Rates of discontinuation and non-publication of upper and lower extremity fracture clinical trials

PURPOSE

To our knowledge, no study has quantified the rate of discontinuation and nonpublication of randomized controlled trials (RCTs) regarding upper and lower extremity fractures.

METHODS

We searched ClinicalTrials.gov on September 9th, 2020, for phase 3 and 4 RCTs pertaining to upper and lower extremity fractures. Trial completion status was determined using records available on ClinicalTrials.gov. Publication status was determined using records on ClinicalTrials.gov and by searching PubMed (MEDLINE), Embase, and Google Scholar. We queried corresponding authors on trial status if a peer-reviewed publication was not identified.

RESULTS

Our final analysis included 142 RCTs, of which 57 (40.1%) were discontinued and 71 (50%) were unpublished. Thirty-six (of 57, 63.2%) discontinued trials failed to provide a reason for discontinuation, the most commonly identified reason for discontinuation was due to inadequate recruitment (13/21, 61.9%). Completed trials were more likely to reach publication (59/85; 69.4%; X² = 32.92; P ≤ 0.001) than discontinued trials. Trials with more than 80 participants were less likely not to reach publication (AOR: 0.12; 95% CI 0.15-0.66).

CONCLUSION

Our analysis of 142 upper and lower extremity fracture RCTs demonstrated one-half failed to reach publication and two-fifths were discontinued prior to trial completion. These findings indicate the need for increased guidance in developing, completing, and publishing RCTs in upper and lower extremity fractures. Discontinuation and nonpublication of orthopaedic RCTs hinder the public's access to collected data and negate the valued contribution from study participants. Discontinuation and non-publication of clinical trials may subject participants to potentially harmful interventions, limit the advancement of clinical research, and contribute to research waste.

LEVEL OF EVIDENCE

III.

Socio-economic variations of breast cancer treatment and discontinuation: a study from a public tertiary cancer hospital in Mumbai, India

BACKGROUND

The study examined the socio-economic variation of breast cancer treatment and treatment discontinuation due to deaths and financial crisis.

METHODS

We used primary data of 500 patients with breast cancer sought treatment at India's one of the largest cancer hospital in Mumbai, between June 2019 and March 2022. This study is registered on the Clinical Trial Registry of India (CTRI/2019/07/020142). Kaplan-Meier method and Cox-hazard regression model were used to calculate the probability of treatment discontinuation.

RESULTS

Of the 500 patients, three-fifths were under 50 years, with the median age being 46 years. More than half of the patients were from outside of the state and had travelled an average distance of 1,044 kms to get treatment. The majority of the patients were poor with an average household income of INR15,551. A total of 71 (14%) patients out of 500 had discontinued their treatment. About 5.2% of the patients died and 4.8% of them discontinued treatment due to financial crisis. Over one-fourth of all deaths were reported among stage IV patients (25%). Patients who did not have any health insurance, never attended school, cancer stage IV had a higher percentage of treatment discontinuation due to financial crisis. Hazard of discontinuation was lower for patients with secondary (HR:0.48; 95% CI: 0.27-0.84) and higher secondary education (HR: 0.42; 95% CI: 0.19-0.92), patients from rural area (HR: 0.79; 95% CI: 0.42-1.50), treated under general or non-chargeable category (HR: 0.60; 95% CI:0.22-1.60) while it was higher for the stage IV patients (HR: 3.61; 95% CI: 1.58-8.29).

CONCLUSION

Integrating breast cancer screening in maternal and child health programme can reduce delay in diagnosis and premature mortality. Provisioning of free treatment for poor patients may reduce discontinuation of treatment.

Can a 3 months treatment with oral Desogestrel prior to insertion of the etonogestrel-releasing contraceptive implant improve continuation rate at 1 year? A randomized trial

OBJECTIVE

To evaluate if daily oral 75 µg of Desogestrel (DSG) for 3 months prior to the insertion of etonogestrel-releasing contraceptive implant (ENG-IMPLANT) might help reduce its premature discontinuation.

RESULTS

A total of 66 women were randomized in the ENG-IMPLANT group (26) and in the DSG + ENG-IMPLANT group (40), respectively, in the Geneva University Hospitals and Basel University Hospital, from August 15th, 2016 through September 30th, 2019. In the DSG + ENG-IMPLANT group, patients were given a 3 months' supply of 75 µg of DSG before the insertion of the ENG-IMPLANT. All women were seen after 3 months for bleeding and satisfaction evaluation, and at 12 months post ENG-IMPLANT insertion. Higher levels of satisfaction at 12-months were found in the ENG-IMPLANT group compared to the DSG + ENG-IMPLANT group (8.5 ± 1.7 vs. 6.6 ± 2.9, p = 0.012). There were no statistically significant differences regarding tolerance (7.8 ± 2.5 vs 6.8 ± 2.6, p = 0.191) and contraceptive continuation (80% vs 72.4%, p = 0.544) between groups.

