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Table of Contents
LETTER TO EDITOR
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 583-584

Polypharmacy in the elderly on immunotherapy: Problem or opportunity?


National Oncology Center, The Royal Hospital, Muscat, Sultanate of Oman

Date of Submission10-Aug-2021
Date of Decision21-Aug-2021
Date of Acceptance07-Sep-2021
Date of Web Publication08-Oct-2021

Correspondence Address:
Ajit Venniyoor
National Oncology Center, The Royal Hospital, Muscat
Sultanate of Oman
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/crst.crst_184_21

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How to cite this article:
Venniyoor A. Polypharmacy in the elderly on immunotherapy: Problem or opportunity?. Cancer Res Stat Treat 2021;4:583-4

How to cite this URL:
Venniyoor A. Polypharmacy in the elderly on immunotherapy: Problem or opportunity?. Cancer Res Stat Treat [serial online] 2021 [cited 2021 Dec 9];4:583-4. Available from: https://www.crstonline.com/text.asp?2021/4/3/583/327775



I read with interest the original article on the efficacy and safety outcomes of immune checkpoint inhibitors (ICIs) in the elderly in India by Abraham et al.[1] and the thoughtful accompanying editorial.[2] I agree with the authors that the outcomes are comparable to those reported from the Western world. I had raised some concerns earlier that these agents could precipitate more severe autoimmune reactions in our population[3] and am glad to note that these apprehensions were misplaced. However, data from an apex institute staffed with oncologists of a higher level of skillsets cannot be taken as “real world” data and there should be an attempt to obtain evidence at the community level.

The authors mention that one of the problems with the elderly is polypharmacy leading to harmful drug interactions.[4],[5] Not surprisingly, at least one of every two patients in their data set had a comorbid condition. As an aside, it would be worth recording the prevalence of non-alcoholic fatty liver disease in this population in future as this condition has some unique interactions with ICIs.[6] I feel that polypharmacy is an opportunity rather than a problem as some commonly used drugs in conditions such as hypertension and diabetes may actually potentiate the activity of ICIs. Long-term survival with the current generation of ICIs seems to have plateaued at <25% and there is keen interest in combining them with immune stimulant and anti-angiogenic drugs to augment their efficacy. Current evidence is confined to combinations with agents such as bevacizumab and tyrosine kinase inhibitors in cancers such as of liver and kidney;[7] these needed extensive trials to ensure safety and are expensive. It is known that commonly used drugs such as metformin, propranolol, antiepileptics, antibiotics, and angiotensin-converting enzyme inhibitors have similar immune stimulant and anti-angiogenic properties.[8] They have been in use for decades, come with known safety profiles, are cheaper, and will be easier to incorporate.[9] Prospective trials in combination with ICIs are ongoing and results are awaited.[9] Larger data sets that include details of non-oncological drugs used by patients on immunotherapy would contribute additional evidence towards repurposing of these drugs, and at significantly lower costs.[10]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Abraham G, Jobanputra K, Noronha V, Patil V, Menon N, Gattani S, et al. Immune checkpoint inhibitors in older patients with solid tumors: Real-world experience from India. Cancer Res Stat Treat 2021;4:270-6.  Back to cited text no. 1
  [Full text]  
2.
Arora S, Kumar L. Immune checkpoint inhibitors in older patients with cancer: A new era in cancer therapy. Cancer Res Stat Treat 2021;4:368-9.  Back to cited text no. 2
  [Full text]  
3.
Venniyoor A. Immune checkpoint inhibitors for Indian patients: A note of caution. Indian J Cancer 2016;53:468-9.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Noronha V, Ramaswamy A, Gattani SC, Castelino R, Krishnamurthy MN, Menon N, et al. Polypharmacy and potentially inappropriate medication use in older Indian patients with cancer: A prospective observational study. Cancer Res Stat Treat 2021;4:67-73.  Back to cited text no. 4
  [Full text]  
5.
Rajesh V, Rao M. Conundrum of polypharmacy in geriatrics: Less is better than more. Cancer Res Stat Treat 2021;4:127-9.  Back to cited text no. 5
  [Full text]  
6.
Zhou J, Zhou F, Chu X, Zhao J, Wu Y, Zhao W, et al. Non-alcoholic fatty liver disease is associated with immune checkpoint inhibitor-based treatment response in patients with non-small cell lung cancer with liver metastases. Transl Lung Cancer Res 2020;9:316-24.  Back to cited text no. 6
    
7.
Venniyoor A. Synergism between anti-angiogenic and immune checkpoint inhibitor drugs: A hypothesis. Med Hypotheses 2021;146:110399.  Back to cited text no. 7
    
8.
Varayathu H, Sarathy V, Thomas BE, Mufti SS, Naik R. Combination strategies to augment immune check point inhibitors efficacy – Implications for translational research. Front Oncol 2021;11:559161.  Back to cited text no. 8
    
9.
Pinter M, Jain RK. Targeting the renin-angiotensin system to improve cancer treatment: Implications for immunotherapy. Sci Transl Med 2017;9:eaan5616.  Back to cited text no. 9
    
10.
Zhang Z, Zhou L, Xie N, Nice EC, Zhang T, Cui Y, et al. Overcoming cancer therapeutic bottleneck by drug repurposing. Signal Transduct Target Ther 2020;5:113.  Back to cited text no. 10
    




 

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