Russell B J, Rowett D, Abernethy A P, Currow D C
Centre for Palliative Care, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.
Intern Med J. 2014 Feb;44(2):177-84. doi: 10.1111/imj.12340.
The balance of benefit versus burden of ongoing treatments for comorbid disease in palliative populations as death approaches needs careful consideration given their particular susceptibility to adverse drug effects.
To provide descriptive data regarding the medications being prescribed to patients who have a life-limiting illness at the time of referral to a palliative care service in regional Australia, with particular focus on lipid-lowering medications.
A prospective case note review of 203 patients reporting the number of medications prescribed and, for lipid-lowering medications, the indication and level of prevention sought (primary, secondary, tertiary). Rates were compared by performance status, disease phase and comorbidity burden.
Mean number of regular medications prescribed was 7.2, with higher rates observed in those patients with a non-malignant primary diagnosis (rate ratio 1.28, confidence interval (CI) 1.11-1.50) or poorer performance status (rate ratio 1.37, CI 1.11-1.69) and lower rates for those in the terminal phase of disease (rate ratio 0.48, CI 0.30-0.76). Over one fifth of patients were prescribed a lipid-lowering medication, and two fifths of these prescriptions were for primary prevention of cardiovascular disease. Patients in the highest quartile of Charlson Comorbidity Index score were 4.6 (CI 2.06-10.09) times more likely to be prescribed a lipid-lowering medication than those in the lowest quartile.
Polypharmacy is prevalent for this group of patients, placing them at high risk of drug-drug and drug-host interactions. Prescribing may be driven by risk factors and disease guidelines rather than a rational, patient-centred approach.
鉴于姑息治疗人群在临近死亡时对药物不良反应特别敏感，因此需要仔细考虑持续治疗合并疾病的获益与负担之间的平衡。
提供有关澳大利亚地区转诊至姑息治疗服务机构时患有危及生命疾病的患者所开药物的描述性数据，特别关注降脂药物。
对203例患者进行前瞻性病例记录回顾，报告所开药物的数量，对于降脂药物，报告用药指征及预防级别（一级、二级、三级）。按功能状态、疾病阶段和合并症负担比较发生率。
常规开具药物的平均数量为7.2种，非恶性原发性诊断患者（率比1.28，置信区间(CI) 1.11 - 1.50）或功能状态较差患者（率比1.37，CI 1.11 - 1.69）的发生率较高，而处于疾病终末期患者的发生率较低（率比0.48，CI 0.30 - 0.76）。超过五分之一的患者开具了降脂药物，其中五分之二的处方用于心血管疾病的一级预防。Charlson合并症指数评分处于最高四分位数的患者开具降脂药物的可能性是最低四分位数患者的4.6倍（CI 2.06 - 10.09）。
该组患者多重用药情况普遍，使他们面临药物相互作用和药物与宿主相互作用的高风险。开药可能受风险因素和疾病指南驱动，而非合理的、以患者为中心的方法。