CONCLUSION

DSG prior to insertion of the ENG-IMPLANT did not improve its continuation rate neither its satisfaction at 1 year. Trial registration NCT05174195. Retrospectively registered, the 30th December 2021.

Adherence and Persistence to Nusinersen for Spinal Muscular Atrophy: A US Claims-Based Analysis

INTRODUCTION

Spinal muscular atrophy (SMA) is a genetic, neuromuscular disease caused by deletions and/or mutations in the survival of motor neuron 1 (SMN1) gene leading to reduced SMN protein levels. Nusinersen, an intrathecally administered antisense oligonucleotide therapy that increases SMN protein levels, is approved for use in adult and pediatric patients with SMA. Data to inform real-world patient adherence and persistence to nusinersen are limited, with disparities in the population with SMA, study design, and results. The objective of this study is to characterize real-world nusinersen adherence and persistence in patients with SMA.

METHODS

This retrospective study examined nusinersen adherence and persistence over a 2-year period in patients with SMA in the USA from the IQVIA PharMetrics Plus claims database. Patients were followed from the date of first evidence of nusinersen treatment (occurring after 1 July 2017) until the end of the study period (31 December 2019) or end of continuous pharmacy and medical benefit enrollment, whichever came first. Subgroup analyses for nusinersen adherence and persistence were performed on the basis of age and presence or absence of spinal complications.

RESULTS

The final cohort consisted of 179 patients with SMA treated with nusinersen. Adherence to nusinersen treatment was 41% at 56 weeks and 39% at 104 weeks. In the base-case persistence analysis, there was a decrease in persistence before 6 months (67%) and further decline at 1 (57%) and 2 years (55%). Patients with spinal complication versus without had numerically higher persistence with nusinersen.

CONCLUSIONS

The findings suggest that adherence and persistence to nusinersen treatment appear low. Demographic (age ≥ 18 years) and clinical factors (no spinal complications) may contribute to nusinersen treatment discontinuation. Future research should explore possible reasons for low adherence and persistence to nusinersen treatment, such as clinical or logistical factors, patient preferences, and payer restrictions.

Bone loss after denosumab discontinuation is prevented by alendronate and zoledronic acid but not risedronate: a retrospective study

A retrospective study of 121 patients who stopped denosumab (Dmab) then received no treatment (NT), risedronate (RIS), alendronate (ALN), or zoledronic acid (ZOL). Bone density (spine and hip) during and after Dmab discontinuation was measured. Treatment with ALN or ZOL, not NT and RIS, mitigated BMD loss after Dmab discontinuation.

INTRODUCTION

Denosumab (Dmab) discontinuation is associated with bone loss and multiple vertebral fractures. The purpose was to compare bone mineral density (BMD) change in patients following Dmab discontinuation with no subsequent treatment (NT) and three bisphosphonate (BP) treatments: risedronate (RIS), alendronate (ALN), and zoledronic acid (ZOL).

METHODS

In a review of 121 patients aged 71.2 ± 8.1 years, discontinuing Dmab (mean 5.4 doses), 33 received NT and 88 received BP (22 RIS; 34 ALN; 32 ZOL). BMD change after 1 year was compared between groups at the lumbar spine (LS), femoral neck (FN), and total hip (TH). Risk factors for bone loss after Dmab discontinuation were compared between groups and incidence of vertebral fractures was determined.

RESULTS

Following Dmab discontinuation, LS mean change (g/cm2; 95% CI) was for NT: - 0.041 (- 0.062 to - 0.021); RIS: - 0.035 (- 0.052 to - 0.017); ALN: - 0.005 (- 0.020 to 0.009); and ZOL: - 0.009 (- 0.025 to 0.008). Differences in LS were found between NT and ALN (p =  0.015), and NT and ZOL (p=0.037), but not between NT and RIS. The only significant difference in TH was found between NT and ZOL (p 0.034) with no group differences in FN. BMD gains during Dmab treatment were associated with BMD loss after Dmab discontinuation. In a subset, discontinuation after Dmab treatment (> 5 doses) followed by ALN (n = 22) and ZOL (n = 11) showed no difference in BMD. Five of 7 vertebral fractures occurred after Dmab discontinuation in NT.

CONCLUSION

Subsequent treatment with ALN or ZOL but not NT and RIS mitigates BMD loss after Dmab discontinuation.

