Food Does Not Affect the Pharmacokinetics of Tesaglitazar, a Novel Dual Peroxisome Proliferator-Activated Receptor α/γ Agonist

Tesaglitazar is a dual peroxisome proliferator-activated receptor (PPAR) alpha/gamma agonist in development to treat lipid and glucose abnormalities associated with type 2 diabetes. This study evaluated the effects of food on tesaglitazar pharmacokinetics. In an open, randomized, 2-way crossover study, 20 healthy men received tesaglitazar 1 mg during fasting and after a high-fat, high-calorie breakfast. Blood samples were taken to assess pharmacokinetic variables. Systemic exposure to tesaglitazar was unaffected by food intake. Estimated ratios were 0.99 (90% confidence interval [CI], 0.94-1.04) for fed/fasted area under plasma concentration-time curve and 0.82 (90% CI, 0.78-0.86) for fed/fasted maximum plasma concentration (C(max)). Mean C(max) was approximately 18% lower (0.41 [95% CI, 0.38-0.43] versus 0.50 [95% CI, 0.47-0.53] mumol/L), and median time to C(max) was increased (2.00 vs 0.75 h) in fed versus fasted state. The median difference of t(max) was 1.25 h (P = .0001, signed-rank test). Tesaglitazar was well tolerated. Tesaglitazar pharmacokinetics is unaffected by food intake, allowing once-daily administration of tesaglitazar with or without food in clinical practice.

Effects of self-rated health on sick leave, disability pension, hospital admissions and mortality. A population-based longitudinal study of nearly 15,000 observations among Swedish women and men

Background

Simple global self-ratings of health (SRH) have become increasingly used in national and international public health monitoring, and in recent decades recommended as a standard part of health surveys. Monitoring developments in population health requires identification and use of health measures, valid in relation to targets for population health. The aim of the present study was to investigate associations between SRH and sick leave, disability pension, hospital admissions, and mortality, adjusted for effects of significant covariates, in a large population-based cohort.

Methods

The analyses were based on screening data from eight population-based cohorts in southern and central Sweden, and on official register data regarding sick-leave, disability pension, hospital admissions, and death, with little or no data loss. Sampling was performed 1973–2003. The study population consisted of 11,880 women and men, age 25–99 years, providing 14,470 observations. Information on SRH, socio-demographic data, lifestyle variables and somatic and psychological symptoms were obtained from questionnaires.

Results

There was a significant negative association between SRH and sick leave (Beta −13.2, p<0.0001, and −9.5, p<0.01, in women and men, respectively), disability pension (Hazard ratio 0.77, p<0.0001 and 0.76, p<0.0001, in women and men, respectively), and mortality, adjusted for covariates. SRH was also significantly associated with hospital admissions in men (Hazard ratio 0.87, p<0.0001), but not in women (Hazard ratio 0.96, p0.20). Associations between SRH on the one hand, and sick leave, disability pension, hospital admission, and mortality, on the other, were robust during the follow-up period.

Conclusions

SRH had strong predictive validity in relation to use of social insurance facilities and health care services, and to mortality. Associations were strong and robust during follow-up.

Smoking enhanced the expression of MDR-1 in rat prostatic carcinoma

Smoking is associated with the development of different malignancies, especially lung carcinoma. Considerably less interest has been devoted whether the outcome of cancer treatment can be affected by ongoing smoking. In the present study, the effects of ongoing smoking was evaluated on the expression of classical multidrug resistance (MDR-1) in a tumour tissue not usually related to smoking, prostatic carcinoma in rats. The expression of mdr1 was evaluated by quantitative RNA-RNA solution hybridisation and the distribution of the glycoprotein P-170 was examined by immunohistochemistry using the monoclonal antibodies C219 and C494. A group of animals was exposed to cigarette smoke in a nose-only exposure system for 1 h/day, 5 days/week for four weeks. The results demonstrated a significant enhanced expression of mdr1 RNA in the rumours from smoke exposed animals and the immunohistochemical analysis also displayed an increase of the positively stained cells following smoking. These results indicate that alteration at least at the level of transcription is involved in the overexpression of P-170 following smoking. An effect on translation or post-translation cannot be excluded. The observations might add to the experience of drug resistance seen in the clinical situation in tumours associated with carcinogens such as smoking.

