Grand Rounds

Medication Self-Management: Important Concepts for Advanced Practitioners in Oncology

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ABSTRACT

Case Study

Mrs. K is a 66-year-old female with a long history of hypertension and hyperlipidemia and a 45-pack-year history of cigarette smoking. She was diagnosed with multiple myeloma (MM), a cancer of the bone marrow plasma cells, 5 years ago. At diagnosis, she received a combination of IV pegylated liposomal doxorubicin (Doxil), vincristine, and dexamethasone before receiving an autologous stem cell transplant. She achieved a 5-year remission from her treatment for MM.

Mrs. K was recently brought to the office by a friend who was concerned about mental status changes, an increase in back pain from baseline, and a persistent cough. She was found to have relapsed MM as evidenced by hypercalcemia and worsening anemia. Chest x-ray showed pneumonia and was also suggestive of chronic obstructive pulmonary disease (COPD). She was started on a course of antibiotic therapy to treat her pneumonia and an inhaler for her shortness of breath.

Mrs. K’s mental status improved with IV bisphosphonates and hydration to treat her hypercalcemia and dehydration. Her back pain was treated with increased doses of oxycodone. She started a highly effective oral regimen of lenalidomide plus dexamethasone for treatment of relapsed MM. Fortunately, she had prescription coverage and her copayment was only $20. She took each pill at bedtime as directed for 3 weeks out of the month with 1 week off. She was instructed by the nurse to have blood drawn every 2 weeks for the first 12 weeks of therapy to monitor her complete blood counts. The nurse created a calendar of all the dates of her follow-up appointments, visits, and lab schedules. She reviewed all of the important side effects of this medication and indicated when to call the office.

Mrs. K verbalized an understanding of the importance of taking this medication at the same time each day, on the appropriate schedule, and the importance of frequent lab tests to monitor the disease and side effects of treatment. She needed to refill the medication prescription each month and would be required to have her lab work drawn at the end of her 3-week cycle to evaluate her need for a refill. Mrs. K was directed to call her nurse if she developed any number of side effects, which were listed on an information sheet, which she was able to recite. The nurse made called Mrs. K’s house at the end of each month of therapy to ensure she understood the treatment plan, to assess for side effects, and to ensure that she was taking the medication as prescribed.

Mrs. K responded well to the medication, remained adherent to the regimen, and achieved a good remission. She placed her calendar on the refrigerator and wrote down any side effects she noticed as well as the time she took her medication every day. She wrote her lab and office appointments on the calendar. She felt good about staying on schedule and confident that the treatment was “working.”

Unfortunately, 1 year after starting her new treatment for MM, Mrs. K’s husband was hospitalized with chest pain and later had a stroke that resulted in hemiparalysis. During her husband’s hospitalization, she forgot to take her antihypertensive and antimyeloma medications at the scheduled time. She felt her hypertension had been controlled and her cancer was in remission; she rationalized that “it will be okay to skip a few doses.”

Mrs. K’s husband was discharged after 3 weeks in the hospital and everything changed. He had been responsible for all the finances during their 35 years of marriage but now was unable to do the bills. He continued to become weaker with subsequent readmissions for heart failure and pneumonia. Mrs. K became worried about her husband’s declining health and functional status. In addition, she realized their assets were fewer than she thought. She had trouble remembering to pay bills and was worried about prescription and health insurance coverage. Their insurance carriers were about to change, which would result in higher copays for her medication as well as her husband’s. She became forgetful: she missed her own laboratory and office appointments because she was busy transporting her husband to physical therapy and office visits, and no longer remembered to use her own calendar for her medications.

The nurse from the oncology office continued to provide telephone reminders to refill her cancer medications but Mrs. K was not always home and did not always return her messages. Mrs. K’s social network was limited to a few friends and she only had one son living in another state who rarely came to visit. She became depressed and her own health began to decline.

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