Identifying Patterns of Discontinuing and Recommencing Pre-exposure Prophylaxis in the Context of Sexual Behavior Among Gay and Bisexual Men in Australia

We mapped gay and bisexual men's (GBM) patterns of using pre-exposure prophylaxis (PrEP) over time and explored sexual behavior as PrEP use changed. We conducted semi-structured interviews between June 2020 and February 2021 with 40 GBM living in Australia who had changed their PrEP use since initiating. There was considerable diversity in patterns of discontinuation, suspension, and recommencement of PrEP. Reasons for changing PrEP use mostly centered on accurate perceived changes to HIV risk. Twelve participants reported condomless anal intercourse with casual or fuckbuddy partners after discontinuing PrEP. These sex events were unanticipated, condoms were not a preferred option, and other risk reduction strategies were applied inconsistently. Service delivery and health promotion can support safer sex among GBM when PrEP use fluctuates by promoting event-driven PrEP and/or non-condom-based risk reduction methods during periods off daily PrEP, and guiding GBM to better recognize changing circumstances of risk and when to recommence PrEP.

Real-world Outcomes With Cumulative Bortezomib Dose and Efficacy in the Treatment of Transplant-ineligible Multiple Myeloma With Cyclophosphamide, Bortezomib, and Dexamethasone

BACKGROUND

Higher cumulative dose of bortezomib, a key component of Multiple Myeloma (MM) treatment regimens, has been shown to improve outcomes in MM patients, but must be balanced with toxicities including peripheral neuropathy. In this study, we studied the effect of cumulative bortezomib dose on survival, depth of response, and discontinuation rate in transplant ineligible MM patients.

PATIENTS AND METHODS

Data from 70 patients treated with Cyclophsophamide, Bortezomib, and Dexamethasone (CyBorD) in a single Canadian center were grouped according to above vs below median cumulative bortezomib dose and analyzed for progression-free survival (PFS), overall survival (OS), depth of response, and discontinuation rate.

RESULTS

There was a trend for lower discontinuation rate (45.7% vs. 68.6%, P = .052) and significantly lower rate of neuropathy-related discontinuation (5.7% vs. 22.9%, P = .035) in patients who received higher than 43.1 mg/m² of bortezomib. The higher-dose group showed a trend for higher rate of complete response (14.3% vs. 5.7%, P = .225) and significantly higher rate of very good partial response or better (77.1% vs. 51.4%, P = .024). There was significantly longer PFS (24.3 vs. 9.1 months, P = .012) and a trend for longer OS (22.4 vs. 61.3 months, P = .061) in the higher-dose group. In landmark analysis after 180 days, PFS (23.5 vs. 24.3 months, P = .941) and OS were similar in both groups.

CONCLUSION

Higher cumulative bortezomib dose showed a lower rate of discontinuation, longer survival, and deeper response. Determining risk of treatment intolerance remains important for treatment.

Disease activity after discontinuation of disease-modifying therapies in patients with multiple sclerosis in Argentina: data from the nationwide registry RelevarEM

INTRODUCTION

The discontinuation of disease-modifying therapies (DMTs) in multiple sclerosis (MS) is commonly seen in real-world settings due to several factors.

AREA COVER

The aim of this study is to describe the frequency of disease activity after discontinuation of DMTs in MS patients included in the Argentinean MS and NMOSD registry.

DISCUSION

Patients with relapsing remitting MS (RRMS) and active secondary progressive MS (SPMS) were included based on the following criteria: they discontinued treatment for more than 6 months, they had been treated with a DMT for ≥2 years, and they had at least 6 months of follow-up in the registry after discontinuation. Demographic and clinical data were collected. Disease activity during follow-up was defined as the presence of a clinical relapse or a new magnetic resonance (MRI) lesion (either new lesions on T2-weighted sequence and/or contrast enhancement). Bivariate analysis was applied to identify clinical and demographic factors related to disease activity.

CONCLUSION

We included 377 patients (75.5% RRMS, 22.5% SPMS) who had discontinued DMTs. The mean (SD) follow-up after discontinuation was 15.7 (7.9) months. After discontinuation, the presence of relapse was detected in 18.8% and 3.5% in RRMS and SPMS, respectively; and new MRI activity in 22% and 3.5%, respectively. We found that higher risk of relapse and MRI activity was associated with younger age (p < 0.001), shorter disease duration (p < 0.001), and RRMS phenotype (p = 0.006). Males showed higher MRI activity (p 0.011). This study provides real-world data that can guide physicians when considering discontinuation of DMTs.

Characteristics, prevalence and sources of stress in individuals who discontinue assisted reproductive technology treatments: a systematic review

By considering the reasons behind discontinuing assisted reproductive technology (ART) treatment, several studies have indicated that 'stress' is an important issue, but the prevalence of stressors and stress responses, either acute or chronic, remains unclear. In this systematic review, we evaluated the characteristics, prevalence and causes of what was perceived and reported as 'stress' by couples who discontinued ART treatment. Electronic databases were systematically searched, and studies were considered eligible if they evaluated stress as a possible reason for ART discontinuation. Twelve studies were included, with 15,264 participants from eight countries. In all studies, 'stress' was assessed through generic questionnaires or medical records, not by validated stress questionnaires or biomarkers. The prevalence of 'stress' ranged from 11-53%. When the results were pooled, 'stress' was cited as a reason for ART discontinuation by 775 out of 2507 participants (30.9%). Clinical factors associated with worse prognosis, physical discomfort due to treatment procedures, family demands, time pressure and economic burden were identified as sources of 'stress' that contributed to ART discontinuation. Precisely knowing the characteristics of the stress associated with infertility is essential to devise preventive or supportive interventions to help patients to cope and endure the treatments. Further studies are necessary to investigate whether the mitigation of stress factors can reduce ART discontinuation rates.