Gastroesophageal reflux disease in primary care: using changes in proton pump inhibitor therapy as an indicator of partial response

OBJECTIVE

Up to one-third of patients with gastroesophageal reflux disease (GERD) in primary care have residual symptoms despite proton pump inhibitor (PPI) therapy. We aimed to characterize partial response to PPIs among adult patients in UK primary care.

MATERIAL AND METHODS

Newly diagnosed GERD patients aged 20-79 years who were prescribed PPI for treatment of GERD were identified in The Health Improvement Network. Those with a treatment change suggesting partial response to PPIs (new treatment added to PPI, increased PPI dose, or switching PPI) during the subsequent 6 months were identified as potential cases and confirmed after manual review of each patient's complete computer medical record including free-text comments. Patients without these treatment changes were study controls. A nested case-control analysis was conducted using logistic regression.

RESULTS

The proportion of newly diagnosed GERD patients with partial response to PPI therapy was 18.6% (1201/6453). Partial response was associated with female gender (odds ratio [OR]: 1.20; 95% confidence interval [CI]: 1.05-1.37), anxiety or depression (OR: 1.15; 95% CI: 1.00-1.31), and prescription of ≥ 6 drugs in the month before GERD diagnosis (OR: 1.42; 95% CI: 1.14-1.78). Among new PPI users (n = 2907), partial response was associated with esophageal ulcer or Barrett's esophagus at initial diagnosis (OR: 3.14; 95% CI: 1.60-6.17).

CONCLUSIONS

Approximately one in five newly diagnosed patients with GERD appear to have a partial response to PPI therapy. Female gender, polymedication, and a severe initial diagnosis may be associated with partial response.

Stress urinary incontinence and quality of life: a reliability study of a condition-specific instrument in paper and web-based versions

AIMS

Quality of life is an important outcome measure in studies of urinary incontinence. Electronic collection of data has several advantages. We examined the reliability of the Swedish version of the highly recommended condition-specific quality of life questionnaire International Consultation on Incontinence Modular Questionnaire-Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTSqol), in paper and web-based formats in women with stress urinary incontinence.

METHODS

Women aged 18-70 years, with stress urinary incontinence at least once weekly, were recruited via the project's website and answered the ICIQ-LUTSqol questionnaire. Respondents completed either the paper version twice (n = 78), or paper and web-based versions once each (n = 54). The ICIQ validation protocol was followed.

RESULTS

The mean interval between answers was 18.1 (SD = 3.1) days in the paper versus paper setting and 15.0 (SD = 7.8) days in the paper versus web-based setting. Internal consistency was excellent, with Cronbach's alpha coefficients of 0.87 for the paper version and 0.86 for the web-based version. There was a high degree of agreement of overall scores with intraclass correlations in the paper versus paper and paper versus web-based settings: 0.95 (P < 0.001) and 0.92 (P < 0.001), respectively. The mean of each individual item's weighted kappa value was 0.61 in both settings.

CONCLUSIONS

The questionnaire is reliable in women with stress urinary incontinence, and it can be used in either a paper or a web-based version.

Discontinuation of low-dose acetylsalicylic acid therapy in UK primary care: incidence and predictors in patients with cardiovascular disease

BACKGROUND

Discontinuation of low-dose acetylsalicylic acid (ASA) leads to an increased risk of cardiovascular and cerebrovascular events in patients taking low-dose ASA for secondary cardiovascular prevention. However, little is known about the rate of discontinuation in everyday clinical practice.

OBJECTIVES

To assess the rate of low-dose ASA discontinuation in primary care, and identify factors that predict discontinuation.

METHODS

The Health Improvement Network, a large UK primary care database, was used to identify patients aged 50-84 years who received at least two consecutive prescriptions for low-dose ASA for secondary cardiovascular or cerebrovascular prevention in 2000-2007 (n = 35,639). Discontinuation was defined as a period of at least 90 days after completion of the last prescribed course of ASA during which no repeat prescription was issued.

