Samuel Breiner, PharmD candidate

As the world population is aging, prevalence of chronic disease onset increases. Polypharmacy is high in cardiometabolic disease populations—specifically patients with stroke, heart disease, and diabetes.

While polypharmacy may help individuals manage these medical conditions, research shows that inadequate management and consumption of multiple medications may lead to:

drug-drug interactions causing significant morbidity and mortality

Studies pertaining to polypharmacy have been increasing over the last decade—yet, interventions aimed to prevent and manage polypharmacy are limited. These interventions may have potential to improve patient outcomes. The 

International Journal of Clinical Pharmacy

 recently published a review investigating available evidence of polypharmacy interventions in cardiometabolic diseases and determining outcome measures.

The review identified 6 studies that met specific criteria for interventions to better manage and reduce polypharmacy in patients with stroke, heart disease, and diabetes. All the studies provided complex, multifaceted interventions. The researchers addressed interventions when they identified problems in 4 important health outcomes:

surrogate markers, such as A1c in diabetes studies

Each study investigated complex interventions, but the methods behind each of these interventions lacked detail on how investigator developed and chose them. Most interventions were pharmacist-led and consisted of medication review, drug-related problem identification, medication management, and patient education.

The literature search only provided 6 experimental trials—each utilized different methods and intervention techniques

All studies used in the review had high risk of bias along with differences in the definition of polypharmacy, interventions, and outcomes

The review’s findings were limited to diabetes and heart disease only due to lack of literature on patients experiencing strokes and cardiometabolic multimorbidity

Overall, findings for polypharmacy interventions in people with cardiometabolic diseases are inconsistent. The study analysts conclude that longer, more frequent interventions with more direct patient care can improve patients’ quality of life and health care costs while decreasing drug-related problems. Researchers must provide additional descriptive interventions with organized methods to prove the findings from this review.

 is a 2021 PharmD candidate at The University of Connecticut in Storrs.

Lum M, Cheung M, Harris D, et.al. A scoping review of polypharmacy interventions in patients with stroke, heart disease and diabetes [published online ahead of print, 2020 Apr 21]. Int J Clin Pharm. 2020 Apr;42(2):378-392. doi: 10.1007/s11096-020-01028-x.

Articles

Studies pertaining to polypharmacy have been increasing over the last decade&mdash;yet, interventions aimed to prevent and manage polypharmacy are limited.

Polypharmacy Interventions Have Potential to Improve Patient Outcomes

Breast cancer is the most common cancer diagnosed in females and is the second leading cause of death behind lung cancer. In 2020, an estimated 320,000 new cases of either invasive or non-invasive breast cancer will be diagnosed in women.

Treatment advancements have increased breast cancer survivorship. Oncologists prescribe adjuvant endocrine therapy (AET), tamoxifen, or aromatase inhibitors, for women with hormone-sensitive breast cancer to reduce recurrence and mortality. Researchers have evidence that AET reduces recurrence rates, but therapy is prescribed for 5-10 years—allowing for suboptimal adherence for many women.

Clinicians developed and evaluated 4 previous interventions to enhance AET adherence but found inconclusive results. Some limitations behind these studies may explain the inconclusiveness:

Interventions weren’t based on identification of potentially modifiable psychosocial factors influencing AET adherence

They mainly relied on written educational materials/reminders

None of the 4 reported using a structured approach for intervention development, implementation and evaluation

Research in Social and Administrative Pharmacy

 published the results on the development of the PAcHA program, a community pharmacy-based intervention, in February 2020. This program was used to enhance AET adherence, and the article focused on the process of developing the intervention.

Clinicians can prescribe AET for 30-day periods, creating frequent patient encounters with community pharmacists—and allowing for a potential role in enhancing AET adherence. Pharmacists’ access to medication claims can help them detect nonadherence, and suggest strategies to enhance it.

On the downside, community pharmacists report they feel untrained and poorly equipped to monitor oral medication in oncology.

Intervention Mappin (IM), a 6 step-by-step approach to guide development and evaluation of complex behavioral interventions in health promotion, guided the PAcHA program. Previous AET adherence-enhancing interventions attempts have proven ineffective. Using a structured approach like IM has the possibility to increase success rates for efficacy and implementation of interventions targeting adherence.

If proven effective, the step-by-step IM approach may potentially optimize AET benefits among women with breast cancer and address pharmacists' needs for better monitoring of oral anticancer therapies.

Improving patient adherence to AET will continue to reduce breast cancer recurrences and mortality rates.

 is a 2021 PharmD Candidate, the University of Connecticut in Storrs.

U.S. Breast Cancer Statistics. BreastCancer.org. 

https://www.breastcancer.org/symptoms/understand_bc/statistics

 Updated January 27, 2020. Accessed May 2, 2020.

Labonté M, Guillaumie L, Dionne A, et.al. Development of a community pharmacy-based intervention to enhance adherence to adjuvant endocrine therapy among breast cancer survivors guided by the Intervention Mapping approach [published online ahead of print, 2020 Feb 12]. 

. 2020; S1551-7411(19)30530-3. doi: 10.1016/j.sapharm.2020.02.004.

A community pharmacy-based intervention program was utilized to enhance AET adherence.

Enhancing Adherence to Adjuvant Endocrine Therapy

Pharmacists are the most accessible health care professionals and have critical roles in managing patients’ chronic diseases. Diabetes is a top 5 chronic disease nationwide, and medication therapy management is vital in the prevention and delay of microvascular and macrovascular complications.

Pharmacists in Ontario, Canada have participated in the MedsCheck Diabetes (MCD) program, which delivers medication review services to patients with diabetes, since 2010.

 Since its implementation, nearly 50% of patients with diabetes received an initial medication review. Follow-up, on the other hand, declined substantially to only 17.5% of patients receiving assessment.

 published results from a survey completed by community pharmacists in its April 2020 issue. It identified the most substantial barriers to routine monitoring and follow-up for diabetes patients.

Altogether, 7270 Canadian pharmacists were invited to complete a survey using the Theoretical Domains Framework Version 2 (TDF v2), and 346 of those pharmacists completed it.

The TDF found both positive and negative influences affecting delivery of routine monitoring and follow-up for patients with diabetes.

Positively influencing domains consisted of:

beliefs about consequences for people with diabetes

Negatively influencing domains consisted of:

Other themes that pharmacists described as potential barriers included time and competing priorities, reimbursement, patient engagement, workflow and human resources, access to labs and clinical information, information technology, and support from the owner/manager.

Pharmacists’ concerns for the patient population with diabetes—along with their skills, knowledge, and belief in their roles for management&mdash;were apparent in the responses. Positive mindsets are key to advancing pharmacists’ benefit in monitoring diabetes and providing follow-up of care. Yet, despite these positive influencing factors, several factors remain as barriers and explain the substantial decline in follow-up for this patient population.

From basic education about the scope and role of pharmacy to more complex workplace strategy, changes are needed to optimize the pharmacist role in managing patients with diabetes. Whether it be new reimbursement strategies, expanding certified pharmacy technicians’ tasks, or increased staffing, the changes and patient benefits will not happen overnight. Trial and error will need to occur to optimize diabetic patient short- and long-term health goals.

MacCallum L, Mathers A, Kellar J, et al. Pharmacists report lack of reinforcement and the work environment as the biggest barriers to routine monitoring and follow-up for people with diabetes: A survey of community pharmacists [published online ahead of print, 2020 Apr 9]. 

. 2020;S1551-7411(19)31114-3. doi:10.1016/j.sapharm.2020.04.004

A recent survey identified the most substantial barriers to routine monitoring and follow-up for diabetes patients.