Adherence to endocrine therapy in patients with hormone receptor-positive early-stage breast cancer: a retrospective study

BACKGROUND

The persistence and adherence to endocrine therapy (ET) in hormone receptor-positive (HR +) breast cancer patients remain far less than optimal.

AIM

This retrospective study aimed to evaluate adherence to ET and to identify influencing factors in early-stage HR + breast cancer patients.

METHOD

A stratified random sampling method was used to select patients admitted for breast cancer surgery at a university hospital in Shanghai, China. Patients who received ET medications in the hospital information system (HIS) were included. The primary outcomes were early discontinuation of and adherence to ET. Potential factors influencing the discontinuation and adherence were assessed using univariate and multivariate logistic regression analyses.

RESULTS

In total, 706 patients were included, and 161 (22.8%) discontinued ET in less than five years from the first prescription. The discontinuation rates from the one-year to the five-year treatment were 5.38, 16.70, 32.27, 51.52, and 50.00%, respectively (P < 0.001). The rates of adherence (defined as medication possession ratio ≥ 80%) from the first to the fifth year were 85.18, 82.25, 82.18, 72.92, and 73.68%, respectively (P = 0.18). Age, insurance, and surgery type impacted ET discontinuation and adherence. However, the type of medication only impacted the adherence to ET.

CONCLUSION

Persistence and adherence to ET in patients with breast cancer remain far from optimal and decrease over time. More attention should be paid to patients aged ≥ 70 years and those without insurance who tend to have early discontinuation of ET.

Family planning method discontinuation among Nigerian women: Evidence from the Nigeria Demographic and Health Survey 2018

Objectives

The cessation of family planning among sexually active women who do not intend to have children increases the number of unplanned pregnancies and the risks to maternal health. This study examined the predictors of family planning method discontinuation among sexually active Nigerian women.

Methods

Data from the Nigeria Demographic and Health Survey (NDHS) were used. A total of 4553 women 15-49 years of age who had stopped using family planning methods in the previous 5 years were included in the study. Descriptive and binary logistic regression were used in the analysis.

Results

More than 60% of the women sampled had stopped family planning and had no intention of having children. Respondents discontinued family planning because of adverse effects (15.2%) and method failure (12.9%). Predictors of modern family planning discontinuation were secondary education (OR = 1.302, 95% CI: 1.006-1.685), Islamic religion (OR = 1.281, 95% CI: 1.059-1.550), residence in the South-East geopolitical zone (OR = 0.248, 95% CI: 0.195-0.316), having three or more children (OR = 0.848, 95% CI: 0.735-0.978) and having paid employment (OR = 0.838, 95% CI: 0.715-0.982).

Conclusion

Socio-economic and cultural factors influence discontinuation of family planning among Nigerian women. Policy options are needed to increase family planning uptake, identify common adverse effects of family planning and focus on raising public awareness regarding the negative consequences of discontinuing family planning on individuals, families and the nation.

Comparative effectiveness of long-acting injectable antipsychotics in patients with schizophrenia in Japan

OBJECTIVE

To compare the effectiveness of different long-acting injectable antipsychotics (LAIs) (aripiprazole, paliperidone, risperidone, and fluphenazine/haloperidol) in patients with schizophrenia in Japan.

METHODS

We conducted a retrospective cohort study using two administrative claims databases. The study population consisted of outpatients with schizophrenia who initiated LAIs between May 1, 2015, and November 30, 2019. We directly compared the risk of psychiatric hospitalization and LAI discontinuation among the LAIs based on hazard ratios (HRs) using Cox proportional hazards regression models.

RESULTS

The numbers of eligible patients who initiated aripiprazole, paliperidone, risperidone, and fluphenazine/haloperidol were 303, 124, 73, and 123, respectively. Regarding psychiatric hospitalization, aripiprazole and paliperidone were associated with significantly lower risk compared to fluphenazine/haloperidol (HR of aripiprazole: 0.47, 95 % CI: 0.28-0.78, HR of paliperidone: 0.50, 95 % CI: 0.28-0.89); HR of risperidone showed the same trend as the aripiprazole and paliperidone. Regarding LAI discontinuation, aripiprazole and paliperidone were associated with significantly lower risk of LAI discontinuation compared to fluphenazine/haloperidol (HR of aripiprazole: 0.53, 95 % CI: 95 % CI: 0.35-0.80, HR of paliperidone: 0.57, 95 % CI: 0.35-0.92). Aripiprazole was also associated with a significantly lower risk compared to risperidone (HR: 0.56, 95 % CI: 0.32-0.98).