RESULTS

During the study, 11,729 patients (32.9%) discontinued ASA therapy (mean follow-up 2.5 years). The discontinuation rate was lower in patients with ASA indicated for myocardial infarction than for other indications. The diagnosis of gastrointestinal disorders during the study (overall odds ratio: 1.74; 95% confidence interval: 1.61-1.88) was associated with increased rates of ASA discontinuation, whereas co-prescription of a proton pump inhibitor from the start of ASA therapy was associated with a decreased rate of discontinuation (odds ratio: 0.80; 95% confidence interval: 0.75-0.86). Co-prescription of several other cardioprotective medications was also associated with a reduced risk of discontinuation, as were increasing age, prior hospitalization and overall number of co-medications.

CONCLUSION

Continuous co-prescription of a PPI with low-dose ASA may improve adherence and outcomes, particularly in patients at both cardiovascular and gastrointestinal risk.

A population-based study of nearly 15 000 observations among Swedish women and men during 1973-2003

OBJECTIVES

Global self-rated health (SRH) has become extensively used as an outcome measure in population health surveillance. The aim of this study was to analyse the effects of age and secular trend (year of investigation) on SRH.

DESIGN

Prospective cohort study, using population-based data from eight ongoing cohort studies, with sampling performed between 1973 and 2003.

SETTING

Sweden.

PARTICIPANTS

11 880 women and men, aged 25-99 years, providing 14 470 observations.

PRIMARY OUTCOME MEASURE

Global SRH.

RESULTS

In multiple ordinal logistic regression analyses, adjusted for the effects of covariates, there were independent effects of age (p<0.0001) and of year of investigation (p<0.0001) on SRH. In women the association was linear, showing lower levels of SRH with increased age, and more recent year of investigation. In men the association was curvilinear, and thus more complex. The final model explained 76.2% of the SRH variance in women and 74.5% of the variance in men.

CONCLUSIONS

SRH was strongly and inversely associated with age in both sexes, after adjustment for other outcome-affecting variables. There was a strongly significant effect of year of investigation indicating a change in SRH, in women towards lower levels over calendar time, in men with fluctuations across time.

Morbidity associated with sleep disorders in primary care: a longitudinal cohort study

OBJECTIVE

Few epidemiologic studies evaluate the relative contribution of different risk factors on sleep problems. The aim of the present study was to assess demographics, comorbid characteristics, and health outcomes in patients with sleep disorders.

METHOD

A population-based cohort study with nested case-control analysis was conducted in adults using the U.K. General Practice Research Database. Information was collected for 12,437 patients with a new sleep disorder diagnosis during the year 1996 and 18,350 age- and sex-matched controls. Logistic regression analysis was used to compute odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

The incidence of a new sleep disorder diagnosis was 12.5 per 1000 person-years. There was a clear association of sleep disorders with smoking and excessive alcohol consumption; prior psychiatric disorders, including stress (OR = 3.6, 95% CI = 2.9 to 4.4) and depression (OR = 3.1, 95% CI = 2.8 to 3.3); prior circulatory diseases, including heart failure (OR = 1.8, 95% CI = 1.4 to 2.2) and coronary heart disease (OR = 1.4, 95% CI = 1.2 to 1.6); and prior gastrointestinal diseases, including gastroesopha-geal reflux disease (OR = 1.4, 95% CI = 1.2 to 1.7) and irritable bowel syndrome (OR = 1.5, 95% CI = 1.2 to 1.9). Use of hypnotics and anti-depressants was increased in the year after diagnosis. Relative 1-year mortality risk was 3-fold higher in the sleep disorder group than in controls, with a noticeably higher proportion of deaths due to suicide.

CONCLUSION

The fact that sleep disorders were associated with several morbidities, most strongly with psychiatric disorders as well as with increased mortality, underscores the importance of sleep problems as indicators of health status.

Imaging intraplaque inflammation in carotid atherosclerosis with 11C-PK11195 positron emission tomography/computed tomography

AIMS

We sought to determine whether intraplaque inflammation could be measured with positron emission tomography/computed tomography angiography (PET/CTA) using (11)C-PK11195, a selective ligand of the translocator protein (18 kDa) (TSPO) which is highly expressed by activated macrophages.

