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Drug Interactions in Cancer Patients Treated with Oral Anticancer Drugs Van Leeuwen, R

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Drug Interactions in Cancer Patients Treated with Oral Anticancer Drugs Van Leeuwen, R University of Groningen Prevalence of potential drug-drug interactions in cancer patients treated with oral anticancer drugs van Leeuwen, R. W. F.; Brundel, D. H. S.; Neef, C.; van Gelder, T.; Mathijssen, R. H. J.; Burger, D. M.; Jansman, F. G. A. Published in: British Jounal of Cancer DOI: 10.1038/bjc.2013.48 IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record Publication date: 2013 Link to publication in University of Groningen/UMCG research database Citation for published version (APA): van Leeuwen, R. W. F., Brundel, D. H. S., Neef, C., van Gelder, T., Mathijssen, R. H. J., Burger, D. M., & Jansman, F. G. A. (2013). Prevalence of potential drug-drug interactions in cancer patients treated with oral anticancer drugs. British Jounal of Cancer, 108(5), 1071-1078. https://doi.org/10.1038/bjc.2013.48 Copyright Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons). Take-down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons the number of authors shown on this cover page is limited to 10 maximum. Download date: 23-09-2021 FULL PAPER British Journal of Cancer (2013) 108, 1071–1078 | doi: 10.1038/bjc.2013.48 Keywords: chemotherapy; potential drug–drug interactions; oncology; pharmacology; risk factors Prevalence of potential drug–drug interactions in cancer patients treated with oral anticancer drugs R W F van Leeuwen*,1,2, D H S Brundel2, C Neef2, T van Gelder1,3, R H J Mathijssen4, D M Burger5 and F G A Jansman6,7 1Department of Pharmacy, Erasmus University Medical Center, ’s-Gravendijkwal 230, Rotterdam 3015CE, The Netherlands; 2Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center, P. Debyelaan 25, Maastricht 6229HX, The Netherlands; 3Departments of Internal Medicine and Hospital Pharmacy, Erasmus University Medical Center, ’s-Gravendijkwal 230 230, Rotterdam 3015CE, The Netherlands; 4Department of Medical Oncology, Erasmus University Medical Center, Daniel den Hoed Cancer Center, ’s-Gravendijkwal, Rotterdam 3015CE, The Netherlands; 5Department of Pharmacy, Radboud University Center for Oncology (RUCO), Radboud University Medical Center, Geert Grooteplein 10, Nijmegen 6526 GA, The Netherlands; 6Department of Clinical Pharmacy, Deventer Hospital, Nico Bolkesteinlaan 75, Deventer 7416SE, The Netherlands and 7Department of Pharmacotherapy and Pharmaceutical Care, State University Groningen, Antonius Deusinglaan 1, Groningen 9713 AV, The Netherlands Background: Potential drug–drug interactions (PDDIs) in patients with cancer are common, but have not previously been quantified for oral anticancer treatment. We assessed the prevalence and seriousness of potential PDDIs among ambulatory cancer patients on oral anticancer treatment. Methods: A search was conducted in a computer-based medication prescription system for dispensing oral anticancer drugs to outpatients in three Dutch centres. Potential drug–drug interactions were identified using electronic (Drug Interaction Fact software) and manual screening methods (peer-reviewed reports). Results: In the 898 patients included in the study, 1359 PDDIs were identified in 426 patients (46%, 95% confidence interval (CI) ¼ 42–50%). In 143 patients (16%), a major PDDI was identified. The drug classes most frequently involved in a major PDDI were coumarins and opioids. The majority of cases concerned central nervous system interactions, PDDIs that can cause gastrointestinal toxicity and prolongation of QT intervals. In multivariate analysis, concomitant use of more drugs (odds ratio (OR) ¼ 1.66, 95% CI ¼ 1.54–1.78, Po0001) and genito-urinary cancer (OR ¼ 0.25, 95% CI ¼ 0.12–0.52, Po0001) were risk factors. Conclusion: Potential drug–drug interactions are very common among cancer patients on oral cancer therapy. Physicians and pharmacists should be more aware of these potential interactions. Drug–drug interactions in patients with cancer are common, and drug interactions (Ko¨hler et al, 2000). Drug–drug interactions are most drug–drug interactions can cause considerable adverse drug estimated to be the cause of death in B4% of cancer patients reactions (ADRs) (Ko¨hler et al, 2000). In the general population, (Buajordet et al, 2001). Patients treated systemically for cancer are it has been reported that 20–30% of all ADRs are caused by drug– particularly at risk for drug–drug interactions. Typically, patients *Correspondence: