An Observational Study of the Prescribing Practices and Patient Reported Outcomes Measures in Older People with Myelodysplastic Syndrome
Authors: Molga Angela , Wall Michelle , Chhetri Rakchha , Wee Amilia , Singhal Deepak , Giri Pratyush , To Timothy , Hiwase Devendra K 
Published: November 2019

Objectives:
Older people (≥65 years) living with myelodysplastic syndrome (MDS) have a poor prognosis, often compounded by comorbidities and polypharmacy. Polypharmacy is usually defined as the regular use of ≥5 medications and is common among older adults; however the appropriateness of therapy in older patients with malignancies requires a consideration of quality of life as well as prognosis rather than a discrete number. Such a patient-centred approach would identify potentially inappropriate medications (PIM) and also potentially omitted medications (POM). There is little data on the impact of PP, PIM and POM on patient reported outcome measures at baseline in older people with MDS. This study assesses the prevalence of PP, PIM and POM in older patients with MDS.
Methods:
Patients ≥65 years with MDS were enrolled from Jan 2014 to Nov 2018 at the Royal Adelaide Hospital. Patients were included in the study if they were seen by the Geriatrician for a Comprehensive Geriatric Assessment (CGA; Table 1), had geriatric screening assessments performed for frailty, completed patient-reported outcome measures using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) at enrolment, specifically the domains of physical condition of medical treatment interfering on family (q26), social (q27) and financial aspects (q28), overall health (q29) and overall quality of life (q30).
Results:
The average age of patients at the time of enrolment was 75 years (62-89 years). Other patient characteristics are in Table 1. Forty-one (64%) patients were on supportive care and 21 (33%) were treated with azacitidine. The prevalence of PP, PIM and POM was 39% (25/64), 47% (30/64), and 64% (41/64) respectively. These were evaluated by a Geriatrician/Clinical Pharmacologist using the STOPP/START criteria after reviewing the CGA reports for each patient. The most common PIM was aspirin without an evidence-based clinical indication. The number of PIM ranged from 1 to 7 for an individual patient. The most common POM were vaccinations - only 1/64 (2%) patient had a documented influenza and pneumococcal vaccination status as per national guidelines, followed by laxatives for concurrent opioid use.
Twenty-three percent (15/64) reported an overall poorer quality of life (defined as q30<4), of which 80% (12/15) were on supportive care and 20% (3/15) were on azacitidine. Nineteen percent (12/64) reported poor overall health (q29 <4), 20% (13/64) reported that their physical condition or medical treatment interfered with their family life, 31% (18/64) felt the impact on their social activities, and 13% (8/64) reported financial difficulties as a result of their condition or treatment. The majority were on supportive treatment - 10/13 (77%), 11/18 (61%), 6/8 (75%) respectively. The presence of PIMs (44 vs. 86 months; p=0.18) and POM (57 vs. 45 months; p=0.9) were associated with shortened survival however this was not statistically significant. Additionally PIMs, POMS, and polypharmacy were not associated with adverse perceptions on family, social or financial aspects of daily life. Similarly, there was no difference in cognitive frailty (defined as having an abnormal score for MMSE or other cognitive assessments or a confirmed diagnosis of dementia on treatment), physical frailty (defined as having an abnormal score on any one or more of the physical domains: iADL, ADL, TUG, falls) or multimorbidity (defined as having an abnormal score for CCI or MDS-CI).
Conclusions:
A significant proportion of older patients with MDS are multimorbid and report adverse impacts related to their condition on their family, social and financial aspects of their lives. Older patients are just as likely to have beneficial medications omitted as having potentially inappropriate medications requiring intervention. This study highlights the importance of deprescribing and reviewing goals of therapy with consideration for patient reported outcomes.

Disclosures
No relevant conflicts of interest to declare.