METHODS AND RESULTS

Patients (n = 32; mean age 70 ± 9 years) with carotid stenoses (n = 36; 9 symptomatic and 27 asymptomatic) underwent (11)C-PK11195 PET/CTA imaging. (11)C-PK11195 uptake into carotid plaques was measured using target-to-background ratios (TBR). On CTA images, plaque composition was assessed by measuring CT attenuation of the carotid plaque. Eight patients underwent carotid endarterectomy and ultrathin contiguous sections were processed for TSPO and CD68 (using immunohistochemical staining, (3)H-PK11195 autoradiography, and confocal fluorescence microscopy). Carotid plaques associated with ipsilateral symptoms (stroke or transient ischaemic attack) had higher TBR (1.06 ± 0.20 vs. 0.86 ± 0.11, P = 0.001) and lower CT attenuation [(median, inter-quartile range) 37, 24-40 vs. 71, 56-125 HU, P = 0.01] than those without. On immunohistochemistry and confocal fluorescence microscopy, CD68 and PBR co-localized with (3)H-PK11195 uptake at autoradiography. There was a significant correlation between (11)C-PK11195 TBR and autoradiographic percentage-specific binding (r = 0.77, P = 0.025). Both TBR and CT plaque attenuation had high negative predictive values (91 and 92%, respectively) for detecting symptomatic patients. However, the best positive predictive value (100%) was achieved when TBR and CT attenuation were combined.

CONCLUSION

Imaging intraplaque inflammation in vivo with (11)C-PK11195 PET/CTA is feasible and can distinguish between recently symptomatic and asymptomatic plaques. Patients with a recent ischaemic event had ipsilateral plaques with lower CT attenuation and increased (11)C-PK11195 uptake.

Discontinuation of low dose aspirin and risk of myocardial infarction: case-control study in UK primary care

OBJECTIVES

To evaluate the risk of myocardial infarction and death from coronary heart disease after discontinuation of low dose aspirin in primary care patients with a history of cardiovascular events.

DESIGN

Nested case-control study.

SETTING

The Health Improvement Network (THIN) database in the United Kingdom.

PARTICIPANTS

Individuals aged 50-84 with a first prescription for aspirin (75-300 mg/day) for secondary prevention of cardiovascular outcomes in 2000-7 (n=39,513).

MAIN OUTCOME MEASURES

Individuals were followed up for a mean of 3.2 years to identify cases of non-fatal myocardial infarction or death from coronary heart disease. A nested case-control analysis assessed the risk of these events in those who had stopped taking low dose aspirin compared with those who had continued treatment.

RESULTS

There were 876 non-fatal myocardial infarctions and 346 deaths from coronary heart disease. Compared with current users, people who had recently stopped taking aspirin had a significantly increased risk of non-fatal myocardial infarction or death from coronary heart disease combined (rate ratio 1.43, 95% confidence interval 1.12 to 1.84) and non-fatal myocardial infarction alone (1.63, 1.23 to 2.14). There was no significant association between recently stopping low dose aspirin and the risk of death from coronary heart disease (1.07, 0.67 to 1.69). For every 1000 patients, over a period of one year there were about four more cases of non-fatal myocardial infarction among patients who discontinued treatment with low dose aspirin (recent discontinuers) compared with patients who continued treatment.

CONCLUSIONS

Individuals with a history of cardiovascular events who stop taking low dose aspirin are at increased risk of non-fatal myocardial infarction compared with those who continue treatment.

Study of a cohort of patients newly diagnosed with depression in general practice: prevalence, incidence, comorbidity, and treatment patterns

OBJECTIVE

To estimate the prevalence and incidence of depression; investigate its association with risk factors including comorbidities and drug and health care use; and describe treatment patterns of depression in primary care using The Health Improvement Network database.

METHOD

In this cohort study, subjects with a first recorded diagnosis of depression (Read code) between January 1, 2002, and December 31, 2004 (n=47,170) were identified from a source population of 1,287,829 subjects aged 10-79 years. A comparison group was sampled from the same population and frequency matched to the depression cohort by age, sex, and calendar year (n=50,000). Depression diagnoses were validated using physician-completed questionnaires. Odds ratios and 95% CIs for the relationship of depression with a range of factors were estimated using unconditional logistic regression in a nested case-control analysis.

RESULTS

The prevalence of depression was 11.23% (95% CI, 11.18-11.28). This prevalence decreased with increasing age and was higher in women than in men. The incidence was 13.89 per 1,000 person-years (95% CI, 13.82-14.08). Depression was associated with frequent use of health services, smoking, pregnancy in the previous year, anxiety, stress, sleep disorders, digestive and respiratory disorders, and pain. In the trimester following diagnosis, 82% of cases were treated-98% with antidepressants and 81.5% with selective serotonin reuptake inhibitors (SSRIs).