Dr RWF van Leeuwen; E-mail: [email protected] This study was presented at the 37th ESMO Annual Meeting (Vienna, Austria, 28 September to 2 October 2012, #1402). Received 16 November 2012; revised 16 January 2013; accepted 17 January 2013; published online 14 February 2013 & 2013 Cancer Research UK. All rights reserved 0007 – 0920/13 www.bjcancer.com | DOI:10.1038/bjc.2013.48 1071 BRITISH JOURNAL OF CANCER Drug interactions with oral anticancer drugs with cancer receive a high number of drugs concomitantly, of PDDIs among ambulatory cancer patients on oral anticancer including cytotoxic agents, hormonal agents, targeted agents, and treatment, with the primary intent to create awareness among supportive care agents among medication prescribed to treat oncologists and pharmacists regarding the risk of potentially comorbidities. An additional problem is that the mean age of harmful drug–drug interactions. The secondary objective was to cancer patients is increasing. Older patients generally have more obtain more insight into possible determinants for the occurrence comorbidities for which they also receive drug treatment (Yancik of these PDDIs. and Ries, 2000). The risk for drug–drug interactions in elderly cancer patients is further increased because of altered age- and comorbidity-related physiologic changes (e.g., altered drug absorp- MATERIALS AND METHODS tion due to mucositis or altered excretion due to renal and hepatic impairment) (Scripture and Figg, 2006). Study design and patients. A multicentre cross-sectional study of Here, a potential drug–drug interaction (PDDI) was defined as the prevalence of PDDIs was conducted in ambulatory cancer the occurrence of a potentially harmful combination of prescribed patients treated with oral anticancer drugs in three Dutch centres: drugs in a given patient, rather than the occurrence of an actual the Maastricht University Medical Center (Maastricht), St. adverse event for a patient. Radboud University Medical Centre (Nijmegen), and Deventer In clinical practice, PDDIs can be distinguished as pharmaceu- Teaching Hospital (Deventer). All ambulatory patients with the tical, pharmacokinetic, and pharmacodynamic interactions diagnosis of a solid tumour or a haematological malignancy, who (Scripture and Figg, 2006). Pharmaceutical PDDIs occur for were receiving one of more oral anticancer therapies (with or instance when two chemically or physically incompatible com- without additional intravenous anticancer drugs), were included in pounds are combined (e.g., cisplatin and mesna; Verschraagen the study. Exclusion criteria were (i) the use of (oral) experimental et al, 2003). Pharmacokinetic interactions refer to an influence on trial agents, (ii) age o18 years, and (iii) the use of oral anticancer the absorption, distribution, metabolism, or elimination of the drugs for non-malignant diseases. This study was registered under drug itself or a combination of drugs. A common pharmacokinetic number ISRCTN01739090, and was approved by the medical interaction concerns drugs metabolised by the cytochrome P450 ethics boards of all three participating institutes. (CYP) enzymes. By inhibition or induction of CYP iso-enzymes, blood and tumour concentrations, antitumoural effects, and Procedures. A retrospective search was conducted in the compu- toxicities of specific anticancer therapies may be altered. Other ter-based medication prescription system of the hospital pharmacy pharmacokinetic interactions may result from, that is, inhibition of in these three centres for the dispensing of oral anticancer drugs to the ABCB1 efflux-transporter (or P-glycoprotein); by altering the outpatients over a period of 12 months (between 1 October 2010 activity of ABCB1, the bioavailability of anticancer drugs may be and 1 October 2011). Medications were classified into three groups; influenced. Pharmacodynamic drug interactions usually occur ‘anticancer drugs’, ‘supportive care drugs’, and ‘drugs to treat when two or more drugs have a similar mechanism of action. The additional diseases/comorbidities’. Anticancer drugs were defined effect can be synergistic, additive, or antagonistic. Pharmacody- as oncolytic drugs (Anatomical Therapeutic Chemical code (ATC- namic drug interactions can be beneficial (e.g., enhanced code) L01) and antihormonal agents (ATC-code L02). In addition, pharmacologic effects with fluorouracil and leucovorin), but may data on supportive care and co-medication were collected using the also be potentially harmful (e.g., ototoxicity with furosemide and same computer-based
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