CONCLUSION

Our study suggests that aripiprazole and paliperidone are superior to fluphenazine/haloperidol in the risk of psychiatric hospitalization and LAI discontinuation. Aripiprazole is superior to risperidone in the risk of LAI discontinuation.

Pregnancy planning and management for women with multiple sclerosis: what has changed over the last 15 years? An Italian single-center experience

BACKGROUND

Pregnancy planning is a relevant issue in the management of Multiple Sclerosis (MS), which commonly involves women of childbearing age. Increased knowledge and a wider therapeutic scenario could have changed the approach of neurologists towards this topic over time. Our aim was to describe how pregnancy planning and management for women with MS have changed in the last 15 years.

METHODS

We retrospectively collected clinical data of female patients with relapsing-remitting MS (RRMS), referred to the Neurology Clinic of the University-Hospital "Policlinico G. Rodolico" of Catania, who became pregnant between 2005-2020. We compared data about MS and pregnancy between two time periods according to pregnancy onset (2005-2012; 2013-2020).

RESULTS

190 patients with RRMS carried 253 pregnancies in the observation period. Women undergoing a pregnancy in the last period (2013-2020), as compared to women who had pregnancy in the first period (2005-2012), were older (p<0.01), more often treated before and during pregnancy with high-efficacy disease-modifying drugs (DMD) (p<0.001), and exhibited lower annualized relapse rates (ARR) before (p=0.01) and after pregnancy (p<0.001).

CONCLUSION

Results from our experience suggest that nowadays DMD are more frequently used in women of childbearing age, even during pregnancy, leading to a reduced ARR before and after delivery in absence of increased obstetric complications.

Give women what they want: contraceptive discontinuation and method preference in urban Ghana

BACKGROUND

Unmet need for contraception remains high in Ghana. Reducing the number of women who discontinue their contraceptive use is one way to decrease the number of women with an unmet need. In this study, we investigated factors associated with discontinuation among a cohort of Ghanaian women.

METHODS

Women who were beginning a new method of contraception at one of six urban clinics in Accra and Kumasi, Ghana were invited to participate in our study. Participants were interviewed before and after their counseling session, and at 3-, 6-, 9-, and 12-months post-enrollment to determine continuation. During follow-up, participants who were no longer using their method were asked why, if they were using any method of contraception, and if so, which method. Logistic regression analysis was performed to identify factors associated with discontinuation for reason other than pregnancy or desired pregnancy.

RESULTS

Of the 472 women who reported leaving their counseling session with a method, 440 (93.2%) had at least one follow-up contact. Of the 440 women, 110 (25%) discontinued their method at some point over the 12-month period, and 94 (85.5%) did so for reasons other than pregnancy or desired pregnancy. In the multivariate regression analysis, women who reported they were given their method of choice were 12.0% less likely to discontinue due to a non-pregnancy reason (p=0.005); those who used a long-acting reversible contraceptive (LARC) method were 11.1% less likely (p=.001); and those who reported they would choose to use that method again, one measure of satisfaction, were 23.4% less likely (p<.001).

CONCLUSIONS

To our knowledge, the current study is the first to explore method preference and its relation to continuation. Women in our study who reported they were given the contraceptive method of their choice were less likely to discontinue using that method for non-pregnancy-related reasons. Further, those who adopted a LARC method and those who reported they would make the same method choice again were less likely to discontinue. Women should be supported in selecting a contraceptive method of their choice. Providers should work with their clients to find a method which meets their preferences.

Discontinuation of biologic therapy in patients with rheumatoid arthritis and ankylosing spondylitis: analysis from multicenter cohort study

Despite of the availability of several effective bDMARDs, a significant proportion of rheumatoid arthritis (RA) and ankylosing spondylitis (AS) patients discontinued bDMARDs. The aims of this study were to analyze causes of bDMARDs discontinuation in RA and AS included in the Moroccan registry RBSMR. A historical prospective multicenter cohort study based on the RBSMR database at 12 months of follow-up, which included 225 RA and 170 AS. Using T student, Mann-Whitney U, chi-squared or Fischer exact tests, baseline demographic and clinical features were compared between patients discontinuing bDMARDs and patients remaining on initiated bDMARDs or switching bDMARDs. Logistic regression models were used to identify factors associated with drugs discontinuation. 61 RA discontinued bDMARDs and 47 AS interrupted anti-TNF. The most common reasons for drugs discontinuation were adverse events (7.5%) in RA patients and social security reimbursement problems (16.8%) in AS. RA patients discontinuing bDMARDs were more frequently first-line biological drugs users, more frequently female and had more comorbidities and lower DAS28 CRP than RA patients remaining on initiated bDMARDs or switching bDMARDs (p < 0.001, p = 0.01, p < 0.001 and p < 0.001 respectively). Female sex and comorbidities were the significant predictors of bDMARDs discontinuation in RA patients. Higher baseline BASDAI had a protective role on anti-TNF interruption in AS patients. Adverse events and social security reimbursement problems were the main reasons for drugs discontinuation in RA and AS patients respectively. Female sex and comorbidities in RA patients, baseline BASDAI in AS patients impacted bDMARDs discontinuation in real-life settings.