CONCLUSIONS

We found a high prevalence and incidence of depression diagnoses in primary care in the United Kingdom. Following diagnosis, the majority of individuals were prescribed SSRIs. A diagnosis of depression is associated with a number of prior comorbidities, which could mask the depression. This fact should be taken into account when screening individuals in primary care.

Helicobacter pylori infection and gastritis: the Systematic Investigation of gastrointestinaL diseases in China (SILC)

BACKGROUND AND AIM

Helicobacter pylori infection remains common in East Asia, though its prevalence is decreasing in Western countries. H. pylori-related atrophic gastritis (AG) may reduce the likelihood of gastroesophageal reflux disease (GERD). We investigated the prevalence of H. pylori infection and AG and their association with endoscopic findings and symptom-defined GERD in Shanghai.

METHODS

A representative random sample of 3600 Shanghai residents aged 18-80 years was invited to complete a general information questionnaire and a Chinese version of the Reflux Disease Questionnaire, to provide blood samples for H. pylori serology and pepsinogen (PG) I/II assay (to detect AG, defined as PGI < 70 µg/L and/or PGI/PGII < 7), and to undergo endoscopy. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by multivariate logistic regression.

RESULTS

A total of 1022 Shanghai residents underwent endoscopy and were valid for inclusion in the study. Of these, 71.7% tested positive for H. pylori, 63.8% had AG and 30.5% had moderate/severe AG (PGI < 50 µg/L and/or PGI/PGII < 5). Helicobacter pylori infection was equally common in all age groups. Severity of AG increased with age in women. Reflux esophagitis was inversely associated with AG (OR, 0.23 [CI, 0.09-0.55] for moderate/severe AG compared with no H. pylori or gastritis). However, symptom-defined GERD showed no clear association with AG.

CONCLUSIONS

Helicobacter pylori infection and AG are very common in Shanghai, and the infection is acquired early in life. Atrophic gastritis is inversely associated with reflux esophagitis but is not significantly associated with symptom-defined GERD.

Risk of upper gastrointestinal bleeding with low-dose acetylsalicylic acid alone and in combination with clopidogrel and other medications

BACKGROUND

This study evaluated the risk of upper gastrointestinal bleeding (UGIB) associated with use of low-dose acetylsalicylic acid (ASA) alone and in combination with other gastrotoxic medications.

METHODS AND RESULTS

The Health Improvement Network UK primary care database was used to identify individuals 40 to 84 years of age with a UGIB diagnosis in 2000 to 2007 (n = 2049). An age-, sex-, and calendar year-matched control group (n = 20,000) was identified from the same source population. The relative risk (RR) of UGIB associated with use of low-dose ASA (75 to 300 mg/d), clopidogrel, and other commonly coadministered medications was estimated by multivariate logistic regression. The risk of UGIB was increased in current users of low-dose ASA (RR, 1.80; 95% confidence interval [CI], 1.59 to 2.03) or clopidogrel (RR, 1.67; 95% CI, 1.24 to 2.24) compared with nonusers. Compared with low-dose ASA monotherapy, the risk of UGIB was significantly increased when low-dose ASA was coadministered with clopidogrel (RR, 2.08; 95% CI, 1.34 to 3.21), oral anticoagulants (RR, 2.00; 95% CI, 1.15 to 3.45), low-/medium-dose nonsteroidal antiinflammatory drugs (RR, 2.63; 95% CI, 1.93 to 3.60), high-dose nonsteroidal antiinflammatory drugs (RR, 2.66; 95% CI, 1.88 to 3.76), or high-dose oral corticosteroids (RR, 4.43; 95% CI, 2.10 to 9.34); this was not apparent with coadministration of statins (RR, 0.99; 95% CI, 0.81 to 1.21) or low-dose oral corticosteroids (RR, 1.01; 95% CI, 0.58 to 1.77).

CONCLUSIONS

Use of low-dose ASA is associated with an almost 2-fold increase in the risk of UGIB compared with nonuse. This risk is increased further in individuals taking low-dose ASA along with clopidogrel, oral anticoagulants, nonsteroidal antiinflammatory drugs, or high-dose oral corticosteroids.