of mental illness History of substance abuse History of unstable housing Family/social support Caregiver assistance at office visits and during at-home or inpatient care Access to patient-assistance programs or health insurance Visual and cognitive impairment Memory deficits Physical limitations Polypharmacy due to multiple co-morbid conditions

4 -Treatment-related factors Complexity of treatment regimen Dosing frequency Timing of dose in relation to food intake Number of concomitant medications or treatments Substantial behavior changes due to treatment Food and alcohol restrictions Duration of therapy Adverse effects: Frequency, severity, type, management -Health care provider-related factors Relationship with health care provider Supervision, monitoring, communication, referrals, and follow-up Convenience and efficiency Location, open hours, ease of scheduling Continuity of care (Co-location of services were especially relevant in elderly patients)

5 Overcoming barriers Patient education Patient specific factors that effect adherence Patient specific assessments to individualize plan and follow-up care Early recognition and resolution of side effects Patient/health care provider relationship Developing trust relationship Duration and frequency of on interactions

6 Monitoring adherence Patient self-report Blister packs and pill counting at visits Microelectronic monitoring system (MEMS) Telephone follow-up Involvement of family members/caretakers

7 Cancer treatment maintenance therapies Chronic disease model Endure adherence over potentially long periods of time Geriatric model Multidisciplinary model (pharmacist, PCP, social worker, psychology)

8 Prescribing safely Signatures to ensure use of double check system Full patient name, DOB, allergies, BSA, diagnosis, number of cycles and cycle number, dose calculation Review of medication list at each visit Safe handling and storage

9 Oral chemotherapy process Name of patients prescribed oral chemotherapy Date of prescription with date of first dose Patient is to call whom with questions Patient calendars Fragmentation of care-first time aware of oral drug was when call to triage nurse with problem EMR was hindrance-no way to flag or identify oral chemotherapy patients Nurses inadequately prepared to teach

10 Strategies Weekly call list Standardized documentation forms for telephone calls: admin instructions, precautions monitoring adverse events Routine calls at 48 hours after beginning and one week f/u visits Providing education for nurses on oral chemotherapy

11 Implications for nursing Oral chemotherapy clinics Many of the interventions occurred within one month of the initial clinic visit Oral chemotherapy education How they work Potential side effects How to manage side effects if they occur Clearly written directions for administration Safe storage and handling of medications

12 Implication for nursing Medication therapy management Food-drug interactions Drug-drug interactions Contact oncology nurse before beginning any new medications prescribed by another provider (local pharmacy may not have their cancer treatment drug on their list) Disease and symptom management Follow up care plans

13 CYP3A Inducers Carbamazepine Ethosuximide Griseofulvin Nelfinavir Oxcarbazepine Phenylbutazone Primidone Rifabutin Rofecoxib (mild) Sulfadimidine Troglitazone C Dexamethasone Glucocorticoids Nafcillin Nevirapine Phenobarbital Phenytoin Progesterone Rifampin St. John s wort Sulfinpyrazone

14 CYP3A Inhibitors Amiodarone Anastrozole Azithromycin Cannabinoids Cimetidine Clarithromycin Clotrimazole Cyclosporine Danazol Delavirdine Dexamethasone Diethyldithiocarbamate Diltiazem Dirithromycin Disulfiram Entacapone (high dose) Erythromycin Ethinyl estradiol Fluconazole (weak) Fluoxetine Fluvoxamine Gestodene Grapefruit juice lndinavir lsoniazid ltraconazole Ketoconazole Metronidazole Mibefradil Miconazole (moderate) Nefazodone Nelfinavir Nevirapine Norfloxacin Norfluoxetine Omeprazole (weak) Oxiconazole Paroxetine (weak) Propoxyphene Quinidine Quinine Quinupristin dalfopristin Ranitidine Ritonavir Saquinavir Sertindole Sertraline Troglitazone Troleandomycin Valproic acid (weak) Verapamil Zafirlukast Zileuton

15 Future More qualitative research is needed to explore patient needs and underlying processes influencing medication non-adherence and non persistence. Continuing education on oral therapies for health care providers Improved protocols for implementation of oral therapies

16 The End

17 References Banna, G. L., Collovà, E., Gebbia, V., Lipari, H., Giuffrida, P., Cavallaro, S.,... & Ferraù, F. (2010). Anticancer oral therapy: emerging related issues. Cancer treatment reviews, 36(8), Jacobs, C. (2009). Neuroendocrine tumors: nursing implications for oral targeted agents and patient management: part II. Clinical journal of oncology nursing, 13(2), Mathes, T., Antoine, S. L., Pieper, D., & Eikermann, M. (2014). Adherence enhancing interventions for oral anticancer agents: A systematic review. Cancer treatment reviews, 40(1), Roop, J. C., & Wu, H. S. (2014, March). Current practice patterns for oral chemotherapy: results of a national survey. In Oncology nursing forum (Vol. 41, No. 2, pp ). Oncology Nursing Society. Winkeljohn, D. (2010). Adherence to oral cancer therapies. Clinical journal of oncology nursing, 14(4), Wong, S. F., Bounthavong, M., Nguyen, C., Bechtoldt, K., & Hernandez, E. (2014). Implementation and preliminary outcomes of a comprehensive oral chemotherapy management clinic. American Journal of Health-System Pharmacy, 71(11),

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