Tapering or discontinuation of biological disease-modifying antirheumatic drugs in axial spondyloarthritis: A review of the literature and discussion on current practice

Biological disease-modifying antirheumatic drugs (bDMARDs) have taken up an important role in the management of axial spondyloarthritis. Once stable remission or low disease activity has been achieved with bDMARDs, it may be possible to maintain this state with lower levels of these drugs. Studies consistently demonstrate that tapering of tumor necrosis factor alpha inhibitors (TNFi) is not inferior to full-dose continuation in terms of maintaining treatment response, while data for tapering of interleukin-17 inhibitors (IL-17i) is lacking. Complete discontinuation of TNFi and IL-17i, however, often results in relapse and should not be recommended at this moment. Clear safety benefits of tapering or discontinuation have not been shown, although studies were typically not designed to address this. Current evidence does not support specific tapering or discontinuation strategies, although stepwise disease activity-guided regimens do allow for a more personalized approach and might be preferred. The definition of what constitutes an appropriate disease state to initiate tapering or discontinuation is unclear, and requires further study. Also, reliable predictors of successful tapering and discontinuation have not yet been identified. Fortunately, if tapering or discontinuation fails, most patients are able to regain disease control when reverted to the original bDMARD regimen. Finally, most patients indicate that, when asked, they would be willing to try tapering if the rationale is clear and if it is in their best interests. The decision to taper or discontinue should be made through shared decision-making, as this could improve the likelihood of success.

Evidence-Based Approach to the Discontinuation of Immunomodulators or Biologics in Inflammatory Bowel Disease

BACKGROUND

Biologics and immunomodulators are key drugs in the long-term treatment of inflammatory bowel diseases, while they may negatively impact patients' quality of life due to concerns of adverse events, need for frequent hospital visits, and medical expenses. The basic concept of drug withdrawal should be based on the risk of relapse and the efficacy of re-treatment. Considering a number of patients may relapse even if treatment is continued, the disadvantage of discontinuation should be recognized not by all relapse after discontinuation, but by the increase in relapse.

SUMMARY

Discontinuation of immunomodulator monotherapy is associated with an increased risk of relapse. However, prolonged remission might be an indication of withdrawal, concerning the long-term adverse effect including lymphoma and nonmelanoma skin cancers. When considering discontinuation from combination therapy of anti-tumor necrosis factor (TNF) agents with immunomodulators, therapeutic drug monitoring may be useful to understand the pharmacokinetic effect. However, recent randomized controlled trials, as well as large-scale observational studies, demonstrated that discontinuation of anti-TNF agents, but not of immunomodulators, resulted in a significantly higher risk of relapse even in deep remission. Therefore, discontinuation of anti-TNF agents should be considered with caution and close monitoring combined with fecal calprotectin may be necessary. On the other hand, evidence of not only short-term relapse rate but of the true long-term influence on the patient's quality of life should be clarified by a multidimensional approach.

KEY MESSAGES

Discontinuation of treatment should be implemented based on shared decision-making with careful interpretation of evidence and the condition.

Active Surveillance for Intermediate-risk Prostate Cancer: A Systematic Review, Meta-analysis, and Metaregression

CONTEXT

Active surveillance (AS) is increasingly selected among patients with localized, intermediate-risk (IR) prostate cancer (PCa). However, the safety and optimal candidate selection for those with IR PCa remain uncertain.

OBJECTIVE

To evaluate treatment-free survival and oncologic outcomes in patients with IR PCa managed with AS and to compare with AS outcomes in low-risk (LR) PCa patients.

EVIDENCE ACQUISITION

A literature search was conducted through February 2022 using PubMed/Medline, Embase, and Web of Science databases. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed to identify eligible studies. The coprimary outcomes were treatment-free, metastasis-free, cancer-specific, and overall survival. A subgroup analysis was planned a priori to explore AS outcomes when limiting inclusion to IR patients with a Gleason grade (GG) of ≤2.

