TOP-PIC: a new tool to optimize pharmacotherapy and reduce polypharmacy in patients with incurable cancer.

PURPOSE: Polypharmacy is a significant problem in patients with incurable cancer and a method to optimize pharmacotherapy in this patient group is lacking. Therefore, a drug optimization tool was developed and tested in a pilot test. METHODS: A multidisciplinary team of health professionals developed a "Tool to Optimize Pharmacotherapy in Patients with Incurable Cancer" (TOP-PIC) for patients with a limited life expectancy. The tool consists of five sequential steps to optimize medications, including medication history, screening for medication appropriateness and drug interactions, a benefit-risk assessment using the TOP-PIC Disease-based list, and shared decision-making with the patient. For pilot testing of the tool, 8 patient cases with polypharmacy were analyzed by 11 oncologists before and after training with the TOP-PIC tool. RESULTS: TOP-PIC was considered helpful by all oncologists during the pilot test. The median additional time required to administer the tool was 2 min per patient (P < 0.001). For 17.4% of all medications, different decisions were made by using TOP-PIC. Among possible treatment decisions (discontinuation, reduction, increase, replacement, or addition of a drug), discontinuation of medications was the most common. Without TOP-PIC, physicians were uncertain in 9.3% of medication changes, compared with only 4.8% after using TOP-PIC (P = 0.001). The TOP-PIC Disease-based list was considered helpful by 94.5% of oncologists. CONCLUSIONS: TOP-PIC provides a detailed, disease-based benefit-risk assessment with recommendations specific for cancer patients with limited life expectancy. Based on the results of the pilot study, the tool seems practicable for day-to-day clinical decision-making and provides evidence-based facts to optimize pharmacotherapy.

NT-pro-BNP as a Predictor for Recurrence of Atrial Fibrillation after Primary Cryoballoon Pulmonary Vein Isolation.

NT-pro-BNP is produced in the cardiac atria and ventricles in response to increased wall stress. It may be a marker of both AF disease progression and co-morbidities that affect success after pulmonary vein isolation (PVI). This single-center retrospective study analyzed the association between pre-procedural NT-pro-BNP serum levels and the long-term outcome after a first-ever PVI in cryo-technique. Patients were followed by searching the hospital information system and conducting structured telephone interviews. Treatment failure was defined as any relapse of atrial fibrillation (AF) occurring 90 days after the index PVI at the earliest. Kaplan−Meier survival curves and Cox proportional hazards models were computed to assess the impact of NT-pro-BNP on AF recurrence. Following 374 patients over a median of 3.8 years (range: 0.25−9.4 years), baseline NT-pro-BNP was associated with the combined endpoint in univariate analysis (HR 1.04 per 100 pg/mL increase, 95% CI: 1.02−1.07, p < 0.001). Results were virtually unchanged in the multivariate model or if the data were log-transformed. Intraprocedural left atrial pressure correlated positively with log NT-pro-BNP. NT-pro-BNP was associated with AF relapse during a long-term follow-up after first-ever cryo-PVI in our cohort of patients with predominantly normal left ventricular function. This lab parameter is easy to obtain and has significant potential to guide treatment decisions.