EVIDENCE SYNTHESIS

A total of 25 studies including 29 673 unselected IR patients met our inclusion criteria. The 10-yr treatment-free, metastasis-free, cancer-specific, and overall survival ranged from 19.4% to 69%, 80.8% to 99%, 88.2% to 99%, and 59.4% to 83.9%, respectively. IR patients had similar treatment-free survival to LR patients (risk ratio [RR] 1.16, 95% confidence interval (CI), 0.99-1.36, p = 0.07), but significantly higher risks of metastasis (RR 5.79, 95% CI, 4.61-7.29, p < 0.001), death from PCa (RR 3.93, 95% CI, 2.93-5.27, p < 0.001), and all-cause death (RR 1.44, 95% CI, 1.11-1.86, p = 0.005). In a subgroup analysis of studies including patients with GG ≤2 only (n = 4), treatment-free survival (RR 1.03, 95% CI, 0.62-1.71, p = 0.91) and metastasis-free survival (RR 2.09, 95% CI, 0.75-5.82, p = 0.16) were similar between LR and IR patients. Treatment-free survival was significantly reduced in subgroups of patients with unfavorable IR disease and increased cancer length on biopsy.

CONCLUSIONS

The present systematic review and meta-analysis highlight the need to optimize patient selection for those with IR features. Our findings support limiting the inclusion of IR patients in AS to those with low-volume GG 2 tumor.

PATIENT SUMMARY

Active surveillance is increasingly used in patients with localized, intermediate-risk (IR) prostate cancer. In this population, we have reported higher risks of metastasis and cancer mortality in unselected patients than in patients with low-risk features, underscoring the need to optimize the selection of patients with IR features.

Effects of zoledronate on bone mineral density and bone turnover after long-term denosumab therapy: Observations in a real-world setting

BACKGROUND

The rebound effect after denosumab discontinuation is lessened with subsequent zoledronate therapy. However, it is unclear whether this mitigation is sufficient after long-term denosumab treatment.

OBJECTIVE

This retrospective observational study analysed bone mineral density (BMD) and bone turnover marker (BTM) changes after denosumab therapy according to treatment duration and subsequent zoledronate regimen.

METHODS

We measured the outcomes of 282 women with postmenopausal osteoporosis who discontinued denosumab and received zoledronate 6 months later. In patients with longer denosumab therapy (≥5 years), BTMs were measured every 3 months and a second zoledronate infusion was administered if BTM levels increased by ≥2-fold. The BMD of all women was measured before denosumab therapy, at the last injection and 1 to 2 years after the first zoledronate.

RESULTS

Bone loss after switching from denosumab to zoledronate was higher in patients with 10 ± 2 denosumab injections (n = 84) compared to 5 ± 2 injections (n = 144, p < 0.001 for lumbar spine and femoral neck), but there was no further increase with treatment durations of ≥15 ± 2 injections (n = 54, p = 0.35 and p = 0.20, respectively). BTMs in patients with ≥10 denosumab injections were elevated 6 months after zoledronate in some patients, but not all. Twenty-four women received a second zoledronate dose 6 months after the first one. BTMs in these patients were subsequently lower, but bone loss at both the lumbar spine and hip was comparable to that in patients with only one zoledronate dose (p = 0.37 for lumbar spine and p = 0.97 for femoral neck).

CONCLUSIONS

Rebound-associated bone loss reached a plateau after denosumab treatment durations of 4-6 years, irrespective of the frequency of subsequent zoledronate therapy.

Real World Adherence to and Persistence With Oral Oncolytics in Multiple Myeloma: A Systematic Review and Meta-analysis

INTRODUCTION

Oral oncolytic treatments (OOTs) have improved the prognosis of patients with multiple myeloma (MM). However, the effectiveness of these therapies is undermined by poor adherence. We aimed to characterize the real-world adherence to, and persistence with, OOTs for MM.

MATERIALS AND METHODS

MEDLINE, EMBASE, and the International Pharmaceutical abstracts databases were searched for relevant observational studies published in English up to November 21, 2021. This was supplemented by manual searches of abstracts from the annual meetings of the American Society of Hematology, the American Society for Clinical Oncology, and the European Hematology Association as well as screening the references of included articles. Random-effects meta-analysis was performed.

RESULTS

Following screening of 11,557 articles, 19 studies involving 27,129 patients in 8 countries (France, the US, Germany, Italy, the UK, Brazil, South Korea, and Belgium) prescribed OOTs (lenalidomide, thalidomide, pomalidomide, panobinostat, ixazomib, and melphalan) for MM were included. The overall pooled proportion of adherent patients was 67.9% (95% confidence interval [CI]: 57.1%-77.8%). The pooled proportion of adherent patients was higher in self-reported questionnaire-based studies compared to those using prescription/dispensing data (81.6% vs. 61.0%; P-value for difference = .08). Across 5 studies involving 15,363 patients, a pooled proportion of 35.8% (95% CI: 22.0-50.9) discontinued treatment. Factors reported to be associated with nonadherence included increasing age, higher comorbidity, polypharmacy, and a lack of social support.

CONCLUSION

In patients with MM, adherence to and persistence with OOTs remains suboptimal. To achieve desired clinical outcomes, interventions to improve adherence and minimize discontinuation may be warranted.

User Perspectives on Professional Support and Service Use During Psychiatric Medication Discontinuation

Psychiatric medication discontinuation is common and can have negative impacts. Until recently, most research on discontinuation happened in an adherence/compliance framework. There is now recognition that discontinuation may be a desired goal for many individuals. The purpose of the present paper is to describe the results of a pioneering survey to explore professional support to service users during medication discontinuation to inform clinical practice and guide future research. Survey responses from 250 service users were summarized with regard to their use of prescriber and psychotherapy services during the process of discontinuing psychiatric medication. Only 65% of respondents reported seeing a prescriber and less than 50% reported seeing a psychotherapist while attempting to discontinue psychiatric medication. Combined with respondents' answers describing the decision-making process and support received from these services, this paper identifies gaps in service and the need to improve providers' ability to support individuals while they discontinue psychiatric medication.

Vitamin B6 decreases the risk of levetiracetam discontinuation in children with epilepsy: A retrospective study

OBJECTIVES

Levetiracetam (LEV) is an anti-seizure medication (ASM) known to have significant behavioral side effects in children with epilepsy. These side effects may be improved by supplemental vitamin B6 (pyridoxine) use. Our research aimed to study risk factors for LEV side effects and the role of vitamin B6 in altering this risk.

METHODS

We retrospectively analyzed the demographic and clinical profile of all pediatric patients on LEV treatment between July 2019 and December 2020. T-tests, Chi-square and Fisher exact tests were used to assess predictors of LEV discontinuation. A p-value of <0.05 was considered statistically significant.

RESULTS

150/240 (62%) children were on additional medications besides LEV for epilepsy management. Thirty-five percent children reported side effects, especially behavioral and mood concerns. Of the patients who reported side effects on LEV, 71% were taking vitamin B6 (n = 59). The rate of LEV discontinuation was significantly lower for children on vitamin B6 than children not taking B6, regardless of monotherapy or polypharmacy (49% v 88% respectively, p = 0.001). Over half of the patients who were able to remain on LEV reported improved behavior with B6 supplementation as compared to those who were unable to continue LEV (17/30, 57% versus 0/26, 0%; p < 0.001).

CONCLUSIONS

Levetiracetam side effects significantly impact the tolerability of this ASM in children with epilepsy. Our results suggest that vitamin B6 supplementation can significantly reduce the odds of discontinuing LEV due to its behavioral side effects.

Hypnotic Discontinuation in Chronic Insomnia

Insomnia disorder is common in adults and children. The estimated prevalence ranges from 9% to 15% in the general population, with higher prevalence in certain subpopulations. Hypnotic medications are those that tend to produce sleep and are frequently used to treat insomnia. Commonly used hypnotics in adults include benzodiazepines (BZDs), BZD receptor agonists, antihistamines, antidepressants, melatonin receptor agonists, orexin receptor antagonists, and antipsychotics. However, hypnotic discontinuation is difficult and often unsuccessful. This article discusses strategies to discontinue hypnotics and evidence supporting their use.

Prospective Longitudinal Health-related Quality of Life Analysis of the Finnish Arm of the PRIAS Active Surveillance Cohort: 11 Years of Follow-up

BACKGROUND

Living with an untreated cancer may alter quality of life (QoL) in the long term.

OBJECTIVE

To prospectively study long-term changes in general, mental, and physical QoL in a contemporary active surveillance (AS) patient cohort with low-risk prostate cancer (PCa).

DESIGN, SETTING, AND PARTICIPANTS

The study population consisted of patients enrolled in the PRIAS trial in Helsinki University Hospital (n = 348). The RAND-36 questionnaire was used to assess general QoL at the start of AS and at 1, 3, 5, 7, 9, and 11 years during follow-up. Patients who had undergone robot-assisted laparoscopic prostatectomy (RALP; n = 88) also received the questionnaire after treatment.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Changes over time were analysed using multilevel mixed-effects regression models, and reported as the mean and95% confidence interval. A rule of 0.5 × standard deviation was used to estimate changes of clinical importance.

RESULTS AND LIMITATIONS

Median follow-up until the end of AS or last follow-up was 7.2 (range 0.3-12.7) yr. A decrease was observed in six of eight QoL subdomains at 7 yr. However, all scores were above age-stratified reference values. There was no difference between the group who continued AS throughout the study period and the group who discontinued AS and underwent RALP. More than half of the study cohort discontinued AS (n = 198; 57%), 135 men (68%) because of events specified in the protocol and only seven (3.5%) because of anxiety. Metastatic disease developed in six patients (1.7%), and two cases (0.6%) of PCa-related death were recorded among 348 patients in more than 12 yr of overall follow-up. The lack of a randomised control population is a limitation of the study.

CONCLUSIONS

Contemporary protocolised AS does not impair general QoL. Men undergoing a treatment change (RALP) did not experience a decrease in QoL before or after their treatment change.

PATIENT SUMMARY

Active surveillance is a safe treatment option for men with low-risk prostate cancer. We show that this follow-up strategy does not cause a decline in patients' general quality of life.